Author(s): Taylor N. Erickson, MPH;

Reviewer(s): Hendrika W. Meischke, PhD, MPH; India J. Ornelas, PhD, MPH; Christine Wilson Owens; Ehsan Shayegan, MA, MAPP; Genji Terasaki, MD

Date Authored: November 6, 2023

Overview

Washington state and King County continue to be top resettlement destinations for refugees in the United States; however, newly arrived refugees experience many challenges and barriers when accessing health services after resettlement. EthnoMed’s mission is to provide culturally appropriate and relevant resources on refugee and immigrant health topics. One available resource is EthnoMed’s Primary Care Provider Toolkit. First developed in 2011, the original toolkit offers clinical recommendations and guidance for providers that serve refugee communities in King County. The goal of this project was to gather qualitative data from refugee community leaders to develop recommendations for EthnoMed’s updated Primary Care Provider Toolkit. Through this project, 15 key-informant interviews were conducted with leaders of Afghan, Ukrainian, and Iraqi refugee communities in King County. Community leaders were asked about the health needs and barriers to health care that new arrivals experience after resettlement. The qualitative findings from these semi-structured interviews were analyzed and synthesized into nine recommendations for the updated version of EthnoMed’s toolkit. By integrating community voices into this updated version, EthnoMed can develop a more culturally appropriate and patient-centered resource that will better inform primary care practices for providers that serve refugee communities.

healthcare provider hands and patient hands, explaining primary care
Health provider working with refugee newcomer

Background and Objectives

In 2011, the Primary Care Provider Toolkit resource was developed in response to the complex health needs of the growing refugee population in King County, Washington. This cross-sector community resource was developed by a team of health professionals, including social workers from Lutheran Community Services Northwest (LCSNW), graduate students from the University of Washington, and physicians from the International Medicine Clinic and Pediatric Clinic at Harborview Medical Center. The original resource includes information on health screenings, treatment recommendations, referrals, links, and resources. The primary audience for this toolkit is primary care providers that serve newly arrived refugees in King County.
The toolkit’s main objectives are:

  1. Explain overseas PRE-departure assessment and POST-departure screening needs
  2. Facilitate exchange of information between Public Health Refugee Screening and primary care providers
  3. Share links, referrals & other information, including contacts to interpretation services
  4. Advocate [for] and empower refugee patients

The original toolkit was developed over 10 years ago, with a subsequent update in 2015; however, sections of its information is now out of date, or is not relevant to the communities that are being predominantly resettled in King County. EthnoMed is seeking to update the resource to reflect the current landscape and needs of local refugee communities. The original toolkit lacked community input; therefore, the goal of this project was to effectively gather community feedback about the health needs and barriers to accessing health services that new arrivals experience in King County. This input will then be incorporated into EthnoMed’s updated version of its Primary Care Provider Toolkit resource so as to center community experiences at the heart of its guidance and information. In particular, this project considers the perspectives and experiences of three groups in King County: Afghan, Iraqi, and Ukrainian refugee communities.
This project focused on the following objectives:

  1. Conduct key-informant qualitative interviews with community leaders from Afghan, Iraqi, and Ukrainian refugee communities in King County, Washington.
  2. Develop recommendations for the updated version of EthnoMed’s Primary Care Provider Toolkit that reflect community experiences and perspectives.

Methods

This project involved 15 semi-structured interviews with leaders of the Afghan, Iraqi, and Ukrainian refugee communities in King County, Washington: 4 with Afghan community leaders, 6 with Ukrainian community leaders, and 5 with Iraqi community leaders. Interviewees were employees and volunteers of federally-qualified health centers (FQHCs), refugee resettlement agencies, Harborview’s Community House Calls Program, and local community-based organizations that serve refugees. All interviewees worked or volunteered in settings that maintain direct contact with refugees in King County. Almost all of these individuals identified with the refugee communities that they are now serving. All 15 interviews were conducted in English on Zoom, and lasted approximately 30 minutes to 1 hour. A single interview guide was used for all interviews, and consisted of 16 open-ended questions about the health needs and primary care experiences of refugee communities in the area.

