The term culture shock was first introduced in the mid-1950s to describe the anxiety produced when a person moves to a completely new environment and experiences discomforting levels of disorientation. When normal guidelines for appropriate social interaction disappear and self-sufficiency is severely challenged, it is natural for human beings to become very stressed. The process of overcoming culture shock is called acculturation, and, depending on an individual’s specific circumstances, it can be a long and arduous process indeed. The level of stress endured throughout the acculturation process by an individual may vary from a small amount to the point where it “virtually destroys one’s ability to carry on.” (Berry, 1990).
With the changing demographics in Colorado, healthcare providers across the state will continue to see significant numbers of individuals and families who have immigrated to the U.S. or applied for refugee/asylee status here. Many of these newcomers are from countries where the national culture is dramatically different from that of the United States. It is important for healthcare providers to understand the special challenges some of these patients present due to the stresses they may have endured before coming to the US and the extreme hardships many face in trying to establish themselves in this country. Awareness of common immigrant/refugee health considerations, including acculturation stress, can help eliminate health disparities among certain immigrant and refugee populations.
Immigration Status Basics
Immigrant: A person who comes to a country to take up permanent residence who does not fit the definition of a refugee or asylee. (http://en.wikipedia.org/wiki/Immigration)
Refugee: Any person who is outside his/her country of nationality or, in the case of a person having no nationality, is outside any country in which he/she last habitually resided, who is unable or unwilling to return to such country because of persecution or a well-founded fear of persecution on account of race, religion, nationality, membership in a particular social group, or political opinion. Refugees are a category of immigrants who arrive with legal resident status in the United States and as such are entitled to all of the rights and responsibilities of legal residents. Refugee status is determined by the Department of Homeland Security before a person is eligible for resettlement in the United States. Refugees are eligible for refugee health services for a period of eight months from the date they entered the United States.
Asylee: An individual who has received permission to remain in the United States, under Section 208 of the Immigration and Nationality Act (INA), based on a “well founded fear of persecution” should the alien return to their native land. A prospective asylee applies for this permission from within the United States, unlike a refugee who applies from abroad. Asylees of all nationalities are eligible for Refugee Health Assessment Program services within 90 days of US entry.
Immigrant and Refugee Acculturation Stress
Acculturation refers to the changes that groups and individuals undergo when they come into contact with another culture (Williams & Berry, 1991). Acculturative stress is a more specific term that refers to the stress that directly results from and has its source in the acculturation process (Berry, 1990). Immigrants and refugees who experience intense feelings of loss after leaving their native country may go through a period of cultural bereavement which can compromise their ability to make necessary adaptations. Multiple stressors that are often part of their new environment include discrimination, language barriers, unemployment and/or low income, feelings of not belonging in the host society, and a sense of anxious disorientation in response to the unfamiliar environment. Acculturating individuals may also feel pulled between traditional values, norms, and customs and those in the new society (e.g., parent–child conflict related to the child’s encountering the new culture through school; role conflict related to a mother’s having to work).
The degree of acculturative stress an individual experiences is greatly reduced when certain favorable conditions exist. The presence of immediate and extended family networks is crucial, as is social support from outside the family in the new community. Favorable socioeconomic status, education and income also ease the acculturation process. Studies also suggest that individuals adapt differently to acculturation stress based on variables such as self-esteem, resilience, knowledge of the new language and culture, realistic/positive expectations for the future, and a high degree of tolerance for and acceptance of cultural diversity in their newly adopted society.
Due to their experiences throughout the resettlement process, some immigrants and many of the refugees arriving in the United States require comprehensive medical services. Refugees have to have overseas pre-departure screenings as well as health screenings within 30 days of arrival in the U.S., but neither replaces reliable health data and complete medical histories which are scarce among many of the incoming populations. Common health considerations include immunizations,treatment for infectious and parasitic diseases, HIV/AIDS care, oral health care, lead screening, nutrition/diet, and mental health services. Additionally, health considerations specific to children include diarrheal diseases, acute respiratory infections (ARI), and malnutrition.
Preparing for Medical Consultation with Refugees
It is most common for people from refugee backgrounds to have gone without access to comprehensive health care for years. Their initial contact with US health care providers may be the first opportunity in their lives to receive client-focused, high quality health care. At the same time, building a relationship and providing optimal care to refugees can be a challenge for health professionals. Refugees often lack knowledge of English, leading to feelings of isolation and mistrust. The health system will often seem very complicated to refugees and they may need assistance with acquiring prescriptions and other tasks. Many may be suffering from serious mental illnesses due to trauma and grief and may be stigmatized by their society. There may be shame associated with certain contracted diseases such as HIV. Additionally, women may often prefer a female practitioner and may experience strong emotional and psychological responses during gynecological exams due to past sexual abuse.1
Health-Related Cultural Practices
Body Modification
Virtually all cultures engage in some sort of body modification, such as tattooing or piercing. The reasons for this are complex and may relate to personal enhancement, hygiene, rites of passage, traditional healing and other sociological reasons. Some of these practices are temporary, such as henna paintings on the extremities, which are considered by some Middle Eastern groups to have healing properties. Other procedures such as scarification are permanent and may involve procedures such as cutting, burning or piercing.
