Primary Care of Refugee Women
Primary Care of Refugee Women
- Mary Tornabene, APN, CNP
Many factors influence refugees' health status and ability to access and engage in U.S. medical systems.
- Mary Tornabene, APN, CNP
Refugees flee their country because of persecution, war, and violence; thus, all have well-founded fears for their safety should they return. To become a legal refugee, an individual must first apply to the United Nations High Commissioner for Refugees. Those who are referred to the U.S. begin the screening and vetting process, which takes 18 to 24 months.
The health of refugee women is largely framed by their culture and the nature of their trauma. The shock of deprivation, persecution, and forced migration occurs throughout the path to resettlement: It begins before women are forced to leave their homes and continues during migration, at refugee camps, and after resettlement. Factors such as language barriers, health literacy, and beliefs about women's roles all influence refugees' health status and ability to access and engage in U.S. medical systems (see EthnoMed).1,2,3
Language differences and lack of health literacy can impair a refugee's capacity for self-care. Routines such as filling a prescription can be confusing if one does not understand the language and has never received a prescribed medication. What to do with the piece of paper, where to go to the pharmacy, and how to manage prescription refills are common issues. Moreover, not understanding the U.S. healthcare system makes use of services less likely.2 Communication barriers can negatively affect care, so bilingual health educators, case managers, and patient navigators are all beneficial. Vetted female interpreters can increase refugees' comfort, knowledge, and participation.3
Refugee women have unique competing concerns. The process of resettlement itself is stressful and time consuming as women and their families prioritize housing, transportation, and finances. Thus, undergoing screening evaluations such as mammograms or Pap smears in the absence of symptoms is often difficult for refugee women to comprehend, especially in the context of their culture.1,4 While some providers may feel uncomfortable downwardly adjusting their goals to promote screening, putting the patient's cultural background as well as her psychological and physical suffering first can actually lead to more-frequent screening and better outcomes.
Nature of Trauma
Premigration trauma can take many forms. Healthcare resources might have been inadequate in the country of origin — and war, deprivation, and persecution leave lasting physical and psychological marks. Furthermore, the impact and sequelae of torture predict multiple physical and psychological problems.5,6 A 2015 meta-analysis suggests that up to 44% of all refugees and asylees have been tortured (see CVT). Rape was reported in almost one third of female torture survivors, 80% of whom experienced at least two forms of torture.7 Refugees may have also experienced other abuses including concussive trauma, witnessing torture and executions, cutting, asphyxiation, forced postures, and electric shock.7,8 Documenting a woman's torture history can prevent the triggering of re-traumatization while helping her provider understand many of her complex physical and mental health issues, ultimately augmenting her adherence to healthcare.9
The sequelae of torture are severe both physically and mentally. Physical condition often varies based on the severity of the trauma and the methods used. Even in the absence of any visible deformities, there may be complaints of unexplained complex pain. A comprehensive plan of care that includes physical and occupational therapies as well as psychological and psychiatric support can be beneficial.9
The process of migration itself is heterogeneous; while some refugee women locate resettlement camps easily, others may not. Because they may be forced to flee with only what they can carry, women might leave essential medications behind or be separated from their families (including small children). While they are displaced, they may experience limited nutrition, hygiene, sanitation, and safety. They are often exposed to extreme environmental conditions and their health is further threatened by infectious diseases. The healthcare available in refugee camps may be difficult to access, leading to — or worsening — anemia, dental issues, eosinophilia, vitamin deficiencies, parasites, abnormal cervical cytology, hepatitis, and HIV infection.10 Because chronic health issues also often go neglected, refugee women should be checked for associated complications and provided with culturally specific interventions to achieve and maintain health.
At the Intersection of Trauma and Culture
Female genital cutting (FGC; removing parts of the external female genitalia) is practiced in over 30 countries in Africa, the Middle East, and Asia. The procedures can cause severe bleeding, infection, and chronic problems with urination and childbirth. Clinicians should document all findings in detail and provide referrals to specialists in both the physical and psychological care of FGC survivors (see WHO guidelines).
Infectious disease screening by panel physicians occurs on arrival, but ongoing screening and management of disease happens in the community. In 2015, 66% of all active tuberculosis cases occurred among the foreign born, a rate 13 times higher than in domestically born persons (see CDC). The population of sub-Saharan Africa remains disproportionately infected with HIV, having almost 70% of the world's cases (see Avert). Among African immigrants living in the U.S., the estimated rate of HIV infection is six times higher than that among the U.S.-born general population. Also, African-born persons in the U.S. have more heterosexual transmission and relatively more HIV cases among women; hence, routine HIV testing and counseling is indicated.11 Given that not all regions of the world have access to HIV treatment and prevention, educating refugees about control of HIV infection and availability of effective treatment can reduce fear of diagnosis prior to testing. HIV-positive refugee women have had varying experiences with antiretroviral medications. The regimens available in their countries of birth differ from those in the U.S., with more side effects and adverse outcomes. Having intermittent access to less-effective medications can cause viral mutations — and even with the best medications, the virus can be difficult to control
Mental Health Disorders
Post-traumatic stress disorder (PTSD), depression, and anxiety are the most commonly reported mental health issues for refugee women.7 Such women experience depression at higher rates than refugee men.9 Their risk for mental health disorders continues for years and may not be related only to trauma, but also to post-resettlement factors including lower socioeconomic class.12
By creating safe, welcoming environments characterized by cultural and language competence and trauma-informed care, clinicians can establish enduring relationships to promote health and control disease among refugee women.
Ms. Tornabene is a Family Nurse Practitioner at Heartland Health Outreach, Heartland Alliance for Human Needs and Human Rights, Chicago.
Note to readers: NEJM Journal Watch Women's Health ordinarily accompanies each feature with a Patient Information handout. Because of the diversity of languages and cultures among refugees, we are instead providing a link to EthnoMed's patient education resource page (available online at https://ethnomed.org/patient-education), which lists sources of information about many topics in several languages, as well as links to other helpful organizations. To obtain written materials appropriate to their patient populations, clinicians may also seek assistance from refugee support groups in their communities or the nearest urban areas. Some offer print or video materials that do not rely on written language.