To identify common themes among the three refugee communities included in this project, a thematic analysis was applied to all interview data. Dedoose software was used to code interview transcripts and to identify key excerpts that emphasize community needs and perspectives.

Findings

Below is a brief summary of major findings from analysis of interview transcripts. These larger themes describe common considerations and health issues that were discussed throughout the 15 interviews conducted for this project. Six common themes were identified across all three refugee communities, and additional themes were identified that were specific to either one or two communities, as opposed to be shared across all three groups.

Themes Across All Three Refugee Communities

THEME 1: Language access services are an important component of health care that must be considered when serving refugee communities.

Interviewees across all three groups discussed how interpreters increase accessibility of health services for refugees after resettlement, but communities emphasize that there are important considerations that providers should be aware of when using these services. These considerations include the genders of interpreters, and community leaders called for asking patients if they have a preference for the gender of the medical interpreter used during appointments. Additionally, community leaders caution providers against using patients’ family members as medical interpreters during appointments. Community leaders also called for more in-language, written materials available to patients with limited English proficiency. These resources may include pamphlets or brochures about health topics.

THEME 2: Mental health continues to be an important issue for refugee communities.

Mental health was among one of the most heavily discussed topics among all three refugee communities included in this project. Interviewees speculated that refugee communities may not have an in-depth understanding of what mental health is, how it physically manifests, and what support is available. Many of the mental health conditions discussed during interviews included anxiety, depression, and post- traumatic stress disorder (PTSD). Language barriers and stigma may be important barriers to accessing mental health services. Community leaders called for increased intervention around mental health, and emphasized the need for culturally appropriate education about mental health for patients.

THEME 3: Community leaders feel that providers should understand factors that can influence patient-provider interactions.

Community leaders described factors that can impact interactions between providers and patients. These factors included the gender of health care providers and trust. Community leaders feel that patients should be asked what gender of provider they prefer for appointments, and that this preference should be heavily prioritized. Refugee patients may not trust health care providers in the area, and this may be due to unfamiliarity with the American health care system, or unfamiliarity with the individual provider. Interviewees believe that trust can be built over time as patients continue to see the same provider and have more positive interactions with them. One suggestion for improving trust was for providers to learn more about the cultures of their patients; however, it must be emphasized that patients are individuals with their own sets of values, beliefs, and experiences; there will not be universal cultural characteristics across all refugee communities. Community leaders feel that providers should make space for patients to share their own individual identities and beliefs.

THEME 4: Community leaders feel that providers should be aware of the major differences between the American health care system and foreign health care systems.

Refugee communities in King County are arriving from countries with health systems that are vastly different than what is in the United States. Community leaders shared that many patients have different expectations when interacting with health services after resettlement based on their experiences in their countries of origin. A lack of understanding about how the US health care system works may contribute to frustration, and may discourage community members from accessing health services. Community leaders called for increased education for community members about how to navigate the US health care system.

THEME 5: Community leaders identified health conditions that require particular attention from health care providers that serve refugees.

During interviews, community leaders discussed health conditions that they felt require more attention from health care providers that are serving newly arrived refugee communities. This is not a comprehensive list of health conditions for providers, but describes conditions that providers should pay particular attention to when providing care to refugee patients. The first condition was tuberculosis (TB), and while the domestic health examination addresses TB, community leaders feel that patients may need additional support after resettlement. Other health conditions included diabetes and dental health care. A final health condition discussed was COVID-19. While community leaders did not necessarily indicate that there was a high prevalence of COVID-19 among refugee communities in King County, they did identify this condition as an opportunity for increased education about COVID-19 vaccinations.

THEME 6: Community leaders feel that providers should have a basic understanding of which community-based organizations are available to refugees in the area.

A final theme that was identified from conversations with community leaders is the importance of social networks and community-based organizations for recently resettled refugees in King County. Almost all of the individuals interviewed for this project are involved with community-based organizations that serve local refugees, and many of these groups have direct contact with newly arrived refugees. Community leaders shared the wide array of educational campaigns, events, and outlets that organizations use to disseminate information on health topics to community members. This information is usually delivered in the native languages of refugee communities, and are framed in culturally sensitive manners, which improves acceptance among community members. When asked if refugee community members trust other community members more than health care providers, almost all community leaders responded that patients would probably trust other community members more. This is largely due to shared language, culture, and experiences among the refugee community.