Body modification procedures may include:
- “Coin Rubbing” and “Fire Cupping” are common among Southeast Asian cultures. Both are traditional healing methods. In coining, the edge of a coin is rubbed over the skin which creates a red stripe. In fire cupping, heated suction cups are used on the skin which leaves red marks.
- Artificial penile nodules in Southeast Asian men – foreign bodies are implanted under the skin of the penis to enhance sexual performance.
- Scars or lesions, especially in African cultures – found on the trunk of face, and other parts of the body; the cutting or burning procedures producing the scars or lesions may be done for ritual reasons, body enhancement, or for traditional healing.
- Male circumcision, particularly among Muslim males.
- Amputation of the uvula in some African groups is a traditional healing practice. Female genital cutting (FGC), also called female circumcision or female genital mutilation (FGM). Common in parts of Africa, the Middle East, and Asia, FGC/FGM is illegal in the United States.
Delays In Seeking Treatment
Some groups of refugees may delay medical treatment because they will first resort to traditional diagnosis (either herbal or spiritual). This may cause a serious delay resulting in disease or death. Thus, they may seek medical care late in an illness. It has been observed by refugee camp aid workers that mothers do not seek medical care in good time, bringing their children in when they are already at a critical stage. There may also be problems of adherence to treatment regimes that require long-term sustained used of medicine. Doctors should stress the importance of regular check-ups for pregnant mothers and children (especially well-baby check-ups). Providers as well as nurses will be required to explain the significance of “prevention” since refugees may not be familiar with this concept.
Trauma among Refugees
Most refugees arriving in this country will have been exposed to traumatic events. These may include:
- The experience of being transplanted from their country of origin to a highly industrialized country where technology is unfamiliar
- Threats to their own lives or those of their family or friends
- Witnessing death squad killings, mass murder and other cruelties inflicted on family and friends
- Disappearances of and separation from family members or friends
- Perilous flight or escape with no personal protection
- Forced marches
- Extreme deprivation – poverty, unsanitary conditions, hunger, lack of health care
- Persistent and long-term political repression, deprivation of human rights and harassment
- Removal of shelter or forced displacement from homes
- Refugee camp experiences involving prolonged squalor, malnutrition, physical, psychological and sexual abuse, absence of personal space, and lack of safety.
Major Psychosocial Issues in Resettlement
Housing: In countries of second asylum housing is usually very different from the refugee’s place of origin. They may not be used to having hot and cold water, and flush toilets, hence they may need instructions on related safety issues.
Transportation: A major reason for noncompliance with health care for refugees is lack of transportation to the clinics.
Difficulty learning a new language: Language creates a great deal of the stress associated with relocation. Most communities offer ESL (English as a Second Language) classes. However learning a new culture, means of livelihood, and all the other new experiences make learning the language very difficult for many. Older people, in particular, have great difficulty surpassing language barriers.
Customs and protocols: Everything in the host country is new, from obtaining food and registering for school, to childbirth and money matters. The issue of medical insurance or benefits is foreign to refugees in the U.S.
Technology: Items we take for granted, such as washing machines, televisions, VCR’s, telephones, microwaves, and computers are rare in the refugees’ countries of origin.
Conclusion
This newsletter is only intended as an overview of health considerations related to immigrant and refugee populations in the United States. Suggested links for further reading are provided below. There are a number of organizations in the Denver area working closely with immigrants and refugees. They can be excellent resources and links to their websites are also provided here.
Intercambrio de Comunidades
With locations in Denver and Boulder, this organization serves immigrants of all backgrounds. Their mission is to help immigrants achieve greater self-sufficiency and confidence.
References:
1. Refugee Health Care: A Handbook for Health Professionals, The Consultation– Communicating Effectively with Refugee Clients, Minister of Health, New Zealand, November 2001
We gratefully borrowed information for the following portions of this article from the excellent resource The Refugee Health Providers Manual, Refugee Health Program, Office of Minority Health Rhode Island Department of Health, May 2007: Preparing for Consultation with Refugees, Health-Related Cultural Practices, Trauma Among Refugees, and Major Psychosocial Issues in Resettlement.
