From Beyond Our Borders: Providing Health Information to Foreign-Born Populations

Refugees and Immigrants arrive in the United States from all over the world …

Definitions Refugee: “a person who is unable or unwilling to return to his or her country of nationality 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.” ~Immigration and Nationality Act

Distinctions Immigrant: chooses “to move in order to improve the future prospects of themselves and their families,” usually for employment or education opportunities. ~United Nations High Commissioner for Refugees (UNHCR) website

How do refugees get to the U.S.? START: The Refugee flees from his/her country of origin. The refugee registers with the UNHCR. This agency ensures that the individual qualifies as a refugee under international law. The UNHCR refers the individual to a U.S. Embassy with a Refugee Processing Post. END: The refugee is met at the airport and resettlement agencies provide services such as case management, assistance learning English, and housing support.

U.S. Refugee Statistics 73,293 refugees in ,384 refugees in ,236 refugees in 2012 Top countries: Burma (Myanmar), Bhutan, Iraq Refugee “cap” each year 22,113 persons granted asylum in ,988 persons in 2011 Top countries: China, Venezuela, Haiti

Map of Emerging Populations

Refugee Statistics – Top States Texas received the second most number of refugees in 2010 (after California) In 2011 and 2012 Texas received more refugees than California Nearly one-half of all refugees settled in one of six states

Unique Health Issues

Importance of Cultural Competency What is culture? One definition: Characteristic features, beliefs, social norms, and way of life shared by a racial, religious, or social group, or by people in a specific place or time It’s not just about the words! Differences between Western Caucasian and East Asian facial expressions /  - Western emoticons primarily use the mouth ^.^/;_; - Eastern emoticons primarily use the eyes

Culture and Patient Health Beliefs about objects, symbols, food, the body, blood, non-traditional medicine, etc. Communication styles and norms Role of relationships Ways of learning new information Role of translators and interpreters

Culture and Clinical Practice Integrating cultural information into clinical practice Things to watch: styles of speech, eye contact, body language Industry Collaboration Effort Better Communication, Better Care: Provider Tools to Care for Diverse Populations URL for Industry collaboration Effort New Joint Commission recommendations for hospitals, policy makers, and researchers The 4 C’s of Culture: A Mnemonic for Health Care Professionals

Organizations which Work with Refugees UNHCR: Office of the United Nations High Commissioner for Refugees Established December 14, 1950 by the United Nations General Assembly Coordinates international action to protect refugees and resolve problems worldwide

Organizations which Work with Refugees U.S. Committee for Refugees and Immigrants (USCRI) Mission: “To address the needs and rights of persons in forced or voluntary migration worldwide by advancing fair and humane public policy, facilitating and providing direct professional services, and promoting the full participation of migrants in community life.”

Organizations which Work with Refugees Bridging Refugee Youth & Children’s Services (BRYCS) National level technical assistance to organizations which serve refugees and immigrants Particular focus on issues relevant to youth and children Toll-free and expert consultation

Health Information Resources Databases Websites Journals Other

Scholarly Resources/Databases PubMed MeSH Terms Google Scholar CINAHL PsycINFO

Website Evaluation Guidelines Accuracy Authority Bias Currency Coverage Culturally appropriate

More Thoughts on Culture Tailor messages to intended audience Avoid stereotypes Relevant photos/artwork Appropriate symbols Realistic recommended behaviors Back-translate and field test translated material “…more than a patients’ rights issue…critical to safety and quality of care”*

Resources – Websites Refugee Health Information Network (RHIN) Multilingual health information (more than 80 languages) for health providers, refugees and asylees Large section on cultural guidance Country Conditions Reports Multiple formats (print, audio, video)

RHIN Example A community health worker works extensively with refugees from Somalia. Where could she find information about flu shots?

Resources – Websites 2 MedlinePlus – Health Information in Multiple Languages Selected topics now in 49 languages other than English Accessible directly from the homepage Search by language or health topic Strict criteria for translations

MedlinePlus Example A family physician has been seeing some new patients from Burma who appear to be suffering from PTSD. Is there anywhere he could go to locate some patient handouts or other materials in Burmese?

Resources – Websites 3 EthnoMed Merged material from former 24 Languages Project Background information on cultures and cultural competency Patient education materials

EthnoMed Example A physician has been seeing a diabetic patient and believes that he may be non-compliant with his medication regiment. The physician just realized that Ramadan has just begun, and wonders if the patient may be Muslim.

Resources – Websites 4 Healthy Roads Media Multiple languages; multiple formats Includes iPod video and multimedia New Multiple Use videos (for purchase) for EHRs

Resources – Websites 5 DiversityRx: Improving Health Care for a Diverse World Webinars Cultural Competence Conference!

Resources – Websites 6 Health Information Translations Health topics include Diagnostic Tests and Disaster Preparedness Linked to from MedlinePlus! (see Marshallese)

Resources - Journals BMC Public Health Bulletin of the World Health Organization CDC Morbidity Mortality Weekly Report Journal of Immigrant and Minority Health Journal of Refugee Studies Journal of Transcultural Nursing

Resources – Listservs Diversity and Literacy Discussion List Office of the Civilian Volunteer Medical Reserve Corps

Emergency Preparedness for Culturally Diverse Communities Perspective of a “disaster” culture “Disaster culture” in many countries “Everything is from Allah” Spiritual leaders are preferred source of information Limited economic resources are barrier

Resources for Emergency Preparedness Cultural Competency Curriculum for Disaster Preparedness and Crisis Response NN/LM SCR Emergency Preparedness and Disaster Recovery Disaster Information Outreach by Librarians National Resource Center on Advancing Emergency Preparedness for Culturally Diverse Communities

Thank you! Cheryl Rowan Consumer Health Coordinator National Network of Libraries of Medicine, South Central Region Developed by NN/LM SCR Staff. This project funded by the National Library of Medicine, National Institutes of Health, Department of Health and Human Services under contract HHSN C with the Houston Academy of Medicine-Texas Medical Center Library.