Introduction
The increasing frequency of global crises has led to the displacement of people from their homes. It is estimated that approximately 70.8 million people have been forcibly displaced around the world for a variety of reasons including war and persecution (Patel et al., 2021). The exiled individuals often seek refuge in Western nations with complex healthcare systems that fail to address vital health concerns due to cultural and language barriers.
Epidemiological Review
The Afghan population in California faces a variety of health access challenges. The Center for Immigrant Studies estimates that 133,000 foreign-born Afghans lived in the United States in 2019, which was three times the number recorded in 2000 (Camarota & Zeigler, 2021). The States with the highest number of Afghan nationals include California at 54,000, Texas at 10,000, and Virginia at 24,000 (Camarota & Zeigler, 2021). The Center for Immigrant Studies further notes that since 1980, 79% of Afghan immigrants have been admitted to the U.S. due to humanitarian reasons, with 81% of them gaining citizenship through naturalization (Camarota & Zeigler, 2021). In 2019, only 64% of the Afghan population was employed, 25% of the population lives in poverty and 65% of households face challenges accessing services such as Medicaid (Camarota & Zeigler, 2021). The challenges that refugees face increase the prevalence of poor health outcomes among Afghan communities.
Public Health Impact
Exiled individuals are often received in nations such as the United States where they face difficulties accessing healthcare services due to cultural and language barriers, high costs, and unfamiliarity with complex systems. According to Kavukcu and Altlntaş (2019), communication challenges are among the most common issues encountered in the delivery of services to immigrant families. The Afghan population in California faces many of the aforementioned hurdles. Khatri and Assefa (2022) note that providing healthcare services to refugees is critical because they face acculturation, which results in unhealthy lifestyle choices, and most demonstrate multi-morbidity. As a result, affected communities have a high incidence of disease which negatively impacts their quality of life.
Sociological Determinants
The covariates that are directly associated with the Afghan community’s access to healthcare services are the level of education, English proficiency during medical appointments, health insurance status, financial stability, gender, and age. In a study conducted by Alemi and Stempel (2018) on Northern California’s Afghan population, specific findings regarding the immigrants’ level of education were noted. The study found that 32% of the surveyed residents had less than a high school education, 29% had achieved less than a diploma, 13% had attended a technical college and 25% had a bachelor’s degree or higher (Alemi & Stempel, 2018). The researchers also noted that most of the surveyed individuals had moderate English ability. According to Alemi and Stempel (2018), Afghan males with a high level of education, decent employment, and high English proficiency experienced lower levels of mental distress. The findings are linked to the fact that the aforementioned individuals are able to access healthcare services and communicate their problems efficiently, even in the absence of a translator.
Access to insurance is a significant determinant of a community’s health status. The Center for Immigrant Studies notes that the number of Afghan households with at least one individual on Medicaid is 62% (Camarota & Zeigler, 2021). It is estimated that 25.4% of Afghan households live in poverty, while 50.8% live in or near poverty (Camarota & Zeigler, 2021). Children are adversely affected in view of the fact that 35% of all children in Afghan households live in poverty, perhaps because the per capita income of the aforementioned households averages 11,000 dollars annually, compared to 27,000 dollars among native residents (Camarota & Zeigler, 2021). The highlighted differences in income, education, English proficiency, and access to health insurance significantly impact access to healthcare services.
Instrumentation Review
There are various instruments that can be applied in the assessment of the health of Afghan refugees in California and the impact of language interpretation services during medical appointments. In their evaluation of factors that influence healthcare utilization, Alwan et al. (2020) interviewed a sample of refugee caregivers. The researchers noted that the refugees were dissatisfied with the video and in-person translator services (Alwan et al., 2020). The key areas affected were missed appointments, where language challenges led to the misinterpretation of clinical instructions, and long emergency department wait times, as a result of limited access to interpreters (Alwan et al., 2020). The findings are supported by Brandenberger et al. (2019), who note that translators who are well-versed in interpreting medical information are critical in healthcare contexts. The study participants also reported experiencing challenges coordinating care because of difficulties sharing information with providers and keeping appointments. The researchers conducted semi-structured interviews that lasted between 45 and 90 minutes using bilingual investigators (Alwan et al., 2020). The open-ended interview questions were recorded in Arabic and later transcribed into English.
Language accessibility and interpretation during medical appointments are key determinants of access to services among Afghan communities. In a study to assess the barriers that newly arrived refugees face when accessing care, Zeidan et al. (2019) cited inefficiencies in interpreter services as one of the key factors. The researchers measured the impact of translator services by evaluating the efficiency of automated clinic phone services that were equipped with interpretation services when refugees sought help from resettlement organizations. They also evaluated the time it took and the efficiency with which resettlement employees attempted to schedule clinic visits. It was noted that ineffective interpretation caused delays and limited access to specialty care (Zeidan et al., 2019). The researchers also evaluated the time it took a resettlement employee to refer a refugee to the emergency department. Limitations in cultural competence negatively impacted interpretation services which caused delays in access to care (Zeidan et al., 2019). The availability of interpretation services in healthcare contexts is directly tied to outcomes.