Themes Within The Afghan Community

THEME 1: Community leaders feel that providers should be aware of important cultural considerations when serving Muslim patients from Afghanistan.

Afghanistan is a predominantly Muslim country with many individuals who continue to practice their religion even after leaving their home country. For many Afghan refugees in King County, a large part of their identities is rooted in their Muslim values and traditions. Among Afghan nationals that have been resettled in the US, racism and Islamophobia are salient issues that they experience. This is especially true for individuals who wear traditional Muslim dress, such as hijabs. While individuals may have unique ways of practicing their religions, a lack of provider knowledge about key characteristics of the Muslim culture may be extremely detrimental to building trust with patients from Afghanistan.

THEME 2: Community leaders feel that providers must be considerate when discussing sensitive health topics and performing physical examinations with Afghan patients.

Other important considerations for providers to acknowledge is that Afghan nationals, especially women, may be extremely uncomfortable discussing sensitive health topics, such as sexual health, during appointments. While these health topics are important to discuss, providers must acknowledge that patients may be extremely hesitant or even unwilling to engage in conservations about certain health behaviors. It is crucial that providers give patients the opportunity to discuss these topics during health visits, but providers must be sensitive to patients’ level of comfort around these topics. It may be helpful for providers to frame these topics in culturally sensitive manners, or to indirectly ask patients about their health behaviors. Similar sentiments are felt by the Afghan refugee community during sensitive physical examinations, such as pelvic exams, mammograms, or pap smears. Providers serving these communities should be educated on the Muslim culture and values as they relate to physical examinations to tailor their approaches with patients. Patients may also benefit from increased education about these procedures, what they entail, and their importance in identifying health conditions. This education should be framed in a culturally sensitive manner that addresses the concerns of Muslim communities.

THEME 3: There is a need for providers to address elevated blood lead levels (EBLLs) and lead exposure in the Afghan refugee community.

A common health condition that providers should be aware of is elevated blood lead levels (EBLLs) within the Afghan refugee community. This was a topic that came up among all 4 Afghan interviewees. While exposure to lead also occurs in Afghanistan before resettlement, many new arrivals are still exposed to lead after resettlement through common cultural practices. Screenings for elevated blood lead levels are included in domestic health examinations for new arrivals in Washington state; however, providers should be aware of practices within the Afghan community that increase lead exposure after resettlement. Additionally, providers may wish to use this knowledge to tailor their education to Afghan patients about elevated blood lead levels and household lead exposures.

Themes Within The Ukrainian Refugee Community

THEME 1: There is a need for increased education for providers about religious and cultural considerations within the Ukrainian community.

The 6 interviews with Ukrainian community leaders all mentioned the role that religion plays in the health and culture of many Ukrainian refugees. While not all community members identify as religious or engage in religious practices, this topic came up frequently when discussing health and social topics. Providers may wish to educate themselves about how to explain the importance of vaccinations in the context of refugees’ religions. Interviewees shared that there may be anti-vaccination sentiments in the Ukrainian refugee community, which they felt are most common within religious groups. Another topic that providers should be aware of is the way that religion in the Ukrainian refugee community impacts support for members of the LGBTQ+ community. Because of beliefs attributed to their religion, individuals that identify as LGBTQ+ may not receive support from other community members, or may even be shunned or physically harmed by others. Another important consideration for providers to be aware of is the sensitive politics of the war in Ukraine, as well as recognizing Ukraine’s unique history as an independent nation. All 6 Ukrainian interviewees emphasized that providers should not make assumptions about the language that a Ukrainian patient prefers to speak during appointments. While some patients may prefer to speak Russian, it could be extremely traumatic and triggering for other Ukrainian patients to hear Russian spoken during appointments.

THEME 2: Community leaders feel that providers should be aware of how Ukrainian patients access medications after resettlement.

