supporting immigrants and refugees to start a new life in host countries

SUPPORTING IMMIGRANTS AND REFUGEES TO START A NEW LIFE IN HOST COUNTRIES: A CHALLENGE FOR HEALTH PROFESSIONALS Sakellari E1., Sapountzi-Krepia D2 1. BSc, MSc, RHV, PhD Student University of Turku, Finland “Klimaka”- Non governmental organisation, Greece and Department of Nursing Science, University of Turku, Finland 2. BSc, MSc, PhD, RN, RHV Associate Professor, Department of Nursing Technological Educational Institute of Thessaloniki

Abstract: Many people are forced to leave their homes as a result of widespread violation of human rights, political intolerance, repression, civil war and famine. Being in good health and having access to health care in host countries play an essential role in the process of the integration of immigrants and their families in a new environment. Immigrants are highly vulnerable populations in disease and disability because of their living conditions and the problems that are facing due to inadequate immigration policies. Health care policies and services in most ...host countries have to be more flexible and focused on the special needs of this group of population.

Nurses and other health care professionals should be prepared to provide care for immigrants and sometimes it is necessary for them to attend special courses for enhancing their skills to provide culturally congruent care. These qualities are essential for nurses and interested health care professionals, as they will enable them to be on the verge of the provision of health care, which is suitable to the client’s meanings of care. Key words: immigrant, refugee, migrants’ health needs, immigrants’ policy

INTRODUCTION

H

umankind history in every era has to tell to the next generations about people who were forced to abandon their country of origin due to persecution, war and political violence (UNHCR, 2000). Worldwide, about 85 million people are currently residing outside their country of origin (Bollini and Siem, 1995). In most European countries, immigration has been a post-World War II phenomenon, linked in some cases with decolonisation processes (Bollini, 1993) and since the end of the World War II, it is estimated that over 15 million people have become refugees (ClintonDavis and Fassil, 1992). The countries of origin of most of the “uprooted” people are coming from the poor Third World countries. At the end of the 20th Century, there were an estimated 175 million international migrants and nearly 16 million of them were refugees (about 9%) (Commission on Human Security, 2003). Definitions of terms Although the terms immigrant, migrant and refugee represent different concepts, people sometimes use them without distinction in order to declare almost identical in meaning concepts. Therefore it is

essential at this point to be cited the meaning of the main terms included in this paper, in order to help the readers’ comprehension of the whole text. The term ''migrant'' is stated in the Oxford advanced learner’s dictionary of current English (Cowie, 1989) as ‘’…. the person who moves from one place (region or country) to go to live or work to another’’. The term '' immigrant '' is a synthetic term produced by the term migrant and is stated as’’…. the person who has come to live permanently in a foreign country’’ (Cowie, 1989). The term '' refugee'' derives from the word ‘’refuge’’ that means ‘’a shelter from pursuit or danger or trouble’’, and as people who face political or religious oppression in their country, ask for asylum in another country. The Oxford advanced learner’s dictionary of current English (Cowie, 1989) states the term refugee as the person who has been forced to leave his country, home, etc. and seek refuge, especially from political or religious persecution’’. According to the Convention relating to the Status of Refugees and the pre-ambular of the Protocol of 1967:"The term refugee shall apply to one person

ICUS NURS WEB J │ ISSUE 21│JANUARY – MARCH 2005 (NURSING.GR)

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who: owing to well-founded fears of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his nationality and is unable, or owing to such fear, is unwilling to avail himself of the protection of that country of his former habitual residence as a result of such events, is unable or, owing to such fear, is unwilling to return to it." For

between the young and older members of the family and this occurs when the young learn the language and interpret the new culture faster and move away from the traditions of birth. All these stresses may reflect in refugees’ physical and mental well-being (Clinton-Davis and Fassil, 1992).

example war, natural catastrophe or poverty, are not according to this definition, good enough reasons for becoming a refugee (Rinne, 2000).

