Introduction
Adequate health and Well-being is a human right according to the universal declaration of human rights. Each individual is guaranteed proper health care without minding his social-cultural or economic status. Reports are showing that there has been unequal distribution of health services, especially to the immigrants. The aim of this paper is to address the barriers that immigrant communities face in their endeavor to access health care in the United States.
I am going to focus my research on the immigrants from Somalia who have settled in Ohio and in Minneapolis, Minnesota. The paper will touch on the background of Somali immigration into the US and their eventual settlement into these states, the barriers they face while accessing healthcare, and the proposed solutions to these challenges. It will also include fact-finding information from interviews.
Immigrant communities in the US
To address the health issues of the immigrants, one may need to understand the real meaning of the term immigrants. An immigrant is taken to mean anyone who came to a different country from another country and obtains permanent residency. An immigrant could be illegal when he/she lacks proper papers and legal when he/she has the proper documents like visa clearance. People who come to the US for purposes of study, work, or family visit are not immigrants. The number of legal and illegal immigrants in the US goes well beyond 30 million since 1960. Every year, an extra one million immigrants come to the US.
These statistics show that this has been a boost to population growth. A lot of controversies have arisen regarding economic benefits, jobs, and the provision of healthcare. Mexico, India, and the Philippines have the largest number of immigrants in the US. The pew Hispanic center survey has shown that more than 12.7 million Mexican lived in the US in the year 2008 (PHC, 2008). This figure accounts for a modest 32% of the immigrants in the US. The same report showed that Filipino alone comprises another five percent with their number expected to be much higher this year.
What leads to Immigration into the US?
A number of factors have been put forward as to motivating, immigration especially into the US. These factors have been categorized into ‘push’ and ‘pull’ factors. Push factors include aspects such as religious persecution, political and economic hardships. Pull factors are mainly religious, thought, and speech freedoms and the economic benefits. Recent migrations into the United States have been motivated by;
- Promise of humanitarian protection especially to people fleeing persecution and fear of persecution based on various reasons such as race or even political opinion. The refugee Act of 1980 has opened an avenue for people from Vietnam, Rwanda, DRC, Burundi, Kosovo, Somalia, Ethiopia, Sudan, and Sierra Leone to immigrate to America as refugees.
- Based on the reason of family reunification, many immigrants have found their way into the US soil as spouses and children of legal migrants in America.
- Promises for a job and a better standard of living cannot be ruled out of the top motivators to immigration. These promises include a higher salary and more buying power when compared to conditions in their homeland. Professional and semi-skilled workers flock into the US for a chance to earn higher wages and live more comfortably. Mass media and other forms of communication have been attributed to making aware to people in the developing world the lavish life in the US. The Congressional Budget Office (CBO) shows that up to 15% of all those working in the US were born outside America. This move has also been inspired by the availability of work for immigrant workers because there is more work than the natives can handle. Typical worker application procedures by employers take long prompting them to seek alternative solutions to unauthorized immigrant workers in search of jobs in the US. It is indicated that immigration itself is not the problem, the problem has been said to be how it occurs. Generally, the laws have been blamed.
Network-driven immigration-In developing countries, going abroad has become a normative, the right thing to do (Hatch, n.d).
History of Somali Immigration
Somalia is a small country in the horn of Africa neighboring Kenya, Ethiopia, Djibouti and, the Indian Ocean. Somalia has had a long history with many periods of divisiveness starting with its colonization by Great Britain, France, Italy, and Ethiopia in Early 1800. Upon gaining her independence in the mid-twentieth century, Somalia was divided by her colonial masters leaving many ethnic groups outside her borders with some remaining in bordering Kenya and Ethiopia.
This division along ethnic lines has been a constant source of conflicts to date. Earlier in her self-rule, Somalia appeared to be headed for good but later in 1969, its founding father was assassinated by the army General Mohammed Siad Barre. With the ousting of the civilian government, the army led for the following 22 years under Siad Barre whose rule was popular but was sooner replaced with favoritism and corruption. The government of Siad Barre was overthrown by opposition clan-based militias that formed to rebel against his oppressive rule. In 1991, Siad Barre went into exile and the central government disintegrated as the militias failed to form a government (World Bank, 2005).
