(lizardpoint)

Health Concerns of Refugees

By: Kristin Cabatingan, Holly Arana, Madelynn Buckman, Sanisa Mendoza & Shelby Welsh
 Introduction
● Refugee: “Someone who has been forced to
flee his or her country because of persecution,
war, or violence” (Edwards, 2018).
● 68.5 million refugees have been exiled from
their homes (Edwards, 2018).

67% of refugees from these

countries seek asylum in
the United States (Edwards,
2018).
1 person every 2 seconds

(Young, 2018) (Asrar, 2017)

 Stages of Migration Post migration
Pre-migration
● Refugees have
● Refugee still resides in
arrived in host
country of origin countries and
must adapt
In transit
● The physical movement of
refugees from country of
origin

(Wessels, 2014)
 Pre-migration
● Various health issues (Pavli & Maltezou, 2017).
○ country of origin varies greatly
○ insufficient health care
○ lack of clean water
○ minimal concern of healthy lifestyle
○ Anxiety & fear
● War-Torn countries= psychological and physical issues (Wessels, 2014).
○ PTSD
○ Depression
○ Physical deformities/ wounds
○ disease processes: HIV, STDs, etc..
Common Diseases:

Tuberculosis 35%

Hepatitis B 90% of new cases

(Mixon-Hayden et al., 2014) & (Vermont Department of Health, 2016)
(Refugee Health, 2013).
Knowledge Check
Refugees may have various health issues relating to?

A. Country of origin
B. Travel Related issues
C. Living conditions
D. All of the above
In Transit : Transition
Migration Experience and Risk Factors (OXFAM International, 2018)

○ Experience of cruelties and hardships during this journey

○ Many seek sanctuary in a new country, others are forced to leave (OXFAM International [OXFAM], 2018)
○ Studies show that many experience torture, brutal mental and physical abuse and serious traumatic events (Kim, E.,
Yun, M., Jun, J. Y., & Park, W. S., 2018)

Challenges and Uncertainty during Transition

○ Increasing risk of human trafficking and migrant smuggling (OXFAM, 2015)

○ Immigrants that lack knowledge and information of transition
○ Camps are often as dangerous as the country they fled (Wessels, 2014)
○ Fear of being sent back to their country
In Transit: Refugee Camps
● Exposure to traumatic events and images (Masri, 2018)
● Limited resources for shelter
● Overpopulation
● Unsafe living conditions (abcNews, 2018)

○ Physical violence (Wessles, 2014)

○ Interethnic strife
○ Sexual violence (OXFAM, 2018)
○ Disease epidemics (Unite For Site, 2015)
○ Pollution (Masri, 2018)
○ Separation and Death
● What do refugees have to say?
(abcNews, 2018)
In Transit: What Refugees Look
Forward To
● A new life, new experiences
● Building families
● More opportunities
● Safety

(Masri, 2018)
(Immigration Reform.com, 2018)
Knowledge Check:
What diseases are more prominent in refugee camps? (Select all that apply)

1. Diabetes
2. HIV
3. Acute Respiratory Infections
4. Diarrheal Disease
5. Ebola
6. Malaria
(Refugee Health,
2013).
What is the post migration phase?
❏ Settlement stage
❏ Refugees have made it to their new home and are no longer in refugee camps
❏ It is the time that they are now adapting to their new environment
❏ The first stage where healthcare providers can actually do something
❏ Healthcare providers can build a profile on the patient
❏ At this point refugees have access to healthcare (Wessels, 2014)

Cori, 2001
 Physiological Factors
❏ Risk of chronic disease
❏ These risks may have been developed from diseases acquired during
migration

❏ Stress
❏ Related to multiple factors such as money, health, jobs, family

❏ Poverty
❏ Geographical factors
❏ Adapting to new geographical environment

❏ High level of exposure to pre-migration trauma

(Wessels, 2014)
❏ Migration experience has a huge effect on the physiological state of
refugees

McLeod, S., 2018

Psychological Factors
❏ Mental health concerns
❏ Anxiety
❏ Depression
❏ Post traumatic stress
❏ Factors that affect the mental health
❏ Family separation
❏ Lack of social network
❏ Lack of security
❏ Employed/Unemployed
❏ Language barriers

Management Advisory Service, 2018

 Physio
-
logical

Every stressor has an underlying

effect on other factors. It is
important to analyze each factor
with its relation to others.

