Access to Health Care by Refugees: A Dimensional Analysis Amy Szajna, MSN, RN, and Julia Ward, PhD, RN Amy Szajna, MSN, RN, is Instructor, Thomas Jefferson University, Jefferson School of Nursing, Philadelphia, PA; and Julia Ward, PhD, RN, is Assistant Professor, Thomas Jefferson University, Jefferson School of Nursing, Philadelphia, PA. Keywords Access to health care, dimensional analysis, refugee Correspondence Amy Szajna, MSN, RN, Thomas Jefferson University, Jefferson School of Nursing, Philadelphia, PA E-mail: [email protected]


PURPOSE. A dimensional analysis of access to healthcare services by the refugee population was conducted. BACKGROUND. Refugees resettled to the United States are categorized as a vulnerable population and have limited economic and social resources. METHODS. Dimensional analysis was employed to identify the concept by varying perspectives and dimensions. The perspectives from the healthcare provider and the refugee, as the healthcare consumer, were explored. RESULTS. The following dimensions were identified: culture, language discrimination and stigmatization, and logistical concerns. Findings support that specific refugee groups have not been well-represented in the literature. CONCLUSION. Knowledge of this unique population is integral to healthcare professionals who encounter refugees in clinical practice. Regardless of the specific group, access to healthcare services must be determined for better health outcomes.


The elimination of health disparities has attracted the interest of healthcare consumers and policymakers establishing national and global initiatives. It is suggested that access to services directly affects health outcomes and contributes to health disparities (Beal, 2011). Healthcare professionals must be cognizant of factors affecting access to health care by specific populations. While access to healthcare services can have an impact on any individual or group of people, it is an issue that affects the health outcomes of vulnerable populations, such as the refugee population residing in Anglophone Western countries. The concept of access to healthcare services demonstrates unique characteristics when placed within the context of refugee health. Specifically, the cohort associated with access to healthcare services is the foreign-born refugee population who is resettled and granted residency status in the United States. The United Nations High Commissioner for Refugees (UNHCR) identifies refugees as those who have left their country of nationality

because of persecution, civil war, natural disasters, and other well-founded fears which deem the person unable or unwilling to return to it (United Nations High Commissioner for Refugees, The UN Refugee Agency, 1992). As of 2008, 42 million people were displaced from their homes due to the aforementioned circumstances and in the beginning of 2013, an estimated 10.4 million people were classified as refugees (UNHCR, 2013). Refugees resettled to the United States are categorized as a vulnerable population and, according to Aday (2001), have limited economic and social resources. Barriers to accessing health services often relate to language, culture, and difficulty navigating the health and social systems of the host country (Asgary & Segar, 2011). Additionally, chronic diseases including diabetes and hypertension are commonly undiagnosed or unmanaged prior to resettlement in refugee’s host country (Eckstein, 2011). Access to health services within the context of the refugee 83

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Access to Health Care population is a significant issue essential for receiving quality health care. Moreover, access to quality health care in time for the services to be effective is critical and significant for securing good health outcomes (U.S. Department of Health and Human Services [USDHHS], 2012). Identified as a goal of the Healthy People 2020, access to comprehensive, quality health care is achieved through three steps: gaining entry into the health system, accessing a location that provides needed services, and identifying a provider that the consumer can communicate with and trust (USDHHS, 2012). There are several definitions of access, each constructed by frameworks intended to provide researchers with a more comprehensive, systematic approach when exploring access (Karikari-Martin, 2010). Aday and Anderson’s (1974) early framework for the study of access explored the interrelated, multifactors affecting access to healthcare services by consumers. Penchansky and Thomas (1981) described access as a fit between the client and the healthcare system. More recently, the Institute of Medicine (IOM) Model of Access, developed in the 1990s, provides a framework for the exploration of aspects of access related to barriers to access, service utilization, and services mediators, or healthcare providers (IOM, 1993). Each access framework provides a comprehensive model for contextually defining access to healthcare services by healthcare consumers (resettled refugees) within the healthcare system (Anglophone Western nations). The purpose of this study was to determine access to healthcare services within the context of the resettled refugee population using dimensional analysis. The specific question proposed for analysis was: What determines access to healthcare services by the resettled refugee population? Penchansky and Thomas’s definition of access was used for this analysis. Method The authors used dimensional analysis to provide clarity to the concept of access to healthcare services within the refugee population. Chosen for its approach to development of a concept, dimensional analysis provides a framework for understanding how a concept is socially constructed and explores the concept’s contextual meaning across perspectives (Caron & Bowers, 2000). Access to healthcare services, as it relates to the refugee population, is a complex and contextually diverse concept. To adequately explore 84 © 2014 Wiley Periodicals, Inc. Nursing Forum Volume 50, No. 2, April-June 2015

