Introduction
Improving refugees’ access to health care services is critical to managing diseases, promoting wellbeing, and increasing the quality of life in the country. Therefore, it is essential to conduct key informant interviews to collect relevant data and address ongoing challenges. This essay aims to identify the barriers to accessing health care in refugee communities in the United States based on the perspectives of Congolese and Afghan refugees and resettlement agencies, including case managers, ESL teachers, and job developers, in order to determine ways to address the problem.
Refugee Perspective: Congolese Refugees
Findings from the interviews with Congolese and Afghan refugees are presented in this section. It is worth noting that the marital status, household size, general background, religion, education level, and job industry of the interviewees differ, which allows for a more comprehensive perspective on the problem. In this regard, a male Congolese refugee described the health services in his home country as poorer than those in the United States, where doctors’ expertise, quality of treatment, and access to medication are significantly better. The availability of a primary care provider (PCP) in Nevada was listed as an advantage. Nevertheless, the interviewee noted that seeing a specialist was more complicated in the US as they are unavailable in the refugee camp.
Overall, the Congolese refugee felt more “hopeful about getting better medical care” in Nevada. However, his experience accessing health services did not meet his expectations due to the long wait time and a complicated referral process. Furthermore, it can be concluded that Congolese refugees’ experiences with primary care providers are affected by insensitive and arrogant front desk receptionists, as well as a lack of professional interpreters. Inaccurately interpreted concerns and needs affect understanding between the client and doctor. These factors make refugees feel “very uncomfortable and frustrated,” discouraging them from further appointments. Language barrier and discrimination were identified as the main challenges for the Congolese refugee community when accessing healthcare. Therefore, one way to improve their experience is to ensure fair and considerate treatment from medical personnel and front desk representatives. Moreover, easier transportation and quality interpreting services must be available at all stages of healthcare provision.
Generally, the Congolese interviewees’ education level did not exceed 8th grade, while one of the respondents did not obtain any school education. As a result, their lack of English language knowledge contributed to communication difficulties since no adequate interpreting services were provided in refugee camps. Based on the data collected through the interviews, Congolese refugees tend to have a significantly more negative experience while accessing medical care services, compared to Afghan refugees. Different factors, including racial bias, language barriers, and education levels, are likely to cause this difference.
The experiences of Congolese women should be discussed for a comprehensive perspective on refugees’ barriers to accessing health care in the United States. Three female respondents were interviewed regarding their ideas of medical care in refugee camps compared to the United States. When describing health services where they lived before coming to the United States, they emphasized that seeing doctors and receiving treatment was often difficult. All interviewees mentioned the first-come, first-served basis adopted in refugee camps to see a clinician. This approach often resulted in long queues and transportation issues. Other than that, the experiences of the three Congolese women differed based on their camp’s location. The interviewee who had stayed in Uganda noted that “there were four clinicians at the clinic,” while a person staying in Burundi mentioned that “doctors rarely came to the camp.” Therefore, her only experience getting medical services was when she gave birth.
For refugees in Uganda, checkups for communicable diseases and lab tests were provided at the same clinic, and medication, particularly for Malaria, was available “most of the time” at the camp’s pharmacy. In contrast, refugees in Burundi faced a lack of access to many essential medicines. For Congolese refugees staying in Rwanda, “getting medication was really hard because there were too many people that needed it.”
Congolese refugees’ experiences accessing health services in Nevada differed based on their literacy level, knowledge of English, present conditions, and services available at their clinic. For instance, for the woman with “multiple serious health conditions,” the treatment process in the US was too long. She had to wait “2 months to be seen” by a specialist and receive medicine recommendations, which aggravated her health and was “heartbreaking.” Another problem when accessing health services in Nevada was the language barrier and insensitive behavior of the staff. A Congolese refugee noted that she would “not be able to be treated because of the lack of interpretation” unless her children accompanied her during the visit and explained her needs to the staff. Furthermore, the referral process was described as “an endless cycle.”
Another Congolese woman noted that her experience accessing health services in Nevada exceeded her expectations compared to the refugee camp since she “was able to see the doctor within a few days of arriving.” Another refugee explained that she was satisfied with various options to see doctors in the US, including urgent and emergency care, as well as access to a PCP and specialist doctors. Overall, the language barrier and lack of interpretation services can be identified as the main factors that affect Congolese refugees’ experiences accessing health care in the US.