Psych Psych
o- o-
social logical

Psychological stressors such as feelings of worthlessness

or not fitting in can lead to psychosocial factor
Issues Health Care Providers May Face
(Refugee Health, 2013).
Obstacles to Overcome
➢ Language barriers
○ “58% of refugees who had been in the United States for 20 years or more were
Limited English Proficient (LEP)” (Capps et. al, 2015).
○ Ineffective communication
○ Informed consent
➢ Cultural barriers
○ Cultural competence (CAPT, 2016).
○ Unfamiliar, unavailable,
or inaccessible
○ Expectations and pre-experiences (WMCHealth, 2014)

Ahmad, F. (2018). Providing care for refugee patients: challenges and barriers. ARCADA: A Literature, 27-31.
Obstacles to Overcome
➢ Lack of training and guidance
○ Unclear regulations
○ Inadequate training procedures
➢ Limited resources (Heath, 2017)

○ Neglect mental and chronic diseases

○ Lack of appropriate health screening or preventive services (Griswold, Pottie, Kim, Lin,
2018).
➢ Poor quality care, dissatisfaction of care and negative health consequences

Ahmad, F. (2018). Providing care for refugee patients: challenges and barriers. ARCADA: A Literature, 27-31.
Overcoming these Obstacles
➢ Language Barriers Solutions
○ Medical interpreters
○ Materials that are translated into appropriate language and use of visuals (AHRQ, 2014).
➢ Cultural Barriers Solutions
○ Therapeutic Relationship
○ Madeleine Leininger’s theory of Culture Care Diversity and Universality
■ Cultural care preservation
■ Cultural care accommodations
■ Cultural care repatterning

Ahmad, F. (2018). Providing care for refugee patients: challenges and barriers. ARCADA: A Literature, 27-31.
Leininger’s Sunrise Model

(Wayne, 2014)
Overcoming these Obstacles

➢ Lack of training and guidance solutions

○ Evidence-based guidelines (Griswold, Pottie, Kim, Lin, 2018).

➢ Limited resources solutions

○ Hiring/training appropriate staff

○ Engagement and collaborations

(Mieres & Scanlon, 2018)

Ahmad, F. (2018). Providing care for refugee patients: challenges and barriers. ARCADA: A Literature, 27-31.
Knowledge Check
What are the major obstacles health care providers may face?

a. Language barriers
b. Limited resources
c. Lack of training/guidance
d. Cultural barriers
e. All of the above
Health Promotion
➢ Health Belief Model

➢ Therapeutic communication & Nurse

Patient Relationship

■ Patients may have a difficult time

trusting healthcare providers

(Pavli & Maltezou, 2017).

➢ Psychosocial factors

■ Importance of community and

family

➢ Promoting self-care/health practices at

Potter & Perry, 2018, p.66
home
Mental Health Education
❖ Mental health issues are common in refugees and asylum seekers
❖ It was found that depression, anxiety, and PTSD are the most prevalent (Ballette, Barbui, Nose, Ostuzzi,
Purgato & Turrini, 2017).
➢ Found in 40% of refugees
❖ Nurses can be helpful tools for those struggling with these disorders
❖ What we can teach:
➢ Signs and symptoms of anxiety, depression & PTSD
➢ References to counselors
➢ Introduce options for therapy

UK Gov, 2018
International Medical Corps, 2016
 Disease/Illness Education
❖ Refugees often have illnesses pre-migration or develop them in-transit
❖ Healthcare is different in every country
➢ May not know how to access healthcare
❖ Refugees may not know how to deal with their illnesses/take medications
❖ What we can teach as nurses:
➢ Give patients information about healthcare (Affordable Care Act, Medicaid)
➢ Review medications
➢ Teach how to take antibiotics properly

McNeely & Morland, 2016 Wall Street Journal, 2017

 Mental Health Treatment Options
❖ PTSD:
➢ PTSD is a severe disorder and is seen frequently with refugees

➢ Trauma-focused psychotherapy: Most highly recommended treatment for PTSD

■ Prolonged Exposure (PE)

■ Cognitive Processing Therapy (CPT)

■ Eye-Movement Desensitization and Reprocessing (EMDR)

➢ Medication options

■ SSRI’s & SNRI’s such as Zoloft, Paxil, Prozac & Effexor

National Center for PTSD, 2018

 Mental Health Treatment Options
❖ Anxiety & Depression
➢ Anxiety and depression are both seen in refugees
➢ Treatment for anxiety and depression often go hand in hand
➢ Medications:
Everyday Health, 2017
■ SSRIs: Prozac, Zoloft, Lexapro, Celexa
■ SNRIs: Effexor, Cimbalta, Fetzima
■ Tricyclic Antidepressants: Tofranil, Pamelor
■ MAOIs: Nardil, Marplan, Parnate
■ More options than these
➢ Counseling
➢ Psychotherapy

Anxiety and Depression Association of America, 2018

 Mental Health Treatment Options
❖ Complementary & Alternative Medicine (CAM) Therapies
➢ Proven to help symptoms of PTSD, anxiety & depression
➢ These are often used before medication therapy or in conjunction with medication

Medical News Today, 2017 Luke Glowacki, 2015).