The ensuing anarchy, recurring clan warfare, and cleavages along ethnic lines have continued to fuel endemic clashes in search of resources and power. During the rule of dictator said Barre, Somalia experienced some major conflicts whose impacts resulted in internal displacements while many civilians crossed the border to Ethiopia. During the civil strife to remove said Barre from power, several liberation movements were formed based on clannish. These clan-based militias failed to form a new government but instead involved each other in the unending war in search of control of resources. Gunmen fought to share the loot while warlords emerged that have continued to support these wars economically.
The people of Somalia have continually been divided and the poor faced starvation as their belonging were looted. Though many attempts have been made to help salvage the situation in Somalia, no fruits have been bored and the recent rise of Islamic courts and the rule of Sharia laws have worsened the situation. Resulting from this state of lawlessness and anarchy in Somalia has been more than a million Somali refugees fleeing across the border to neighboring Kenya, Ethiopia, and Yemen while others have moved to other countries in the world notably; The US, Netherlands, Australia, and Canada.
The Somalis in the United States
Somali sailors arrived in the US as early as 1920 and settled in New The early Early 1960s saw the Somali students’ arrivals through government scholarship support. First Somali refugees arrived in the mid the ’80s but their number increased in the 90s following the civil war in Somalia. Up to 56000 Somali refugees were living in the US by 2004. The US office of refugee resettlement gives an estimation of up to 160,000 Somali-born persons. Minnesota, California, and Georgia are home to thousands of Somali immigrants. Minnesota alone harbors 25000 immigrants from Somalia (Carroll, Epstein, Fiscella, Volpe, Diaz and Omar, 2007).
The US government has instituted a resettlement program for the refugees. On arrival, Refugees undergo a TB screening. They also receive cash and medical assistance. Other social and health services are provided and this goes on for the first five years. Those immigrants with young children are given medical assistance for a limited time.
Health problems that immigrants encounter
Most Somali refugees in Minnesota live in refugee camps that have substandard conditions. The most prevalent disease in the camps is tuberculosis with as high as 80% of new cases being reported in these here. Minnesota has recorded a high increase in heart-related ailments and diabetes. Minnesota department of health report that there are cases of recurrence of these diseases when the immigrants are left on their own.
Other health problems facing the immigrants include malnutrition, viral infectious diseases like hepatitis B, HIV/AIDS, malaria, polio, STDs, and diarrhea. Many immigrants of Somali origin find menial jobs in ranches and in other hazardous areas where they have little or no access to medical care, they also lack compensation for work-related injuries, are not immunized against some diseases, and in most cases, there is a risk of imported diseases in camps.
Post-traumatic stress is yet another of the many health-related problems that the Somali immigrants encounter, most of the Somali immigrants have undergone severe traumatic exposure, torture, and sometimes rape in their war torn country(Robertson, Halcon, Salvik, Johnson, Spring, Butcher, Westermeyer and Jaranson 2006). Their arrival in the US is met withighHigh rate of crime in their neighborhood, a high rate of poverty, and other community violence exposure. This tends to complicate their already worsened mental health (Davis, Ressler, Schwartz, Stephens, and Bradley, 2008).
Barriers to obtaining health care
Due to their increasing numbers, immigrants and refugees continueseveralaler of challenges that relate to their health.
Immigrants and refugees encounter a number of barriers in their endeavor to access good healthcare. The most notorious among them are;
- Difficulty cross-cultural communication
- Differing health care beliefs
- Little or no cultural awareness on the provider’s part
- Transportation and insurance problems
- Lack of knowledge about the existence of the services
- Consequences of seeking health care service
Difficulty in cross-cultural communication
Linguistically-based difficulties hinder communication between the provider of the service and the immigrant. The Commissioner on community relations commission City of Columbus, Ohio in an interview had this to say on the language barrier, “Immigrants in Ohio including many African communities and especially the Somalis are facing many difficulties in accessing healthcare services, language barrier tops the list…..’’ Similar sentiments were shared by R. B, the case manager, US TOGETHER, Refugee and Resettlement Agency, “language barrier…”
I also interviewed Teri RN, who is a Director of Nursing of a healthcare agency in Columbus, she said, “I think the major problem for our local Somali geriatric clients is the language barrier. It’s frustrating not to understand the language; it’s hard to depend on another person’s interpretation for care…”
Language barrier leads to lack of trust from the immigrant, and lack of respect towards the physician and the medicine. When such important information as the patient’s medical history, the present needs, belief and even his/her personal health observances are not well communicated, the immigrants may be faced with medical errors. This may include misinformation by the patient leading to misdiagnosis, patient’s lack of compliance due to lack of understanding the instructions and inappropriate use of health services. Consequently, the patient may leave the healthcare facility discontented, untreated, with low confidence in the health system and with general mistrust that prevent him/her making future visits.