A tendency was identified that refugees who only required a primary care provider’s services felt more comfortable than refugees with complex health conditions who also had to see multiple specialists. Navigating the health care system is challenging, especially without proper “communication between PCP and the different specialists,” interpreting services, and the staff’s compassion. One of the interviewees mentioned feeling “unwelcome” due to the PCP’s attitude and lack of concern for her health and conditions. At the same time, another Congolese refugee who had a basic knowledge of English reported feeling comfortable with the staff and primary care provider. Furthermore, accessing quick care appears less problematic for Congolese women compared to seeing specialists.
Language barrier and transportation were listed as the core challenges that the Congolese community faces when accessing healthcare. The need to use Uber services to attend appointments contributes to the overall treatment cost, while going by bus is often complicated and confusing. Furthermore, one of the interviewees emphasized a lack of time to see the PCP and specialists due to a complicated referral process and long wait time. Other problems identified were “lack of access to prescribed medications when going to the pharmacy” and doctors’ indifference towards the patient. One of the interviewees noted that challenges vary for different people in the community based on their needs and knowledge of English and basic healthcare processes, such as making an appointment.
Only one of the Congolese refugees reported no community needs or issues with the US healthcare system. Others noted that ensuring that PCPs are “welcoming, understanding and sympathetic to refugees” would improve their healthcare outcomes, reduce emergency room (ER) visits, and eliminate “uncomfortable and harmful experiences.” The Congolese community requires more patient advocates when coming to the US to provide information, assist with check-in, and call the doctor’s office. Moreover, reading a map and taking multiple buses to visit a health care facility is problematic, particularly for individuals with low English and literacy levels. Interpretation and transportation services are needed to help refugees navigate in the US.
Afghan Refugees
The Afghan refugees describe doctors in their homeland as “very fast and helpful,” while medical knowledge, equipment, and resources are regarded as more advanced in the US. Interviewees emphasize the need to make appointments, get referrals, and wait longer as the main disadvantages of American medical care. Furthermore, health care services in Afghanistan are more flexible and accessible due to longer work hours. The US insurance system is another aspect that is new and unfamiliar to Afghan refugees.
Overall, Afghan interviewees described their experience accessing health services in Nevada as rather positive due to “very supportive” patient staff and having “realistic expectations about the healthcare system.” One example where it did not meet the refugee’s needs includes difficulties scheduling appointments due to limited working hours that prevent clients from accessing medical care conveniently. Furthermore, Afghan refugees generally feel comfortable with their primary care providers, who are professional and show concern. Adaptability and knowledge of English can be identified as factors facilitating understanding and cooperation. At the same time, difficulty rescheduling an appointment and the need for continuous procedures were named as inconvenient aspects of American health care.
Challenges for Afghan interviewees regarding healthcare include the referral process, scheduling appointments, wait time and delays in access to medical care, filling out forms, understanding health insurance, and knowing one’s detailed health history. Faster medical care, easier referral process, reduced wait time, extended work hours, access to interpretation, and doctors’ availability on weekends would improve Afghan refugees’ experience in the US. Furthermore, the community’s needs include such health services as medical consultations at home, free over-the-counter medications, and education for refugees regarding medical insurance and making appointments.
Resettlement Agency Perspective: Case Managers
In this section, findings from the interviews with resettlement workers are presented. Case managers named different durations of working with refugees, ranging from several months to 22 years. Their main motivational factors to work in this position include supporting people in need and promoting cultural awareness by assisting refugees’ needs. In particular, many case managers report having no previous experience in refugee programs before getting employed by the Catholic Charities of Southern Nevada (CCSN), a resettlement agency. However, “working with people from other countries” and “seeing the happiness on the faces of the children” encouraged many individuals to continue their work with the organization.
The most common health and medical issues in case managers’ clients are “period pain” in women, “dental problems, high blood pressure,” as well as “vision issues.” In particular, dental care costs present a major challenge since “the Medicaid dental insurance coverage is very limited.” One of the interviewees listed diabetes and high cholesterol as common health problems among refugees. Many individuals with concerns about their health need checkups, particularly older refugees who require more medical assistance. The needs of vulnerable populations must be considered by resettlement agencies to address patients’ issues effectively and increase the quality of their services. At the same time, literacy and English language problems are widespread, which aggravates communication and the quality of health care.