In the United States, the immigration experiences described by Iranians are the following:

Immigrants-refugees and adaptation to a new environment Immigrants and refugees need to adapt to a new environment, to get familiar with a new culture, to learn a new language and to find a settlement and work. Adaptation is a difficult issue for every person and accommodation is the first need that should be met. Most immigrants in first asylum countries live in camps and settlements run by the United Nations High Commission for Refugees, the host governments and other non-governmental organisations (Clinton-Davis and Fassil, 1992). However, social and psychological problems frequently appear during this process, which may lead to poor health and to problems in the family, at work and at school (Bollini and Siem, 1995). Zotti (1999), describes refugees as people highly vulnerable to disease and disability, because of their living conditions and problems of malnutrition, while Clinton-Davis and Fassil (1992), stress that infectious diseases, epidemics and mental health problems are quite frequent among refugees. Lipson in 1992 warned that international migration even under ideal circumstances is a stressful experience and the amount of stress associated with adjustment that immigrants and refugees face, depends on a variety of factors: 1. Individual factors, including language and occupation skills, level of education, personality variables, social support and family resources. 2. Immigration factors, including reasons for and circumstances surrounding immigration and the magnitude of cultural differences between home and host countries. 3. Social factors, including the availability of an ethnic/community support system, the host country’s reception policies and social issues related to each one immigration group in particular. In the U.K. refugees face social problems in the initial stage of settlement which are related to basic needs such as accommodation, education for their children, employment, etc. In addition, the reversal of the traditional family order can create tensions

a) culture shock, b) problems associated with a poor mastery of English, c) perceived loss of status and d) difficulty in finding work (in comparison to what they did in Iran) (Lipson, 1992). IMMIGRATION POLICIES In December 1948, the Universal Declaration of Human Rights was adopted and proclaimed by General Assembly, in which, among others, it is stated (in Article 3) that everyone has the right to life, liberty and security. Moreover, it has been stated (in Article 14) that everyone has the right to seek and to enjoy in other countries asylum from persecution. Finally, it is stated (in Article 25) that everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing, medical care and necessary social services and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control (Mylonas, 1998). Later, at the United Nations Millennium Declaration, it has been resolved that the participated nations will take measures in order to ensure respect and protection of the human rights of migrants, migrant workers and their families (United Nations, 2000). Specific patterns of migration, or migration streams, shape opportunities for communicable diseases transmission among recipient populations. The introduction of communicable diseases that are endemic in the developing world to industrialised nations has public health implications. Since the public health and policy implications of migrationrelated disease have been little assessed and the international migration has become a norm in modern societies, there should be implemented a multidisciplinary collaboration among health, behavioural and social scientists, drawing from epidemiology and public health, clinical medicine, demography and economics. Collaborative working relationships among scientists in partnership with


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government leadership can yield scientifically legitimate policies and equitable strategies to control communicable disease transmission associated with international migration (Gellert, 1993). Being in good health and having access to health care in host countries play an important role in the process of the integration of immigrants in the new environment and traditional immigration policies have privileged employment, education and housing (Bollini, 1993). Nevertheless, the specific needs of refugees require a comprehensive strategy for health and social services that assembles accurate statistics on refugees at the local level, ensures that refugees have equality of access to services and provides training for staff in refugees’ health. The participation of the refugees themselves in all of these activities is very essential and such a response by the health service will require intersectoral coordination, extra funding and above all, commitment (Karmi, 1992). Those countries that accept refugee populations have acknowledged the special health needs of immigrant communities and have taken steps to ensure that linguistic and cultural barriers are minimised (Bollini and Siem, 1995). Nowadays, the National Health System in the U.K. has a commitment that does not just treat people when they are ill, but works with others to improve health and reduce health inequalities (Salvage, 1998). In Canada, it has been developed since 1989 the “Immigrant/Refugee Health Programme” (IRHP). A main goal of the IRHP is to provide accessible, comprehensive primary health care while attending to the social, cultural and settlement issues that affect new immigrants and refugees. Health, language, settlement and immigration services are integrated on-site at the IRHP, which operates within the multidisciplinary setting of the community health centre. (Fowler, 1998). In New York, there was developed a programme called “New York Task Force on Immigrant Health” and its objectives were: • to improve access to and quality of care for New York City’s immigrants populations, • to facilitate the collection and dissemination of knowledge about the status and behaviours of New York City’s immigrants, • to provide technical assistance on immigrant researchers, clinical providers, policy makers, programme planners and the community, • to identify gaps in the literature that necessitate further research and to stimulate, facilitate and conduct research

•

to establish the atmosphere and structure to support those working in immigrant related fields so that experiences can be shared, efforts can be co-ordinated and care providers and policy makers can be sensitised about immigrant status as an important variable in programme and policy development (Michael et al., 1993).

