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Refugee 101 for Healthcare Providers

Refugee 101 for Healthcare Providers. Refugees from Rwanda arrive in Tanzania. Photo by UNHCR/ P. Moumtzis. Overview. Who is a refugee Refugee resettlement in Tucson Predominant groups and background Resettlement process and agency roles Refugee health Health screenings

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Refugee 101 for Healthcare Providers

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  1. Refugee 101for Healthcare Providers Refugees from Rwanda arrive in Tanzania. Photo by UNHCR/ P. Moumtzis

  2. Overview • Who is a refugee • Refugee resettlement in Tucson • Predominant groups and background • Resettlement process and agency roles • Refugee health • Health screenings • Common health issues and resources • Language interpretation services • Community resources

  3. What does it mean to be a refugee? • What would you do right now if bombs were falling around you? • What would you do if people of your faith or ethnic group were being singled out, tortured, and slaughtered?

  4. What does it mean to be a refugee? • If you had 15 minutes to evacuate your home… what would you take ?

  5. What does it mean to be a refugee? Where would you go? Who would help you? If you could not return home - would you hope that someone would help you?

  6. Who is a Refugee? A refugee is a person who "owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group, or political opinion, is outside the country of his nationality, and is unable to or, owing to such fear, is unwilling to avail himself of the protection of that country…" Article 1, The 1951 Convention Relating to the Status of Refugees Pictures: Courtesy of pubrecord.org and japanfocus.org

  7. Who is a Refugee? This definition of a refugee does not include: • Economic migrants • Asylum seekers • Persons displaced by natural disasters • Internally displaced persons (IDPs)

  8. Refugees in the World

  9. Refugees in USA

  10. Refugee in Tucson

  11. Iraq • About the size of CA Baghdad (Capital ~5.7 million (2004)). • Nationality: Iraqi(s). Population (07/09): 28,945,657. Ethnic groups: Arab 75%-80%, Kurd 15%-20%, others ~ 5%. Religions: Muslim 97%, Christian and others ~ 3%.Languages: Arabic/Kurdish

  12. Iraqi Refugees

  13. Bhutan • Location: Southern Asia, between China and India • Population: `710,000 • Constitutional Monarchy • Languages: Dzongkha (official), Tibetan dialects, Nepalese dialects (among Nepalese) • Ethnicity/race: Bhote 50%, ethnic Nepalese 35%, indigenous or migrant tribes 15% • Religions: Lamaistic Buddhist 75%, Indian- and Nepalese-influenced Hinduism 25%

  14. Bhutanese Refugees

  15. Bhutanese Refugees

  16. Somalia Population (2010 est.): 10,112,453 (growth rate: 2.8%); infant mortality rate: 107.4/1000; life expectancy: 50 Capital: Mogadishu (~ 1,208,800) Languages: Somali (official), Arabic, English, Italian Ethnicity/race: Somali 85%, Bantu and others 15% (including Arabs 30,000) Religion: Islam (Sunni)

  17. Somali/Somali-Bantu Refugees

  18. Population: 67 million (2010) Capital: Kinshasa Languages: French, Lingala, Kiswahili, Kikongo, Tshiluba Major religions: Christianity, Islam Life expectancy: 47 years (men), 50 years (women) (UN) Democratic Republic of Congo

  19. Refugees from Congo

  20. Population: 5.2 million (UN, 2010) Capital: Asmara Languages: Tigrinya (official), Arabic (official), English (official), Tigre, Kunama, Afar, others Major religions: Muslim, Coptic Christian, Roman Catholic, Protestant Life expectancy: 59 years (men), 64 years (women) (UN) Infant Mortality Rate: 41.3/1,000 Eritrea

  21. Eritrean Refugees

  22. Application for resettlement in a third country Rigorous screening (medical and security) Interviews Cultural orientations Waiting time: several months to many years How Do Refugees Reach the US? Picture: www.worldreliefmn.org/the-story-in-pictures/

  23. Refugees in the US Once approved, refugees are assigned to various sponsoring voluntary agencies in the United States 12 Nationwide Refugee Resettlement Agencies 4 in Phoenix 3 in Tucson (see handouts)

  24. Resettlement in Tucson WEEK 1: DES Interview (Food Stamps/AHCCCS) Social Security Card RMAP card PRE-ARRIVAL: Locate & Furnish Apartment Connect utilities ARRIVAL: Pick up at Airport • Home Safety • Orientation 6 MONTHS: Start paying on IOM Travel Loan FIRST 30 DAYS: CORE SERVICES • Ongoing cultural/home orientations • Financial/MG orientations • Health Screening (including TB screening and Immunizations) • Begin initial doctor visits • Register adults for ESL at Pima • Bus passes • School Enrolment • Employment Assistance 1 YEAR: Apply for Permanent Residency (Green Card) 5 YEARS: Apply for Citizenship

  25. Challenges of Resettlement Insufficient financial assistance for the first 90 days ($900 per person) Shortage of Staff Caseload

  26. Resettlement in Tucson • Common challenges for new arrivals: • Living in poverty • Securing employment • Learning the language • Getting around Tucson • Navigating the healthcare system and other government services • Adapting to American culture (time, individualism, the status of women, etc.)