The participants in the study by Zeidan et al. (2019) were subjected to an interview, where they reported their degree of satisfaction with the interpreter services. The in-depth interviews were structured to identify the range of experiences instead of the frequency with which the events were encountered. It was evident that the lack of interpreter services increased the incidence of bad health outcomes and significantly decreased the level of satisfaction among refugees in need of healthcare services.
The comprehensive assessment of the impact of translator services in healthcare contexts in California is possible through the implementation of specific instruments. For instance, semi-structured interviews and questionnaires facilitate the collection of vital data such as the level of education, English proficiency during medical appointments, health insurance status, financial stability, gender, and age. They also allow for the explication of the exact ways in which translator services impact the efficiency of automated clinic phone services, the time it takes and the efficiency with which hospital employees schedule clinic visits, and the time it takes to refer Afghan refugees to the emergency department or specialty care services. Other areas that can be evaluated include missed appointments, care coordination, and emergency room wait times. The aforementioned instruments are essential for the evaluation of the impact translator services have on the health and well-being of Afghan refugees in California.
Interventions
Numerous interventions have been applied in the past to enhance interpretation services for Afghan communities in the United States. The first intervention is in-person interpretation where patients interact directly with interpreters. According to the Centers for Medicare and Medicaid Services (2022), in-person services are beneficial because they guarantee full-time access to interpreter services, facilitate the development of meaningful relationships and encourage the use of fully certified professionals. Reihani et al. (2021) highlight the fact that skilled in-person translators reduce the occurrence of miscommunication, thus reducing frustration among refugees. However, there are challenges associated with the feasibility of providing interpreters for a wide variety of languages.
The employment of qualified bilingual staff is another intervention that is applied in health facilities across the United States, including California. The advantages include the availability of services when needed, and the enhancement of cultural competency at the facility (Centers for Medicare & Medicaid Services, 2022). The employment of dual-role interpreters, who are bilingual healthcare employees who work as certified part-time interpreters has facilitated the improvement of healthcare delivery among Afghan communities. The aforementioned approach offers a cost-effective way of ensuring that administrative and clinical staff work as interpreters when needed, thus reducing operational costs.
Remote interpretation services have also been employed in healthcare facilities across the United States. Telephonic interpretation involves a remote translator’s use of speakers to decipher communication between a patient and a healthcare provider (Centers for Medicare & Medicaid Services, 2022). These services allow for the availability of a translator when needed and help facilitate access to services for uncommon languages. The final approach is the use of translated written material to disseminate medical information. The last modality is the least effective of all those applied in various contexts across the United States.
Summary
A majority of Afghan immigrants have been admitted to the U.S. due to humanitarian reasons. Most of these individuals are unemployed resulting in high levels of poverty. The provision of healthcare services to Afghan communities is critical because they face acculturation and most demonstrate multi-morbidity. The level of education, English proficiency during medical appointments, health insurance status, financial stability, gender, and age determine access to healthcare. The impact of the aforementioned factors can be established using semi-structured interviews and questionnaires. These instruments also aid in the explication of translator effects on phone services, clinic visit scheduling, and referrals to the emergency department or specialty care. Interventions such as in-person interpretation and remote interpretation have shown significant promise, while written translations have had the least positive effect on healthcare access.
Conclusion
The importance of translator services in California’s healthcare context is evident. Afghan communities face a variety of challenges, key among which is low English proficiency. As demonstrated in the studies evaluated in the literature review, limited access to translator services is linked to poor health outcomes. There is a need to examine the extent to which the lack of translator services impacts the delivery and access to healthcare among Afghan refugees in the California context. The objective is to enhance access to services and promote the well-being of individuals and households in a bid to enhance their ability to provide for their families.
References
Alemi, Q., & Stempel, C. (2018). Discrimination and distress among Afghan refugees in northern California: The moderating role of pre- and post-migration factors. PLoS ONE, 13(5), 1–19.
Alwan, R. M., Schumacher, D. J., Cicek-Okay, S., Jernigan, S., Beydoun, A., Salem, T., & Vaughn, L. M. (2020). Beliefs, perceptions, and behaviors impacting healthcare utilization of Syrian refugee children. PLOS ONE, 15(8), 1–16.
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Camarota, S. A., & Zeigler, K. (2021). Immigrants from Afghanistan: A profile of foreign-born Afghans. In Center for Immigration Studies (Issue September).
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Zeidan, A. J., Khatri, U. G., Munyikwa, M., Barden, A., & Samuels-Kalow, M. (2019). Barriers to accessing acute care for newly arrived refugees. Western Journal of Emergency Medicine, 20(6), 850.