Roda H., MSW, LISW-S, Therapist Nexus Counseling Group was also on the view that lack of terms to express certain medical complications in the Somali language was also hindering them from seeking treatment. She said, “The Somali language lacks many advanced medical terminology. The translation for the word “mental health” in the Somali language can be challenging to choose an appropriate word that gives the equivalent meaning of the English language”. She continued “the community is isolated, there is a cultural disconnect from the larger community where the Somalis rarely seek professional mental health counseling and services.”
Proposed Solutions to the language barrier
The national standards of culturally and Linguistically Appropriate Services in heath care (CLAS) have been developed to help address the issue of a language barrier in healthcare for immigrants. This mandate provides guidelines to the interpretation of languages to help in the reduction of cultural and linguistic-based barrier in healthcare providence. CLAS mandates state that;
- Provision of free Language assistance to the patient during all her visits to the heath facility
- The immigrant patients should be made aware of their rights to receive assistance in language interpretation.
- CLAS mandates also state that the patient’s relatives should not be involved in interpretations unless on the patient’s request.
- It is important to consider providing signage and materials related to patients in patient language groups.
This paper is proposing in addition to CLAS mandates, education of immigrant patients about Western medical practices and cultural awareness workshops for service providers so as to deal with the mistrust and misconceptions arising as a result of language obstacles. More funding should be availed to the healthcare department in order to adequately provide immediate medical care to new arrivals before prior engagement. Most of those interviewed for solutions to this barrier felt that there was need to engage Somali professionals in the healthcare provision to Somali immigrants. Roda (Therapist Nexus Counseling Group)
“There is need for health care professionals who understand this community’s culture and language”. She continued “There are few Somali health care professionals such as doctors, nurses and social workers”. On a Similar note, the director of nursing, Enhanced Home Health, also offered his solution, he said, “The local health departments and Somali health care professionals can partner in health educational programs to promote wellness”.
Little or no cultural awareness on the provider’s part
Abdi, RN, Director of Nursing, Enhanced Home Health LLC, suggested cultural disparity as another barrier to healthcare, he said, “Culture plays a crucial role in how a community perceives health and wellness, the Somali culture and other African communities are so unique in this aspect”. Health service provider’s lack of cultural sensitivity could prove disastrous during the provision of healthcare to immigrants.
Solution
It is important that providers consider the immigrants’ culture when taking the patients medical history and the medical exam. This is important in knowing the patient’s health meaning, the way he/she consider body and its work and also the patient’s understanding of where the problem is and what caused the disease. The health provider should also strive to get an understanding of the patient’s native treatment practices to such minor ailments as fever, cleanliness and what rituals take place when a child is born or when one dies. The care giver is supposed to broaden his/her social view towards the problem beyond the individual’s perspective. The provider should strive to lay clear what differences there are between the presumed care and the meaning of treatment. The family should be involved in the immigrant patient’s treatment.
Lack of knowledge about the existence of the services
It has been shown that most Somali immigrants lack adequate knowledge about where to find specialized medical care unless someone who has received the same directs them.
Solution
This barrier could be tackled by increasing the accessibility of the health service to immigrants by taking it to their door steps (Vega, Kolody, Gaxiola & Catalano, 2008). The services could be made more accessible to by taking it to schools and in their mosques to raise awareness about their existence.
Transportation and insurance hindrances
R. B, the case manager, US TOGETHER, Refugee and Resettlement Agency, also included lack of transportation among the barriers hindering access to health care by the Somali immigrants, “…and lack of transportation are the main issues that the community struggles daily, for example, a local hospital system has a policy of: After missing three appointments the client is discharged from the whole system permanently.