A second theme that was identified through analysis of interview transcripts was how Ukrainian refugees access medications after resettlement in the US. The majority of interviewees discussed how Ukrainian refugees are often purchasing over-the-counter medications in local Ukrainian or Russian stores, as opposed to purchasing them in pharmacies or other American retailers. These medications may be imported from foreign retailers and sold in local shops. This may be due to the fact that Ukrainian community members are more familiar with the names or brands of medications that they purchased in their home country, when compared to the medications available in the US. Some interviewees speculated that refugees may be overwhelmed by the amount of over-the-counter medications available in the US, which can make it difficult to know which medication they should buy. One example was the purchase of paracetamol, as it is called in Ukraine, in Ukrainian stores versus acetaminophen as it is known in the United States. While this is a milder example of differences between Ukrainian and American medications, multiple interviewees described how prescription medications including antibiotics may also be purchased in these stores.

THEME 3: Community leaders feel that providers should understand how the current immigration landscape can impact Ukrainian refugees’ decisions to access health care in the US.

A final theme identified within the Ukrainian refugee community pertains to immigration considerations. With the United States’ Uniting for Ukraine refugee pathway, Ukrainian refugees do not receive formal refugee status through US Citizenship and Immigration Services. Instead, Ukrainians that arrive through this pathway are granted humanitarian parole status and are permitted to stay in the US for a period of two years. After two years, it is unclear if Ukrainian refugees have a pathway to US citizenship. This uncertainty may impact the ways in which Ukrainians that recently arrived to the US access health services during their parole period. Community leaders speculated that some Ukrainian refugees who came through this pathway may have hopes of returning to Ukraine after the war and when it is safe again. Alternatively, there may be individuals who would like to stay in the US if immigration services allow this. These considerations may impact individuals’ decisions to access health services in the US.

Themes Within The Iraqi Community

THEME 1: Community leaders feel that providers should be aware of Muslim cultural considerations, and should understand how racism and Islamophobia impact the Iraqi refugee community.

Similar to Afghanistan, Iraq’s population predominantly identifies as Muslim. While individuals may choose to practice their religion based on their own values or beliefs, there are once again common considerations for Muslim patients that came up often during interviews with Iraqi community leaders. Community leaders suggested that providers should educate themselves about Iraqi and Muslim culture to better understand the values and experiences of Iraqi patients. One recommendation was to ask patients directly about their culture and to create space for them to share their perspectives and stories. Additionally, Iraqi patients may be extremely hesitant or unwilling to discuss sensitive health topics such as sexual health, which was similar to Afghan patients. It also may be stigmatized to openly discuss these topics with a provider. When seeing patients from refugee communities, providers should explain why they are asking questions about sensitive health topics, ask patients if they feel comfortable answering them, and respect patients’ decisions if they do not wish to proceed. Finally, another topic that came up often with the Iraqi refugee community was racism and Islamophobia. While Muslim groups from other refugee communities certainly experience racism and Islamophobia as well, this was a topic that came up among all 5 Iraqi community leaders. Many providers that serve refugee communities in King County are well-educated on respecting the diverse cultures and identities of patients; however, providers should be aware of the racism that Iraqi community members experience and how this racism impacts trust. The Iraqi refugee community is very close-knit in King County, and racist experiences may be shared with other community members which could further harm relationships with providers.

THEME 2: Community leaders identified preventive health screenings of certain conditions that should be prioritized with Iraqi refugee patients.

A second theme that was identified through interviews with Iraqi community leaders centered around the need for important health screenings. One need that came up frequently during conversations was addressing sexually transmitted infections (STIs) among Iraqi refugees. While STI screenings are generally included in the domestic medical examination for newly arrived refugees, it is important that providers continue screenings after resettlement. Patients’ behaviors, such as engaging in sexual activity, may have changed since they left their country of origin or after resettlement in the United States. A change in behaviors may increase patients’ risk of health conditions such as STIs, and providers should be aware of these risks. Iraqi refugees may also greatly benefit from increased education about common STIs, how STIs are spread, and how patients can decrease their risk of acquiring an STI. Iraqi community leaders also frequently brought up cancer screenings as a health need among resettled refugees. Interviewees that participated in this project frequently discussed the burden of cancer within the Iraqi refugee community, and called for increased cancer screenings during primary care visits.

