Challenging Dogma - Spring 2008

...Using social sciences to improve the practice of public health

Wednesday, April 23, 2008

Refugee Women's Health Screening in Massachusetts one Shot Deal-Paroma Mitra

Although women and children face the maximum brunt of war and strife, they are a small part of the overall picture of refugee health. Approximately 80% of the refugees are women or children. Refugees are persons who are outside their country of nationality and who are unable or unwilling to return to that country due to persecution or a well-founded fear of persecution because of race, religion, nationality, political opinion, or membership in a social group.(5) The current system does not emphasize on the specific needs of health care in female refugees. Female refugees are at maximum risk since in countries of conflict, they play more traditional roles and are dependent on their families for all types of support, namely physical, monetary, mental and emotional support. During times of conflict, losing or being separated from their families’ leaves them susceptible to all forms of injuries. Female refugees are also extremely vulnerable to sexual violence in the form of rape, genital mutilation and violation of other reproductive rights due to racial and ethnic discrimination Also, they tend to be overcrowded in camps which are unsanitary and hence they are extremely vulnerable to multiple diseases. When they enter a new country of refuge, they come with special needs of their own namely human needs namely physiological, psychological, social and spiritual.

Currently, the Massachusetts Department of Public Health carries out a basic physical examination of refugees. The primary aim of this physical check up is to ensure that refugees don not have any diseases that would prevent them from entering the United States. These exclusions would include certain communicable diseases and mental health associated with violence. The refugees are further divided into Class A and Class B where Class A deals with communicable diseases and Class B deals with physical deformity and violence leading to Mental Health (5). Whereas, there is provision for treatment including follow up for Class A there is no provision for help for Class B refugees. The current refugee and immigrant program is currently conducted under the Department of Public Health in Massachusetts effective since July 1995. According to the current figures, the number of immigrants entering the state is 1100 annually primarily from Africa and central and east Europe especially from regions of strife. (5) Looking at the background these women come from, a physical examination seems inadequate, real emphasis must be paid on issues like mental health, malnutrition, gynecologic health which forms the bulk of the needs of refugee women.

Current Refugee Physiological Care in Massachusetts
Physiological issues like access to health care and diet and nutrition are overlooked in the current Massachusetts outline. Physiology concerns the normal functioning of the human body hence correct physiological care essential to the well being of these women. When refugee women come in for their first physical examination in most of the cases an interpreter is provided to explain the procedure. An interpreter could also help explain the new health care system they are to become a part of. There are language barriers, limitations regarding transportation, the refugee health finances which women traditionally are not trained to understand in their country of origin. Most women are taught not seek formal care but culturally are expected to treat themselves at home.(1) Therefore, an effort must be made to set up interpreters who not only speak the language but understand the cultural background these women come from and provide with tools to access health care. Interpreters can also counsel about topics like diet and nutrition to women as in a study looking a refugee camps it was reported that particularly prone to diet related malnutrition therefore they must be counseled and given correct diet in regard to their status as women who are menstruating or women at child bearing age as current data shows in a lot of refugee camps there is food shortage hence countries of second asylum must make arrangements for adequate nutrition.(3) Mostly women in refugee camps suffer from some form of malnutrition as during times of conflict there is shortage of food supplies and males tend to be fed first. Also, the food supplies often land up being inadequate in essential nutrients leading to large number of diseases. Dehydration is also another common occurrence seen in women as the water shortage is quite common and lack of clean water is very frequent resulting in a lot of cases of dehydration and diarrhea. Efforts must be made to ensure correct nutrition which does not lead to further exacerbation of disease and pre- existing dehydration must be treated with adequately.