In Finland, the government resolution on the health 2015 public health programme states that “all population groups must be given the chance to promote their health and contribute to the workings of society. Exclusion for reasons of age or cultural differences must be avoided, not least because it has obvious effects on health” (Ministry of Social Affairs and Health, 2001a). In addition, the strategies for social protection 2010, in Finland, claim that “justice and equality in working life are crucial for the well-being of the individual. Equality should prevail regardless of gender, age, disability or ethnic origin”. The measures that Finland takes for preventing and combating social exclusion include actions to ensure of a place to live for everybody and provide specific forms of support to help those in the most vulnerable position to attain reasonable housing conditions (Ministry of Social Affairs and Health, 2001b). A review by Bollini, (1993) on health policies for immigrants in seven receiving industrialised countries (France, U.K., Switzerland, Italy, Sweden, U.S.A., Canada), has shown that, in spite of the formal right to health care, access to services is still problematic and argues that the countries could be divided into two groups: a) Those which have a “passive” attitude, that means those which expect immigrants to adapt to the health system that is planned for the native population (France, Switzerland, Italy and U.S.A), and b) Those, which have acknowledged that health problems posed by immigrants and have actively tried to provide alternative solutions (U.K., Sweden and Canada). Sweden is the only country out of these seven, which provides by law routine interpreter services during medical encounters. The European Union wants to harmonise asylum policies across Europe and rewrite the 1951 Geneva Convention on the protection of refugees. On of its aims is also the restriction of immigration to Europe (Richards, 2001). In October 1999, at a special European summit in Tampere (Finland), European leaders committed themselves to working towards establishing a


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Common European Asylum System based on the full and inclusive application of the Geneva Convention, thus ensuring that nobody is sent back to persecution (European Parliament, 1999). European leaders adopted two pieces of legislation relating to asylum, these are: the decision to establish a European Refugee Fund (in September 2000) and a directive on temporary protection in the event of a mass influx (in July 2001) (European Council on Refugees and Exiles, 2001). In Europe, a non-governmental organisation has been developed called European Council on Refugees and Exiles (ECRE). ECRE is an umbrella organisation of 78 refugee-assisting agencies in 31 countries working towards fair and humane policies for the treatment of asylum seekers and refugees. ECRE aims to promote the protection and integration of refugees in Europe based on the values of human dignity, human rights, and an ethic of solidarity (ECRE, 2003). In 2000, the number of refugees living in Greece estimated to be 6.400 people (Boulgaraki, 2002). The procedure of a foreigner’s recognition as a refugee, in Greece, is done according to the Convention of Geneva in 1951 (Law: 2452/1996). Foreigners, who live permanently in Greece, obtain the social security services that natives obtain and they have the same social security rights as well (Law: 2910/2001). According to the Convention of Geneva in 1951, refugees who permanently live in Greece will be treated as Greek- citizens and they will receive the same providence by the public sector (Mpourlogianni-Braila and Petroula, 2002). HEALTH CARE NEEDS OF IMMIGRANTS AND REFUGEES Immigrants and refugees may face health problems, which should be addressed by the host countries. Ethnic background can be related to health problems in many complex ways and according to Uniken Venema, Garretsen and Van Der Maas (1995), these are three factors which may explain how ethnic background relates to health can be identified: a) biological-genetic factors, b) socio-economic factors, and c) socio-cultural factors . Immigrant and refugee health needs should be considered in the broader cultural and socioeconomic context, including access to and the availability of appropriate services (Fishman, 1998).

Assessing refugee requirements can provide important information to identify risk groups, common health and social needs of different groups of refugees and above all involve refugees in determining and expressing their own needs (Clinton-Davis and Fassil, 1992). Refugees face health problems similar to those from other deprived and ethnic minority communities, as well as specific health problems from physical and mental aspects. Additionally, after effects of displacement and social isolation, war, sometimes torture and communicable diseases (tuberculosis being the most important). The growing scale of the problem has prompted the European Commission to look at the refugees’ needs (Fassil, 2000). “Uprooting”, loss of family, tension of coping with the new life, uncertain future, homelessness, unemployment are the main risk factors that seriously affect the physical and mental health of refugees. The lack of proper assessment of refugee needs and background information, the absence of basic medical screening, cultural and language barriers to access health and social services all together add to the difficulties (Clinton-Davis and Fassil, 1992). Common health problems among refugees and immigrants include anxiety, depression, adjustment reactions, effects on the family, etc. The particular presentation depends on the trauma experienced, and the patient’s area of origin and ability to adapt to a strange environment (Gavagan, 1998). Additionally, they may suffer from physical and mental trauma of torture (George, 1998). Increasing social isolation and the loss of stable religious affiliations may result to health declines (Bower, 1998). Studies have shown that one in six refugees have severe physical health problem and two-thirds have experienced anxiety or depression (Botting, 2001). Moreover, immigrant and refugee children may face increased risk of negative health and mental health outcomes depending on factors such as migration experiences, family stability, social supports and personal competencies (Blake et al., 2001). Immigrant children may harbour infectious diseases that US paediatricians may be inexperienced in diagnosing and treating. These include conditions such as malaria, amebiasis, schistosomiasis and other helminthic infections, hepatitis A and B, and tuberculosis (Committee on Community Services, 1997).