Refugees’ health impacts their overall progress toward self-sufficiency goals, particularly for students and workers. As can be seen from the refuges’ responses, arrogant and unapproachable staff, along with interpretation services, discourage many individuals from seeking medical care. In the long-term perspective, such a tendency aggravates the community’s health and quality of life. In this regard, ensuring the staff’s competency and professional behavior can address the problems of poor understanding and communication between the doctor and the patient. In addition, improving access to OBGYN services and birth control are vital to address women’s health issues and prevent unwanted pregnancies.
From case managers’ perspective, “providers should treat their refugee patients with respect” and have “cultural sensitivity” to make services more accessible. For instance, it was established that Congolese refugees are more affected by the language barrier than Afghans. Therefore, “knowing policy and guidelines, being culturally sensitive to patients, and being kind” are the main factors that health service providers must consider to provide better care. It is crucial to know that health needs vary in different refugee populations based on cultural and personal factors. Moreover, “delay of services, delay to schedule medical appointments,” and the need to visit the ER for some patients to receive treatment can be identified as further issues in the US health care sector. Since Covid-19, online learning and social distancing have presented additional challenges for refugees. Their responsibilities included various aspects apart from teaching English, such as mentoring students or educating them on personal hygiene. One of the respondents reported providing “newcomer support and integration services.”
ESL Teachers
ESL teachers that participated in interviews had years-long experience with refugees. One of the school workers mentioned her experience providing English Language Learning (ELL) services and organizing events that support students. She emphasized her love for “advocating for ELL families” as the main motivational factor in working with refugees. ESL teachers are mostly motivated by their love for other people and the need to support vulnerable populations. Some school workers have “a personal connection, passion to support these families” due to their own experience as refugees.
ESL teachers describe the most common health and medical in clients as vision problems and a lack of knowledge of hygiene rules. Moreover, “vaccines need to be up to date for students when they have to go back to school” to prevent the spread of infectious diseases. It is essential to educate parents on the importance of overall health assessments and provide social and emotional help to address mental health problems, and the impact of the hardships refugees experienced before coming to the US.
Overall, the interviewees noted that health issues aggravated their students’ academic progress. For instance, a hearing loss that one of the students experienced complicated his overall development and navigation through the learning process. In addition, social and emotional issues can contribute to other challenges that refugees face in a new country. In this regard, health service providers could ensure educational services for refugees, teaching them about health, wellbeing, hygiene, and safety to improve health outcomes in this social group and make medical care more accessible for them. According to some ESL teachers, it is crucial to have “resources in different languages” and access to a language line and interpretation services. The analysis of the interviews established that many refugees delay their appointments “due to lack of access to interpreters” who could help them communicate with administrative and medical staff. Another aspect that requires improvement to make services more accessible is transportation.
It is essential for health care providers to know about cultural differences and show empathy and patience towards refugees. For instance, school workers noted that “being aware of dietary restrictions, being sensitive to the religion they practice” are essential to provide better care. Social distancing rules and guidelines due to Covid-19 presented additional challenges for asylum seekers in the US. The associated social and emotional issues were “very present,” including lack of communication and friends, as well as navigation in the virtual world.
Job Developers
The job developer interviewed had a 5-year of experience in the field. They reported developing motivation for this job in the process of working. The most common health and medical issues in their clients are “feeling depressed, having a difficult time adjusting to the US, feeling culture shock.” Refugees’ health impacts their overall progress towards self-sufficiency goals by affecting mental health and interfering with their work and studies. From job developers’ perspectives, the language barrier problem must be addressed to make services more accessible. Furthermore, it is essential to know that “doctors need to be more on hand with refugees” to provide quality care. The consequences of Covid-19 include “feelings of frustration, and difficulty with hospitals and ER’s being full.”
Conclusion
Overall, the problem of refugees’ access to health care services is complex since various factors affect individuals’ health outcomes in a new country. In particular, cultural differences, language barriers, availability and cost of services, as well as the financial status of refugees can prevent them from seeking medical help. It is essential to conduct key informant interviews to collect relevant data and address ongoing challenges, such as language barriers, culturally incompetent staff, and complicated procedures while making an appointment.