  27. REFUGEE HEALTH CARE REQUIREMENTS Before going to USA: Medical assessment by International Organization of Migration/IOM: TB-screening, Chest X-ray, RPR tests, and general physical exam; Upon arrival to USA: TB-screening within first 30 days Initial medical screening within 30 days after arrival unless stated differently; Initial dental screening within first 30 days

  28. Health Insurance RMAP Federally-funded temporary public benefits program for new refugees Covers medical costs during first 8 months not covered by AHCCCS Also covers immunizations and dental and eye exams for refugees including over 21 years AHCCCS Arizona/Federal Medicaid health insurance program for qualified low-income residents Coverage for medically necessary care with limitations Broader coverage for children under 21 years and ALTCS members

  29. Preventive Health Screening Mandatory for all refugees within 30-60 days after arrival Funded through RMAP Screening for communicable diseases, mental health, undiagnosed chronic conditions Screening tests including TB, Hepatitis B, HIV, Syphilis, GC/Chl, and Pregnancy test Vaccinations for children and adults Follow-up immunizations for adults to fulfill I-693 requirements Immediate referrals to Center for Well-Being, OB Intake at FMC, Infectious Diseases Providers at UMC

  30. Common Refugee Health Issues Pain Mental Health Chronic Conditions Headache PTSD Anemia Neck pain Asthma Depression Diabetes Back Pain Anxiety Dyslipidemia Abdominal Pain Adjustment Disorder COPD Female Pelvic Pain Social Isolation Hypertension Vitamin D def Vitamin B12 def (Bhutanese)

  31. Vaccine Requirements for Green Card

  32. Patient and Provider Challenges • Language barrier • Differences in health beliefs • Differing beliefs regarding causes of health and ill health (e.g. viruses, organ systems) • Concept of chronic (vs acute) disease • Concept of preventive care (e.g. CA screenings tests) • Difficulty navigating health care system • Understanding medication refills • Keeping set appointment times • Following up with referrals to specialists • Healthy Living: Nutrition, hygiene, sanitation

  33. Link between Migration & Resettlement Health Burden Source: Globalhealth.gov Pre-migration: exposure to infectious & parasitic diseases, physical & psychic trauma  During flight & refugee camps: malnutrition, exposure to the elements, exposure to infectious & parasitic diseases, physical & psychic trauma  Post-migration/Resettlement: increasing susceptibility to chronic diseases, problems & stressors of resettlement (unemployment, language, etc.)

  34. Mental HealthConsiderations

  35. Triple Trauma Paradigm Pre-Flight Disruption, secrecy, fear, traumatic events Flight Food insecurity, separation, lack of trust Resettlement Cultural isolation, loss of status, limited social support

  36. Pre-flight Kidnappings Rapes Threats of harm Family members tortured and killed Tortured by militia or government officials Witnessing and experiencing shootings and bombings Long term discrimination and oppression

  37. Flight Limited resources Lack of status Discrimination Family still in home country or no knowledge of their whereabouts

  38. Post-flight • New town • Foreign Country • New language • New Culture • Unemployed • New Apartment • New neighbors • New school • Crowded locations • Heavy traffic • Financial difficulties • No friends • No extended family • Unable to communicate • Role reversal • Changing Gender Roles • Impact of Torture

  39. Services at Center for Well-Being Clinical Services: Individual, Family and groups counseling for depression, anxiety, and severe trauma

  40. Refugee Well-Being Project: In-home wellness promotion and informational sharing

  41. Survivors of Torture Program: Intensive case management services for those who fit the definition of a survivor of torture

  42. Language and Communication • Tucson Refugees Speak: Acholi, Amharic, Anywak, Arabic (several dialects), Bosnian (Serbian/Croatian), Dari, Dinka, English, Farsi, French, Karen, Kinyarwanda, Kirundi, Krahn, Kurdish, Lingala, Mandingo, Maay-Maay, Nepali, Mende, Ndogo, Oromo, Pushtu, Russian, Turkish, Somali, Spanish, Swahili, Tigrinya, Uzbek, Vietnamese…

  43. Telephone Interpretation Cyracom Language Line

  44. Telephone Interpretation Services: Typical Process • Call the specific health plan’s Member Services number • Request interpretation services and specify language • Be prepared to provide the patient’s: • Name • AHCCCS ID# • DOB • Address • Also be prepared to provide the doctor’s: • Name • Location • NPI #

  45. Telephone Interpretation Tips • Specific process and required information for each health plan varies • See handouts • Contact the applicable health plan’s Customer Service for any questions or problems

  46. What To Expect When Working With Refugees: Refugees who speak limited English Refugees who speak excellent English A family that is less educated A family that is highly skilled and educated People that seem very conservative or foreign People that seem very liberal or westernized Slides from The IRC

  47. A Few Tips: Release your expectations Develop Self-Awareness Be aware of your worldview, values, and behaviors Be aware of your prejudices Develop Awareness of Different Cultures Listen & Learn & Appreciate Address Misconceptions Keep trying and don’t be afraid of mistakes Slides from The IRC

  48. Contact Information • International Rescue Committee (IRC): 319-2128 • Lutheran Social Services: 721-4444 • Catholic Social Services: 623-0344 • See handout form for referrals to IRC’s Wellbeing and Survivors of Torture Programs • See handout on community resources

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