Some of the new immigrants may not understand such policies.” Similar views were aired by L. P. CNP Nationwide Children’s Hospital, Columbus, “The most important barrier of access to care for immigrants here is mainly language and transportation issues”. “Due to limited transportation services, we have decided to accommodate for our local Hispanic and Somali populations by extending our TB-clinic services to the Westside and the Northeast side of the city”.
This problem affect refugees and other Somali immigrants settled in areas with little or no public transport. Those without cars cannot keep up tight appointments and due to regulations, they may be dropped. Lack of insurance and transportation arise due to low or no salary. Most Somali immigrants do menial jobs to earn a living and can therefore not afford an insurance policy (Fennelly, 2006). The managing director of the ‘United Urgent Care, Columbus’, also observed the high number of uninsured Somali immigrants, “Follow up to specialists… high uninsured numbers are the main concern”
Solution
Since these are economic barriers, Healthcare providers should seek to address these issues by arranging for free transportation to and from the healthcare facility. The government should also plan to provide universal health insurance for all poor immigrants and in addition assist them in subsequent paperwork. The managing director of the ‘United Urgent Care’ pointed out that immigrants be educated on the need to use the primary physicians rather than depending on emergency departments, he said, “Patient can be educated to use primary physicians as the first line in practice instead of using emergency department for preventive services”.
Consequences of seeking health care service
Immigrants of Somali origin tend to fear the consequences of seeking healthcare to some types of diseases like STDs and Mental ailments fearing that doing so will impact negatively on the family’s welfare. Some immigrants also fear being deported by law enforcing officers incase they are discovered to be illegal immigrants.
Solution
The government should strive to raise community education regarding common STDs and mental illnesses and advocate for their acceptance. Public health fairs, campaigns, workshops and seminars should be conducted to raise awareness of these health problems and how treatment work. Proper immigrant registration should be put in place to help reduce cases of illegal immigrants (Vega, Kolody, Gaxiola & Catalano, 2008).
Acculturation and family roles
Certain issues in Somali immigrants such as the size of the family, family planning, sexual education and ways to prevent spread of AIDS may be met with resistance as they are largely seen as family matters and not to be known outside.
Solution
This can best be solved by making sure that health practitioners develop a close relationship with the immigrant patients to help develop trust which may increase the chances of the patient opening up (Samuel, Pringle, James, Fielding and Fairfield, 2009).
Summary
The US government receives millions of refugees each year and this is added to an ever increasing US population. It becomes very difficult for the health care providers to cater for all the immigrants health needs. The US government has put in some measures to address barriers to health care accessibility among the immigrants. The unending civil strife in Somalia must be addressed if the problem of Somali immigrants is to be solved. Tough measures must however be put in place to minimize considerably the number of illegal migrants in the country.
References
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Davis, G.R; Ressler, J.K; Schwartz, C.A; Stephens, J.K; and Bradley, G.R. (2008). Treatment barriers for low-income, urban African Americans with undiagnosed posttraumatic stress disorder. Journal of traumatic stress, Volume 21, Issue 2. Web.
Fennelly, K. (2006). Listening to the experts: provider recommendations on the health needs of the immigrants and refugees, Journal of Cultural Diversity. Vol. 13, No.4.
Hatch, P. (n.d.). what motivates immigration to America?. Web.
P HC, (2008). Mexican Immigrants in the United States. Web.
Robertson C. L., Halcon L. Salvik K. Johnson, D. Spring M. Butcher J. Westermeyer, J. Jaranson, J. (2006). Somali and Oromo refugee women: trauma and associated factors, issues and innovations in nursing practice. Blackwell publishing limited.
Samuel, P.S; Pringle, J.P; James, N.W; Fielding, S.J. and Fairfield, M.K. (2009). Breast, cervical, and colorectal cancer screening rates amongst female Cambodian, Somali and Vietnamese immigrants in the US. International Journal for Equity in Health online journal.
Vega, W. Kolody, B. Gaxiola, S. & Catalano, R. (2008). Gaps in service utilization by Mexican Americans with mental. Web.
World Bank (2005). Conflict in Somalia: Drivers and Dynamics. Web.