THEME 3: The accent of medical interpreters may negatively impact Iraqi patients’ ability to communicate with providers.

A third theme that was brought up by all Iraqi interviewees was how the accent of medical interpreters impacts communication between providers and patients. Arabic is one of the most commonly spoken languages in the world, but there are numerous Arabic accents that vary by country or region. If Iraqi patients opt to use a medical interpreter during primary care visits with health care providers, they will most likely use an interpreter that speaks Arabic; however, community leaders pointed out throughout this project that medical interpreters may speak Arabic with an accent that can be difficult or even impossible for Iraqi patients to understand. Providers should be aware of how the accent of Arabic- speaking medical interpreters could impact communication with Iraqi patients. It may also be extremely beneficial to ask patients if they are able to understand the interpreter, or ask interpreters if they can understand the patient.

THEME 4: Iraqi patients may need additional support when navigating situations such as domestic violence or disabilities.

A fourth theme that was identified during interviews is the need for additional support regarding some health topics in the Iraqi community. One topic that came up was the issue of domestic violence in the Iraqi community. While domestic violence is not an issue experienced exclusively by Iraqi refugees, this was a topic that was discussed by the majority of Iraqi community leaders during this project. Domestic violence is an extremely sensitive topic for most individuals, but Iraqi refugees may face increased barriers to accessing support. There may be a lack of knowledge among community members about what domestic violence is, and what protections people living in the United States are entitled to.
Another opportunity for providers to offer additional support to Iraqi refugees is around children who are diagnosed with autism-spectrum conditions or learning disabilities. The conditions discussed included autism, attention-deficit disorder (ADD), and attention-deficit hyperactivity disorder (ADHD). While these experiences are not unique to the Iraqi refugee community, they were commonly discussed with Iraqi community leaders during interviews. According to community leaders, Iraqi parents may be unfamiliar with these diagnoses, the symptoms of these conditions, and how they can best provide for children diagnosed with a disability. The Iraqi refugee community may have misconceptions about these disabilities in children, and may be unaware of what support is available for children living with disabilities. Stigma around disabilities may also impact parents’ willingness to accept diagnoses in children.

Recommendations For EthnoMed’s Primary Care Provider Toolkit

The following nine recommendations were developed based on themes identified from conversations with refugee community leaders. These are recommendations for EthnoMed’s updated Primary Care Provider Toolkit to better address the needs and gaps in health care that refugee communities experience in King County:

  1. Feature an in-depth explanation of what cultural humility is and how providers can practice cultural humility when serving refugee patients.
  2. Include a section on medical interpretation and important considerations for providers when using medical interpreters.
  3. Recommend important health screenings for refugee patients, including screenings for hypertension, cancer, sexually transmitted infections, elevated blood lead levels, diabetes, and tuberculosis.
  4. Outline for providers how immigration status can impact patients’ health decision-making.
  5. Emphasize that providers offer more explanations and education to patients about health services, health conditions, and medications.
  6. Include a more robust section on mental health as it relates to refugee cultures and experiences.
  7. Offer descriptions about health care systems in other countries and how providers can educate patients about the American health care system.
  8. Include sections on domestic violence, disabilities, and LGBTQ+ communities as they relate to refugee health and cultures.
  9. Feature a list of local community-based organizations to connect patients with for further support and education.

Conclusion

The purpose of this project was to develop recommendations for EthnoMed’s updated Primary Care Provider Toolkit for health care providers that serve newly arrived refugees in King County, Washington. Through this project, 15 key-informant interviews were conducted with leaders of the Afghan, Ukrainian, and Iraqi refugee communities. These leaders were able to share community experiences through their roles at organizations or clinics where they directly interact with newly arrived refugees. Nine recommendations for EthnoMed’s Primary Care Provider Toolkit were developed based on the common themes identified from conversations with refugee community leaders in the area. These recommendations attempt to address the needs, barriers, and experiences of refugee communities as they access health services after resettlement.