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Children who are separated from their family in an early age (up to 16 years old) may face mental health problems. The mental health problems are difficult to be diagnosed or they are wrongly diagnosed due to cultural and linguistic barriers (Clinton-Davis and Fassil, 1992). Furthermore, as Krupinski, (1984) argues, in Australia immigrants’ health is related to the patterns of migration. Nevertheless, it has to be stressed that some of the disorders could be related to the immigrants’ country of origin as for example, the “imported diseases” that are either genetically determined or related to the higher prevalence in the immigrants’ own country. Other disorders could be attributed to socio-cultural factors such as eating and drinking habits, child-rearing practices and in the case of psychiatric disorders to family structure and interaction. Another contributory factor to their mental and physical state, is the situation in which immigrants found themselves in the host society, the cultural shock from moving to a new country and working conditions. Moreover, results from an Australian study conducted in a population of Iranian immigrants living in New South Wales, revealed that care has specific meanings, experiences and expressions, for immigrant Iranian informants, which are expressed in a variety of ways in their daily lives. Three themes concerning care identified: a) care means family and kinship ties as expressed in daily life ways and interactions with friends and community, b) care as expressed in carrying out traditional urban gender roles as well as fulfilling emerging new role responsibilities related to equality for female Iranian immigrants, and c) care as preservation of Iranian identity as expressed in traditional cultural events and health care practices (Omeri, 1997). Meadows, Thurston and Melton, (2001) in their study on mid-life immigrants women living in Canada found that women were aware of the synergy among the various aspects of health, due to their daily functioning is most important as it contributes to the well-being of their family. It is the health of the “unit”, rather than of their physical, emotional, spiritual, social and cultural selves. Personal health issues (physical or part of their emotional, spiritual, social or cultural well-being) are often seen as secondary or even tertiary to the survival needs of their families. According to another study concerning GreekCanadian widows, care was reflected in the expectation that grown children would give sick care

to ageing parents (Rosenbaum, 1991) while in another study on women immigrants it was found that women felt isolated in the meaning of being apart from people and resources. Women articulated the need for personal support, which was often not met and the conclusion from the study stressed that immigrant women would benefit if professionals helped them to develop contacts within the community or bring people together who have similar needs or who are undergoing similar experiences (Lynam, 1985). PROVIDED CARE AND ACCESS TO SERVICES The health care system is unique for each ethnic group as it shapes not only the thinking but also the preferences, ideals, attitudes and goals of individuals receiving health care. In order to be able to meet the particular needs of clients from different ethnic groups, health professionals should have knowledge and understanding of people’s culturally based health beliefs connected with care practices (Heikkilä and Ekman, 2000). Clients’ symptom expression, health beliefs and communication with health care professionals are related to their, as well as, to the health professionals’ ethnic/cultural background (Meleis, Lipson and Paul, 1992). Bollini, (1993) stressed that studies conducted in several countries, have shown that people of different ethnic origins usually have a lower health status than that of native residents due to: • barriers on access of health care services, • lack of attention to the needs of ethnic communities within the host health system, • racism and • lack or inadequate training of health professionals in caring people from different cultures. Because nurses are involved in caring for people from a variety of cultural backgrounds, it is vital that they possess an appreciation for and understanding of culturally relevant views of health, illness and the experiences of care for culturally diverse and similar individuals (Zoucha, 1998). Through knowledge, respect and sensitivity, nurses can be effective in meeting the goals of the culturally congruent (Luna, 1989), as one of the important goals of transcultural nursing is to provide culturally congruent care and it is essential to know the client’s meaning of care within their cultural context. Then, health care professionals will be able to provide health care that it is suitable to the client’s meanings of care rather than imposing their own values of acre upon the client (Luna, 1994). Many General Practitioners are unsure of entitlement claims, as it appears to be little


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information given to these individuals in the appropriate language, little understanding of their culture or beliefs and irregular health assessments (Botting, 2001). Regardless of one’s level of acculturation on psychological or social dimensions, variation in language preference seems to be critical determinant of utilization of health services (Solis et al., 1990).