A. Szajna and J. Ward the concept, one must consider its contextual meaning from varying perspectives. Specific to this analysis is the process of dimensionalizing, described as the selection of dimensions, characteristics, or qualities of situations and organizing the relationships among the dimensions in order to construct meaning of the studied concept (Caron & Bowers, 2000). The perspectives of refugees and healthcare providers were analyzed. The use of the concept of access to healthcare by resettled refugees was limited to studies that addressed refugees in Anglophone, Western nations. This restriction was imposed because resettled refugees in non-Anglophone nations are faced with additional linguistic barriers unlike their counterparts who typically have some experience with English.

Data Analysis A series of searches from CINAHL, Scopus, and PsycINFO databases were conducted for the years 2002–2011 using the following terms: “refugees,” “health services accessibility,” “healthcare utilization,” “community health services,” and “health disparities.” Initially, studies that included refugees resettled to the United States were considered. This yielded a limited number of results; therefore, the search was expanded to include all Anglophone, Western nations, as they resettle a high volume of foreign-born refugees annually. Additionally, it was critical to include the English-speaking nations as a criterion because of homogeneity in language which was previously identified as a prominent access barrier. Articles had to have a primary focus on the resettled refugee population, not the general, foreign-born, immigrant population. This was an important parameter because the refugee population differs significantly from other foreignborn populations. Based on the specific refugee definition outlined by the UNHCR and governmental policies related to resettlement and residency status, the unique needs of the resettled refugee population needs to be explored as its own entity. Many articles focused on other foreign-born populations such as undocumented migrants, excluding this group from inclusion in this analysis. After a review of abstracts resulting from the search terms, articles not meeting the specified criteria were eliminated, leaving 20 articles to include in the analysis.

Access to Health Care

A. Szajna and J. Ward Findings Analysis of the literature revealed common dimensions and perspectives, which identified the determinants of access to health care. The four dimensions responsible for defining access to healthcare services as it relates to the resettled refugee population included culture (including spirituality and religion), language, discrimination and stigmatization, and logistical concerns. Embedded within each dimension are the unique perspectives of both the resettled refugees and the healthcare providers. Culture Culture plays a significant role in the definition of access to healthcare services and service utilization patterns among refugees. This was evidenced by seven studies retrieved from the literature search (Asgary & Segar, 2011; Ellis et al., 2010; Lawrence & Kearns, 2005; Lipson, Weinstein, Gladstone, & Sarnoff, 2003; Omeri, Lennings, & Raymond, 2006; Pavlish, Noor, & Brandt, 2010; Redwood-Campbell et al., 2008). Somali refugees acknowledged the importance of handling one’s problems, including health concerns, as a demonstration of autonomy, and thus were less likely to seek healthcare services (Ellis et al., 2010). Both Lipson et al. (2003) and Redwood-Campbell et al. (2008) found that refugees’ access to healthcare services depended on their role within the family structure. Bosnian and Soviet refugees tended to neglect their own healthcare needs in order to focus on the healthcare needs of their children (Lipson et al., 2003). A study exploring healthcare patterns of Kosovar refugee women revealed that access to healthcare services was highly influenced by the patriarch of the family unit (Redwood-Campbell et al., 2008). A study conducted by Pavlish et al. (2010) found that Somali women believed discord surrounding health beliefs and values existed between themselves and the healthcare providers. The Somali women interviewed in the study expressed discontent over the rushed environments of their healthcare centers and felt that healthcare providers had no understanding of Somali treatment options, often being too quick to prescribe pills for any diagnosis. Spirituality and religion, which was considered as a dimension of culture, also played a significant role in the refugee population’s access to healthcare services. Three studies (Carroll et al., 2007; Ellis et al., 2010; Omeri et al., 2006) reported religion and spirituality as