Mental Health as a Vital Factor
Mental Health problems are a part and parcel of every group of society but particularly seen in refugee women. Pre-existing mental disorder may already be present in women which may be triggered by stress due to their surroundings. Other women may be stressed due to what happened in their home country, their flight to a new one and relocation. A study measuring health variables of refugee women for resettlement (10) included biopsychosocial factors such as depression and anxiety as important primary variables as they are seen in about 58% and 24% of women refugees .The most common disorder seen is PTSD (post traumatic stress disorder). (3)In a Yugoslavia study 65% women developed post traumatic stress disorder due to physical and sexual torture. (Kang et all 1965) .Separation from their families leads to additional stress which may exacerbate PTSD. Mental health examination carried out in detail must be mandatory while dealing with refugees and they have special needs that must be addressed adequately to ensure their well- being and they must be followed up on as well by specialists who can deal with the particular sort of stress disorders seen in refugees.

Refugee Women and History of Sexual Abuse and Rape
There is a high prevalence of sexual abuse and rape in refugee women. (1) Especially seen in third world countries, women are traditionally expected to submit to the needs of men and men may take advantage of women already weakened by war for personal abuse and pleasure. It is often reported that soldiers are at the fore front of sexual abuse and often use it as a tool for controlling a population already weakened by war and strife. A study investigating basic women’s right has shown that limitation of sexual and reproductive rights may affect health. (7) It has also been reported that men in second country of asylum may take advantage of frightened and susceptible immigrant women.

Adequate measures must be taken to address this part of mental health and a country or a state granting asylum must provide adequate counseling and support in regard to this. Also health care providers must understand privacy issues and the question of chastity in these women; they may not be able to trust male health care providers completely. It is also important to understand that seeing violence towards others or seeing acts of violence increases sense of vulnerability amongst women.

Refugee Women and Gynecological Issues
Refugee women suffer genital trauma in terms of various degrees of female circumcision which lead to various gynecological and obstetric problems later. (3) There are three different kinds of circumcision, Type 1(seen in Niger, Eritrea, Uganda) which is removal of the clitoris and prepuce, Type 2(seen in Kenya, Somalia, Egypt) deals with excision of clitoris and prepuce along with part of labia minora and type 3(Northern Sudan, Somalia) deals with removal of clitoris and prepuce and sewing up the labia minora with thread and leaving a little gap for urine and menstrual blood. (3)

A lot of countries in Africa namely Somalia and northern Kenya both currently involved in internal strife have high prevalence rates of type 2 & 3 type of circumcision. A large concern of female genital cutting (FGC) is the environment in which it is done in. A lot of the time, a non- sterile blade is used to perform the procedure on young girls by a mid- wife. There is high incidence of hemorrhage and septicemia (3) leading to death. Also a major concern in women who have undergone a type 3 FGC, urinary system infections are very common due to stagnation of urine and they face a large number of urologic as well as gynecological problems. In older women who have undergone the procedure, increased cases of pyometritis, dysmenorrhea, dysparenuia, pelvic inflammatory disease and chronic cervicitis are seen.(3) There is also increased aversion regarding sexual activity leading to different psychological problems from ones discussed above. In addition to this, there is increased incidence of HIV and HBV transmission.

Gynecologic care must be provided to prevent these diseases as far as possible. Women must be regularly checked for gynecologic diseases, regular pap smears and health care surrounding care of the genital region must be given. Also, refugee women have a higher incidence of parity leading to increased cervical prolapse and stress urinary incontinence. Also, special prenatal care must be given to women who have undergone FGC. These concerns if raised by women must be addressed correctly and health care providers must be able to respect the values and needs of women.

Refugee Women and Social Interaction and Expectations
Women are expected to fulfill the “family role” and expected to recreate an atmosphere equivalent to the old home and country putting additional stress on them. (3) They have to adjust to a foreign country and society and are expected to adhere to the ways of the old society as well as cultural traditions in their homeland casting them into particular roles. Role strain occurs when individuals are expected to conform to a form of behavior expected of them which leads to increased amount of stress. (3) It is commonly known that foreign ways are rarely valued by the larger society. This causes excessive strain and burden on women. According to the social networking theory, the surroundings influence the behavior however a new environment does not always necessarily assure of change of behavior. To address this role strain, support groups consisting of members of the same background & society nay help new immigrants to adjust to the ways of a new country and life style. Women should be encouraged to mingle and work in the new society they are in. They are also expected to adjust to a new system in terms of facilities new home and away from parts of their family. The concept of resettling is not addressed currently a high- quality tools are required to measure relevant concepts required for resettling like education. (10)