ADAA, 2018
Knowledge Check
What options are available for treating common mental health disorders in
refugees? (Select all that apply)

1) CAM Therapies
2) Cognitive Processing Therapy
3) Antibiotics
4) SSRI Medications
5) Ignoring the problem
References
abcNews. (2018). Inside lesbos’ moria camp, home to thousands of trapped refugees and migrants. ACB News. [Online image]. Retrieved from

https://abcnews.go.com/International/inside-lesbos-moria-camp-home-thousands-trapped-refugees/story?id=53014062

Ahmad, F. (2018). Providing care for refugee patients: challenges and barriers. ARCADA: A Literature, 27-31. Retrieved from

https://www.theseus.fi/bitstream/handle/10024/151149/Challenges%20and%20Barriers%20.pdf?sequence=1&isAllowed=y

Agency for Healthcare Research and Quality. (2014). The SHARE Approach-Overcoming Communication Barriers With Your Patients: A

Reference Guide for Health Care Providers. Retrieved from https://www.ahrq.gov/professionals/education/curriculum-

tools/shareddecisionmaking/tools/tool-3/index.html

Asar, S. (2017). Rohingya crisis explained in maps [Online image]. Aljazeera. Retrived from

https://www.aljazeera.com/indepth/interactive/2017/09/rohingya-crisis-explained-maps-170910140906580.html

Capps et al. (2015). The Integration Outcomes of U.S. Refugees Successes and Challenges. Migration Policy Institute, 2-4.

Committee on Refugees and Immigrants. (2001). [Online image].Retrieved from http://mason.gmu.edu/~dhaines1/refugees_pubs.htm

Center of the Application of the Prevention Technologies. (2016). Cultural Competence. Retrieved from

https://www.samhsa.gov/capt/applying-strategic-prevention/cultural-competence
 References
Complementary & Alternative Treatments. (2018). Retrieved October 2, 2018, from

https://adaa.org/finding-help/treatment/complementary-alternative-treatment

Corps, & International Med. (2016). An invisible crisis: 5 facts you need to know about mental health [Online image]. Retrieved from

https://medium.com/international-medical-corps/an-invisible-crisis-5-facts-you-need-to-know-about-mental-health-beb0e5ad468

Edwards, A. (2018). Wars, violence, and persecution uprooted record numbers of men, women, and children worldwide last year,

making a new global deal on refugees more critical than ever. The UN Refugee Agency. Retrieved from

https://www.unhcr.org/en-us/news/stories/2018/6/5b222c494/forced-displacement-record-685-million.html

Global Giving. (2018). 13 Powerful refugee stories from around the world. Retrieved from

https://www.globalgiving.org/learn/listicle/13-powerful-refugee-stories/

Griswold, Pottie, Kim, & Lin. (2018). Strengthening effective preventive services for refugee populations: Toward communities of

solution. doi: 10.1186/s40985-018-0082-y

References
Heath, S. (2017). Using Patient-Reported Outcomes Measures to Improve Engagement [Online image]. Retrieved from

https://patientengagementhit.com/features/using-patient-reported-outcomes-measures-to-improve-engagement

Immigration Reform. com. (2018). Family separation? It’s no big deal now. Immigration Reform. com. [Online image]. Retrieved from

https://immigrationreform.com/2018/09/12/family-separation-its-no-big-deal-now/#prettyPhoto

Kim, E., Yun, M., Jun, J. Y., & Park, W. S. (2018). Pre-migration trauma, repatriation experiences, and ptsd among north Korean

refugees. U.S. National Library of Medicine National Institutes of Health. Retrieved from

https://www.ncbi.nlm.nih.gov/pubmed/29651589

Lizardpoint. The world: countries [Online image]. retrieved from https://lizardpoint.com/geography/world-countries-quiz.php

Masri, L. (2018). Inside lesbos’ moria camp, home to thousands of trapped refugees and migrants. ACB News. Retrieved from

https://abcnews.go.com/International/inside-lesbos-moria-camp-home-thousands-trapped-refugees/story?id=53014062