significant factors affecting access to health care in the refugee population. Studies by both Ellis et al. (2010) and Carroll et al. (2007) found that refugees often forgo healthcare service utilization in favor of prayer and spiritual healing by community religious leaders. Healthcare providers also acknowledged that culture significantly influenced access to healthcare services. When differing views on illness occur as a result of cultural differences, conflict may occur (Englund & Rydstrom, 2012). In a study by Johnson, Ziersch, and Burgess (2008), healthcare providers observed that refugees often had a different understanding of illness compared with the Western model of illness. This resulted in longer appointment times explaining Western health concepts to the refugee patients. Healthcare providers identified uncertainty over cultural appropriateness of examination and gender-related issues when counseling refugees on birth control and consent for treatments. Cognizant of culturally driven gender roles, healthcare providers reported feelings of apprehension when explaining reproductive procedures such as Pap smears to their refugee patients (Johnson et al., 2008). While healthcare providers were aware of the importance of culturally competent care, they acknowledged that their own lack of knowledge related to many cultures resulted in a barrier between provider and patient. The opposing views of these two populations can result in disconnect between provider and receiver, which can ultimately affect access to care patterns of refugees. Language Language was identified from the perspective of the refugee population and the healthcare provider, as an influential factor affecting access to health care. Studies by Asgary and Segar (2011), Lawrence and Kearns (2005), Johnson et al. (2008), and Morris, Popper, Rodwell, Brodine, and Brouwer (2009) reported that both refugees and healthcare providers identified barriers with linguistics, interpretation, and translation services as a significant determinant of how access to healthcare services is defined and utilized by the refugee population. Comprehension of written instructions for follow-up healthcare services and legal documents requiring signed consent were also identified as significant barriers and deterrents to accessing healthcare services by refugees and healthcare providers (Morris et al., 2009). In a study by Harris (2003) and Palmer (2006), a common theme raised by refugees was the inability to express their 85

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Access to Health Care illness because of their limited knowledge of English. Consistent availability of interpreters was correlated with high antenatal appointment attendance of African refugee women (Carolan & Cassar, 2007). When exploring the use of interpreters during pregnancy and delivery, many Somali refugee women believed that the interpreters were not competent in medical terminology (Herrel et al., 2004). Providers also identified barriers related to interpretation services. Practitioners reported instances where medical interpreters were affiliated with an ethnic group on the opposite side of a conflict and whispered to the providers while interviewing the patient. Providers also reported that a lack of interpreter availability created instances where refugees were treated with no translation services present (Asgary & Segar, 2011). Discrimination and Stigmatization Fear of discrimination and stigmatization was a common theme reported in the literature. In a study by Omeri et al. (2006), Afghan refugees resettled in Australia reported a fear of discrimination by their healthcare providers due to their Islamic dress. In a study by de Anstiss and Ziaian (2010) and Ellis et al. (2010), refugees reported a fear of stigmatization from other refugees in their community if they sought professional medical treatment for specific health conditions, particularly conditions within the mental health spectrum. A study by Othieno (2007) found that a diagnosis of HIV was a significant deterrent in accessing healthcare services by African refugees. It was suggested that a great deal of stigma was attached to HIV/AIDS, leading to fears of isolation by the community and family. In a study by Asgary and Segar (2011), refugees identified fear of deportation as a significant barrier to accessing healthcare services. Refugees also reported mistrust of healthcare providers, believing that medical care in the United States is centered on monetary gains for the provider (Asgary & Segar, 2011). Described in a study by Palmer (2006), Somali refugees living in the United Kingdom reported lack of support from healthcare providers as a primary barrier to accessing mental health services. Somali refugees reported a strong taboo associated with many health conditions, especially mental illness. Fear of others finding out about their illness if they sought treatment was a common barrier to accessing healthcare services. In another study, perceived discrimination was reported by Somali refugee women and contributed to negative experiences surrounding 86 © 2014 Wiley Periodicals, Inc. Nursing Forum Volume 50, No. 2, April-June 2015

