By: Assim AlAbdulKader, MD; Melanie Golembiewski, MD, MPH; and Heidi Gullett, MD, MPH, from the Neighborhood Family Practice and Case Western Reserve University School of Medicine
Reprinted from the summer 2019 issue of The Ohio Family Physician.
Over the last decade, almost half a million refugees have resettled in the United States1. Since 2010, Ohio has welcomed over 23,000 refugees from more than 20 different countries of origin with the majority from Bhutan, Burma, Iraq, Somalia, and the Democratic Republic of Congo. Most of these refugees live in five Ohio counties: Cuyahoga, Franklin, Hamilton, Montgomery, and Summit2.
There is a growing body of evidence that refugees have a high risk of developing metabolic risk factors shortly after joining American communities, with a chronic disease burden encompassing metabolic syndrome, hypertension, cardiovascular disease, and diabetes3. Several studies have also reported high rates of behavioral health conditions among refugees which are often trauma-related such as PTSD, depression, anxiety, and insomnia4. Multiple studies have also reported barriers to primary and preventive health services among foreign-born individuals. These barriers include race and ethnicity, low socioeconomic status, lack of insurance or underinsurance, lack of access to care, limited English proficiency, health literacy, and various cultural factors6-10. Additionally, navigating a complex healthcare system, in addition to acculturation in new living and working environments, can be challenging for most refugees further exacerbating attainment of health and well-being.
Incidence of cervical cancer and its related mortality in the United States has decreased significantly over the past 40 years in large part due to widespread pap testing11. However, cervical cancer incidence remains the fourth most common female cancer world-wide and the second leading cancer-related cause of death globally12. In developing countries specifically, cervical cancer is often the leading cause of death for women13.
Both in Ohio and across the United States, literature remains limited on cervical cancer screening rates, barriers, and facilitating factors in refugee populations. Lack of knowledge of the healthcare system is a significant contributor to healthcare disparities for refugees and, to a lesser extent, native-born citizens14. Refugees tend to struggle early in their acclimation to understand U.S. health insurance, the concepts of chronic disease, and the value of prevention9. If a specific practice or screening test was not readily available in their native country, acceptance of the concept may be lower8, however religion has also been cited as a facilitator for breast and cervical cancer screening among Muslim women7.
Our current work focuses on understanding how to most effectively support refugee women in receiving preventive care, with a specific focus on cervical cancer screening. In our practice, we found that only 40% of Arabic-speaking women refugees were up to date with cervical cancer screening recommendations, compared with 51% of English- and Spanish-speaking counterparts. We surveyed a sample of Arab women refugees and found that one in four women had never heard of cervical cancer. Although 60% of these women believed that cervical cancer is preventable; almost all of them were not sure about prevention methods. Interestingly, the top barrier to cervical cancer screening as perceived by these women was fear of cancer, while the top perceived facilitator for screening was cited as the clinician’s advice.
Addressing healthcare disparities among refugees requires collaboration between public health and primary care15. Public health approaches that consider the physical, cultural, social, organizational, community, and policy contexts within which people live have the greatest benefit when addressing health inequities16. Based on a structured expert consensus, key strategies to improve healthcare delivery for refugees involve consistent use of evidence-based cancer screening and prevention guidelines; appropriate use of culturally and linguistically appropriate interpreters for healthcare visits; and enhanced community engagement17.
Health needs and disparities are palpable among refugee populations. Refugee women are especially vulnerable due to structural and cultural barriers to health and well-being. Providing and maintaining equitable access to high quality, evidenced-based care in a culturally acceptable manner can be challenging, but we are continuing to learn ways to support these highly diverse newcomers. As the U.S. refugee population continues to grow, we will have ample opportunities to consistently practice medicine with cultural humility in an effort to ensure equitable access to preventive care and improved outcomes for all. As family physicians and health equity advocates, can we bridge the gap?
References are available on the OAFP website.