EXECUTIVE SUMMARY
When working with refugee populations, case managers should be aware of cultural differences that greatly affect how these patients view disease and the American healthcare system.
- Scheduled appointments can mean something entirely different to some refugees, so they might miss crucial doctor visits.
- The underlying cause of diseases also can vary based on a person’s cultural understanding and background.
- The American obsession with news overload can contribute to an atmosphere of fear and distrust of refugees.
Many support services are available to refugee populations. They receive more help than other immigrants, but they also usually need more help — particularly in the form of case management.
Refugees often have suffered through violence and atrocities, which affect their mental health. They also might lack housing that is both safe and affordable. They might be settled in neighborhoods with high crime rates and without grocery stores or playgrounds. They have seen American television and know enough to be scared of potential violence. They often cannot drive and have difficulty understanding public transportation.
All of these are issues for their mental and physical health, but the biggest challenge is cultural.
“There are organizations that can get refugees on track with where to go for healthcare, and some might take them to appointments,” says Marcia Carteret, MEd, director of intercultural communications for the Colorado Children’s Healthcare Access Program (CCHAP), and a senior instructor in the department of pediatrics at the University of Colorado School of Medicine in Denver.
Yet, there remain barriers outside of the logistics, access, and transportation, and the chief barrier among these is cultural. Refugees often do not have an experience framework that prepares them for America’s complex healthcare system.
“They do not understand how our healthcare system works,” Carteret says. “They have a lot of confusion around the different names and types of doctors and setting up appointments or even calling a doctor’s office.”
When a refugee who does not speak English or Spanish calls a doctor’s office and is routed to a phone tree that tells them to press one or two, they have no idea how to reach someone who can help them, she adds.
Another cultural conflict involves the concept of time. For refugees from low-income nations, their entire sense of time and scheduling is based on a premise that they’ll have to wait. If they make an appointment for 9 a.m. to see a doctor, that means — in their world view — that they’ll have to wait until 4 p.m. or later to actually see the doctor. So they will miss their U.S. doctors’ appointments because of this cultural confusion over what a clock time appointment really means, Carteret says.
“Basically, people’s sense of time is very much culturally based,” she says. “And our healthcare system is so time-focused with appointments that are 20 minutes apart, getting people in and out.”
What they most need is education about how the American healthcare system works, Carteret says.
“They need to know that it is very clock-time focused,” she says. “Case managers need to help them understand the idea of patient-centered care and patient engagement, a concept that is very foreign to people from other parts of the world.”
Refugees might expect doctors to be authorities who tell them what to do, and they do not grasp that they need to speak up for themselves and ask questions, Carteret says.
Another issue is health literacy, which is an enormous part of the challenge with immigrant and refugee populations, she says.
“People have very different expectations of physicians and very different concepts of illness causation,” she says. “In many parts of the world, there is no concept of chronic disease.”
Carteret has watched medical residents struggle to explain to parents and children about asthma and how the child has to take the medication even when the symptoms go away.
“Refugees think if the symptoms go away, the child is cured, so they quit the medication,” she explains. “Then when the child has an asthma attack and ends up in the emergency room, the parents think it’s an entirely new illness, and they don’t make any connection with the medication because they don’t understand chronic disease.”
People who come from some parts of the world, such as Latin America, might believe in susto — a disease believed to be caused by acute fright.
When someone becomes suddenly ill, they might believe the person’s disease is caused by a destabilizing event, such as witnessing a car accident, hearing a gun shot, or even seeing a barking dog.
“So they have a hard time communicating with a Western doctor, unless the doctor asks about susto,” Carteret says. “There is a whole litany of these culture-bound illnesses.”
There is another cultural issue that affects refugees, but also everyone else: media overload.
“We need to take a look at how people have an unprecedented access to media overload,” Carteret says. “Whether it’s Twitter or texting or whatever, it’s not helping us become more capable of critical thinking about these important issues like immigration.”
Refugees and immigrants suffer partly because of Americans’ misinformation and confusion about the issues. Constant online news feeds contribute to this confusion, she says.
“Refugees are trying to gain a sense of themselves, trying to become new Americans in these times,” Carteret adds. “I think there truly is a disconnect from the history of the founding of our country; we’re all from immigrant backgrounds unless we’re Native Americans.”
When working with refugee populations, case managers should be aware of cultural differences that greatly affect how these patients view disease and the American healthcare system.
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