A. Szajna and J. Ward prenatal care and childbirth (Herrel et al., 2004). Participants reported discrimination by nurses because of their foreign-born status and inability to speak English. While perceived discrimination of refugees by healthcare providers was reported in the literature, interestingly, discrimination was not reported by healthcare providers. In Begg and Gill’s study (2005), healthcare providers reported awareness and sympathy toward the healthcare needs of refugees, although they reported difficulties in fully meeting the needs of many refugees, particularly the psychosocial needs of this population. Healthcare providers also reported that due to high patient volume and practitioner shortages, many were no longer accepting new patients, irrespective of their refugee status. Since refugees are often resettled to more socioeconomically disadvantaged areas where there are greater provider shortages, it may appear to the refugee population that healthcare providers are discriminating against them (Johnson et al., 2008). Logistical Concerns A significant dimension identified from the analysis was logistics related to access of healthcare services. In a study by Redwood-Campbell et al. (2008), Kosovar refugee women reported difficulty locating a healthcare provider and difficulty finding the location of a clinic as a significant factor contributing to access to healthcare services. Studies by Morris et al. (2009), Moreno, Piwowarczyk, LaMorte, and Grodin (2006), and Lawrence and Kearns (2005) reported that refugees identified transportation as a significant logistical concern affecting their accessibility to healthcare services. A common theme contributing to this dimension was the overall difficulty navigating the healthcare system of the refugee’s host country. Specific navigational problems were related to scheduling appointments, obtaining healthcare provider referrals, and concerns related to health insurance (Asgary & Segar, 2011; Lawrence & Kearns, 2005; Omeri et al., 2006; Redwood-Campbell et al., 2008). Completing resettlement issues related to employment and social security benefits, despite pressing health conditions, often take precedence over seeking health care (Palmer, 2006; Sheikh & MacIntyre, 2009). Refugees with disability resettled in the United Kingdom reported a lack of information related to where and how to access healthcare services (Harris, 2003). Several concerns within this dimension were

Access to Health Care

A. Szajna and J. Ward also identified from the healthcare provider perspective as barriers to accessing health care. They included lack of awareness of the health needs of refugees, lack of training regarding healthcare needs of refugees, and an overall anxiety from the prospect of treating the anticipated overwhelming healthcare needs of refugees (Kralj & Barriball, 2004). Additionally, healthcare providers identified refugees’ overall lack of familiarity with the Western healthcare system resulted in missed appointments, compliance with filling prescriptions, and following up with necessary referrals. Specific to treating refugees, insufficient health histories, a general lack of infrastructure support, workforce shortages and remuneration were also reported from the perspective of healthcare providers (Johnson et al., 2008). This group suggested that the refugees would best benefit from an initial assessment provided by a refugee specialist at a designated community center that could address many of the issues related to the logistic dimension. Interestingly, providers also identified transportation as a significant barrier to access health care by the refugee population. Clinic staff reported an attempt to educate refugees on public transit but recognized that transportation services are often underutilized by their refugee patients (Lawrence & Kearns, 2005). Discussion Access to healthcare services by the refugee population is a concept that is shaped by both the perspectives of the refugee population (healthcare consumer) and the healthcare provider. Moreover, its multidimensionality contributes to its complexity. Common themes, which contributed to the concept’s varying dimensions, included culture, language, fear of discrimination and stigmatization, and refugees’ logistical concerns. According to Aday and Anderson (1974), this dimensional analysis resulted in the identification of the population at risk, namely resettled refugees, and the interrelatedness between the refugees and healthcare services. Knowledge of this unique population is essential to healthcare professionals who encounter refugees in clinical practice. After careful review of the literature, it was determined that there was a significant gap in information regarding the culture dimension. While the majority of the studies examined focused on the African, Central Asian, or Eastern European refugee populations, little mention of the Burmese or Iraqi refugee populations were included in the 20 studies and in