The cultural and linguistic disparities between refugees and American health care providers have compromised the quality of nursing care that nurses want to give and have raised significant questions. Research with refugees has grown as an attempt to improve quality of health care for refugees (Muecke, 1992).

Refugees often face communication barriers, which are not always completely resolved by using family members as interpreters and additional concerns about confidentiality and the potential modification of content may arise (Gavagan, 1998).

Late–in-life Iranian immigrants in Sweden emphasized the importance of feeling safe as an element for experiencing continuity and health. The Swedish welfare system and available medical care for everybody, according to these immigrants, diminishes their insecurity and anxiety. They did not really trust health care providers and particularly physicians. Compared to Iranian physicians, Swedish physicians were less authoritative and less validated as professionals (Emami, Benner and Ekman, 2001).

In a study conducted in U.K. among nurses concerning their experiences on ethnic-minorities, many of the participants, felt that the standard of care given to ethnic-minority clients was not as good as it should have been. The reasons cited for this, were mainly poor communication, lack of knowledge of cultural differences and resources (Murphy and Clark, 1993). Moreover, some groups may also have reduced entitlements to services because of their legal status in the receiving country (Bollini and Siem, 1995). Denial of public services to legal and undocumented immigrants is typically aimed at adults, but children are usually the ones most affected (Lewin, 1997). Furthermore, there are refugees or immigrants who do not know their rights to access the health care services (George, 1998). In the U.S.A., immigrants are less willing or able to access “Medicaid” and other health care services since the passage of new welfare and immigration reform laws (Nation’s Health, 2000). The socially desirable traits of maintaining two parent families and working were the primary factors why immigrant families did not participate in Medicaid (Halfon et al., 1997). The reform and responsibility act also led to problems by creating new procedures for determining the eligibility of immigrants. The act heightened fears among immigrants that if they sought care, they would do so at the risk of their status. Other barriers include cultural and language problems, complex application procedures and the inability to pay for health care services (Nation’s Health, 2000). Mexican-American children have low levels of physician contacts for chronic medical conditions and seem to have a substantial need for medical referral for their conditions. This suggests that although Mexican-American children’s health status may be good, access to health services for those with health problems may be limited (Mendoza et al., 1991).

The elderly Finnish immigrants in Sweden had positive and negative experiences. They considered the caregivers kind, friendly and helpful people who gave to them good care and treatment and they felt confidence in the Swedish health care system. However, there were Finnish immigrants who stated the opposite of the above experiences. Additionally, they supported that they did not receive the care they needed and had not been well cared for (Heikkilä and Ekman, 2000). CONCLUSION Migration, at least in the beginning, is a difficult period in people’s life since they have to face difficult situations in the new environment where they are going to live. Some of these focus on their security, fulfilling their basic needs and the adaptation of their new lives in general. Receiving countries should understand the conceptualization of health issues and the health beliefs of the immigrants in order to cover the special health needs of these communities in a way, which will be appropriate to the immigrants. This can be accomplished by providing specific services to different ethnic groups, assessing their particular needs. Migrant health needs should be considered in the broader cultural and socioeconomic context, including access to and the availability of appropriate services. Health professionals, in order to be able to meet the particular needs of clients from different ethnic groups, should have knowledge and understanding of people’s culturally based health beliefs connected with care practices. Therefore, it can be concluded


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that health care professionals should carefully consider the clients’ cultural background, respect their health care needs and act properly aiming the health promotion, health care services and the quality of care. Moreover, health care educators should provide their students with information and knowledge on trans-cultural health care in order to enable them to deliver proper health care services. Additionally, continuing educational programmes concerning immigration and trans-cultural health care should be designed and implemented for the existing health care personnel. REFERENCES Blake S.M., Ledsky R., Goodenow C., O’Donnell L. and Menard W. (2001), Receipt of school health education and school health services among adolescent immigrants in Massachusetts, Journal of School Health, 71(3): 105-130.

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Corresponding Author: Sakellari Evanthia Nikopoleos 39 112-53, Athens Greece Tel: 003-0108652921


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