In other states, the Baylor nursing home ( near Dallas, Texas) uses community outreach services and centers that is driven by human needs and serves the refugee communities nears Dallas, Texas that comprises of many different societies of refugees such as South- east Asians, refugees from Central America , refugees from Mexico and Saudi Arabia. 70% of the people serving in these communities speak the language of the refugee community and it gradually introduces concepts of all forms of health care. (4) Students are encouraged to mingle in the community they serve and teach basic health care prevention. Massachusetts may also incorporate a similar method of care. In another state, Ohio, the system talks about interlinking between various departments to provide for physical, mental and social care of refugees. (2) It has also paid some emphasis on different needs of women refugees and talks about coordinators that not only address physical examination but set up agencies to help refugees to understand the new system they are now a part of. . It can serve as a basic framework for a revised model of the current Massachusetts system. Based on the Social Learning Theory where modeling may cause behavioral change, having other refugee women to help counsel the incoming women may cause a change in their behavior and attitude towards a new system.

A simple electrical system which we take for granted may seem new and foreign to refugee women. Language too becomes a burden. Electrical appliances, laundry and other things we take for granted may not be as prevalent in third world countries. Women particularly may be overwhelmed as children tend to pick up these modes faster and hence they must be specially taught to use the facilities available in the new country. Women in particular according to a study(9) reveal themes of leaving the good life behind, worrying about their children, feeling ambivalent about marriage and lacking hope in the future. These concerns must be addressed to ensure their well-being.

There is a role change that is seen in refugees as in women may get jobs before their husbands and become the primary bread- winner of their families creating a new gender role. If this causes a strain on familial ties, it leads to additional stress on the women concerned. A way to deal with the stress may be via prayer and worship for many. Religion is a key part of life for many women and religious practices may be a part of everyday living for many. It may be a source of strength for many and religious beliefs must be respected in every aspect of care. A new society may not always compliment the old hence the well-being of the individual is compromised. A social advocacy approach is needed with both individual and collective strategies for responding to the lack of sensitivity shown many times. (8)

Refugee women deserve to be treated with special sensitivity and careThe more we learn and study about them the better we can address their issues. (9) They each have varying needs that must even be assessed at an individual level if possible. Women form the back bone of the family in most places and can become contributors to society if given the opportunity to do so. The best way to address the needs of female refugees is to increase the knowledge and sensitivity regarding special health care. One must understand that these women come from often a tragic and violent past to an unknown and uncertain future. The feeling of being degraded, dismissed or ignored may have serious repercussions on these fragile lives. Massachusetts has a large number of refugees many of whom come from violent pasts and it is in integral part of society’s responsibility to ensure their well being. The Commonwealth could modify their clinical program on a more needs based assessment and follow up rather than a purely physical assessment. This must also contain special assessments of women’s needs separately. New proposals are being made currently to incorporate women’s health into the main framework of the current refugee and immigrant health program. The Massachusetts government and Department of Public Health must look into providing health care as well as addressing the other issues describe above. It is imperative and urgent that the community act to provide basic needs to refugees (6). One routine physical examination is not enough to assess the needs of many of these women, mental, psychological and spiritual health must also be addressed simultaneously.

7. Basic health, women’s health, and mental health among internally, displaced persons in Nyala Province, South Africa, Sudan. Kim G, Torbay R, LawryL. Massachusetts Veterans Epidemiology Research and Information center, Veterans Affairs Boston Health Care System, Boston, MA.Jan, 2005.
8. Listening to different voices. Hrycak N, Jakubec SL. Faculty of Nursing, University of Calgary, Calgary, Alberta, Jun 2006.
9. Pavlish C. Narrative inquiry into life experiences of refugee women and men. International Nursing Review. 54(1):28-34, 2007 March
10. Gagnon AJ. Tuck J. Barzun L. A systematic review of questionnaires measuring the health of resettling refugee women. Health Care for Women International.25 (2): 111-49, 2004 Feb.

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