the literature search at large. Refugees are a heterogeneous group, and while certain trends may be apparent, access to healthcare services cannot be generalized for all refugees. This is a significant issue because refugees are not a homogenous group, and refugees from both Burma and Iraq are culturally unique populations who, due to geopolitical situations, currently are being resettled to the United States in large numbers. To avoid generalization of all refugee populations in regard to access to health care, an important next step is to explore access to healthcare services specific to other refugee populations. More importantly, healthcare providers must aim to provide culturally appropriate care to refugees based upon access to healthcare findings in the literature. Limitations One of the limitations of this analysis was that it was based only on refugees who had resettled to Western, Anglophone nations, including the United States, Canada, Great Britain, Australia, and New Zealand. In actuality, refugees are also resettled to continental European and Latin America nations (UNHCR, 2013). These refugees may also have issues related to healthcare access. Their perspective and the views of their providers were therefore not included in this analysis. Literature published in anything other than the English language was excluded. This limited the number of articles that may have provided further perspective to the concept of access to health care for refugees. Another limitation is that the literature focuses primarily on refugees from Somalia and Asian populations rather than broader populations of refugees. Data show that refugees from over 50 countries were resettled to the United States in 2012 (USDHHS. Office of Refugee Resettlement, 2013). A broader sample including greater diversity among refugee populations would allow for a more thorough examination of access to healthcare issues affecting all resettled refugees. Conclusion Several themes affecting access to healthcare services by the refugee population were identified by both refugees and providers. Issues related to culture were consistently cited in the literature. Genderprescribed roles within one’s culture, familial 87

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Access to Health Care structure, religion, spirituality, and cultural views on illness all contributed to access to healthcare patterns and often served as a barrier. Providers also identified cultural issues as a barrier to care. Barriers to care related to language were a recurring theme in the literature. Even when translation services were available, significant dissatisfaction was reported by both the refugees and providers. Fear of discrimination and stigmatization was reported by refugees as a deterrent to seeking medical care. Refugees feared discrimination by both their healthcare provider and host country government. They also expressed apprehension when seeking care for certain health conditions for fear that it would lead to discrimination from other refugees within their community. Providers reported awareness and sympathy toward the unique needs of their refugee patients but did acknowledge that refugees may fear discrimination by practitioners. Logistical concerns including transportation to care facilities, finding a provider, scheduling appointments, health insurance issues, the need to manage competing resettlement issues, and an overall unfamiliarity of the host county’s healthcare system were a prominent theme in the literature. Similar barriers were identified by providers. By acknowledging the multidimensional issues of access and the presumable differences among the refugee population, specific interventions and alterations in healthcare delivery by healthcare providers can improve access to healthcare services. Providers must acknowledge the unique cultures represented by their refugee patients to ensure they are cognizant of delivering culturally competent care to diverse populations. Barriers to language can be overcome by greater awareness of available interpreter services. Providers must anticipate the need for these services so that translation is available for each provider and patient interaction. While providers did report an awareness and sympathy toward refugee needs, greater education on healthcare delivery to the unique refugee population is essential. Community outreach to dispel stigmas associated with many health issues can slowly encourage refugees, who would otherwise forgo treatment for fear of stigmatization within their community, to seek treatment. To combat logistical concerns identified in this analysis, providers must work closely with their patients’ resettlement agencies and other social services to ensure that patients have access to the resources necessary to achieve optimal health outcomes. 88 © 2014 Wiley Periodicals, Inc. Nursing Forum Volume 50, No. 2, April-June 2015

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Access to health care by refugees: a dimensional analysis.

A dimensional analysis of access to healthcare services by the refugee population was conducted...
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