Management Advisory Service (2018). Psychological responsibility. [Online image]. Retrieved from http://www.mas.org.uk/wellbeing-

performance/psychological_responsibility.html
References

McLeod, S. (2018).[Online image]. Maslow’s hierarchy of needs. Retrieved from https://www.simplypsychology.org/maslow.html

McNeely, C. A., & Morland, L. (2016). The Health of the Newest Americans: How US Public Health Systems Can Support Syrian

Refugees. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4695930/

Mieres, J. H., & Scanlon, P. (2018). Overcoming Barriers to Good Health [Online image]. Retrieved from

https://thewell.northwell.edu/dear-doctor/overcoming-barriers-good-health

Mixon-Hayden, et al. (2015). Hepatitis B virus and hepatitis C virus infections in United States-bound refugees from Asia and Africa.

National Library of Medicine. doi:10.4269/ajtmh.14-0068]

OXFAM International. (2018). Refugee and immigrant crisis. OXFAM International: The Power of People Against Poverty. Retrieved

from https://www.oxfam.org/en/emergencies/refugee-and-migrant-crisis

OXFAM International. (2018). Refugee and immigrant crisis. OXFAM International: The Power of People Against Poverty. [Online
References

Pavli, A., & Maltezou, M. (2017). Health problems of newly arrived migrants and refugees in Europe. Journal of Travel Medicine,

24(4). Retrieved from https://academic.oup.com/jtm/article/24/4/tax016/3095987

Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2017). Fundamentals of nursing (9th ed.). St. Louis, MO: Elsevier

Luke Glowacki. (2017). The Power of Meditation: Sit Your Way to a Happier Life [Online image]. Retrieved from

https://tinybuddha.com/blog/the-power-of-meditation-sit-your-way-to-a-happier-life/

PTSD: National Center for PTSD. (2018). Retrieved from

https://www.ptsd.va.gov/professional/treatment/overview/complementary_alternative_for_ptsd.asp

Reddy, S. (2017). Patients Make More Medication Mistakes [Online image]. Retrieved from https://www.wsj.com/articles/patients-

make-more-medication-mistakes-1500913414

Refugee Health. (2013). Refugee access to care. Retrieved from https://refugeehealthta.org/access-to-care/

Rodriguez, D. (2015). How to Cope With Anxiety and Depression [Online image]. Retrieved from

https://www.everydayhealth.com/anxiety/anxiety-and-depression.aspx
References

Turrini, G., Purgato, M., Ballette, F., Nose, M., Ostuzzi, G., & Barbui, C. (2017). Common mental disorders in asylum seekers and

refugees: Umbrella review of prevalence and intervention studies. Retrieved from

https://ijmhs.biomedcentral.com/articles/10.1186/s13033-017-0156-0

UK Gov. (2018). Dstl supports Mental Health Awareness Week 14 to 20 May 2018 [Online image]. Retrieved from

https://www.gov.uk/government/case-studies/dstl-supports-mental-health-awareness-week-14-to-20-may-2018

Unite for Sight. (2015). Module 1: healthcare in refugee camps and settlements. Unite for Sight. Retrieved from

http://www.uniteforsight.org/refugee-health/module1

Vermont Department of Health. (2016) Tuberculosis & refugee health. Retrived from

http://www.healthvermont.gov/sites/default/files/documents/2016/11/ID_TB_Refugees_16.pdf

Wayne, G. (2014). Madeleine Leininger - Transcultural Nursing Theory [Online image].

Retrieved from https://nurseslabs.com/madeleine-leininger-transcultural-nursing-theory/

References

Wessels, W. K. (2014). The Refugee Experience: Involving Pre-migration, In Transit, and Post Migration Issues in Social Services. St.

Catherine University (pp. 10-14). Retrieved from https://sophia.stkate.edu/msw_papers/

Westchester Medical Center Health Network. (2014). Achieving Equitable Health Care Outcomes: Building a Health Literate and

Culturally Competent Organization [Online image]. Retrieved from http://www.crhi-ny.org/center-for-regional-healthcare-

innovation/cultural-competence

Whiteman, H. (2017). Yoga can help to treat depression, studies show [Online image]. Retrieved from

https://www.medicalnewstoday.com/articles/318774.php

Young, E. (2018). Forced displacement above 68m in 2017, new global deal on refugees critical [Online image]. The UN Refugee

Agency. Retrieved from http://www.unhcr.org/news/press/2018/6/5b27c2434/forced-displacement-above-68m-2017-new-global-

deal-refugees-critic