Cultural Competence and Cultural Humility in Migrant and Refugee Health
Written and compiled by Anjani Maher, Community Engagement Intern 2021-22 May 23, 2022
Presently, there are around 84 million people worldwide who are displaced. Among those, 26.6 million are refugees fleeing their home countries for protection. This number does not even include the current 2022 Ukrainian refugee crisis which the UNHCR estimates around 6 million refugees have left the country. In the course of these migrations, migrant and refugee health and mental well-being is likely to deteriorate, leaving them more susceptible to infectious diseases and other health complications. It is crucial to understand the health risks and needs of migrants during their migration process and when they reach their host country.
Culturally competent healthcare resources are particularly important for the migrant population because it may reduce the prevalence of poor and inequitable health outcomes for vulnerable populations. In order to make sure there is cultural competence in the United States healthcare system, it is important to understand its definition in relation to health care which is, "the ability of systems to provide care to patients with diverse values, beliefs and behaviors, including tailoring delivery to meet patients' social, cultural, and linguistic needs" (Betancort et al. 2002).
We want to make sure that the migrant population has proper access to quality care and coverage as well as ensure their needs are understood and met in a manner that protects their safety. However, we must realize that one can never be fully competent in a patient’s culture and experiences and that there is no endpoint to competence in practice. This is where cultural humility comes into play. Cultural humility stresses "understanding the complexity of identities — that even in sameness there is difference — and that a clinician will never be fully competent about the evolving and dynamic nature of a patient's experiences" (Khan 2021). One must be continuously curious and willing to genuinely learn about the identities of patients as well as understand their own biases and privileges.
This resource demonstrates how social determinants of health such as healthcare access, socioeconomic status, education, language barriers, and immigration status all affect the vulnerability of migrant populations. Their immigration status and fear of deportation may keep the migrant population from accessing medical and mental health services that they need and are entitled to in this country.
When our healthcare system learns to ensure all five components of culturally competent primary care — ensuring accessibility, fostering accountability, developing a sustained partnership, providing healthcare in the context of family, and providing healthcare within the context of community— we can better understand the health needs of our migrant population and tailor treatment to protect the safety and relationships between migrants and healthcare providers.
Click on the different tabs below to navigate through the various sectors of health migrant populations encounter.
Debunking Health Myths
This section will debunk some myths associated with immigrant and refugee health. Myth: Migrants and refugees bring over communicable diseases from their country of origin to their host countries. Fact: Most migrants are actually healthy when they leave their home country but fall sick when migrating and staying in other countries. This is due to unsanitary living conditions in refugee camps and detention centers as well as insufficient food and water.
Myth: Most refugees migrate to wealthy, developed countries. Fact: An estimated 85% of refugees flee to developing countries such as Turkey, Jordan, and Uganda which have poor health care systems and are often not culturally or linguistically competent. Myth: Migrants are a burden to the U.S. healthcare system. Fact: Migrants make up about 3 million healthcare workers who actually provide care and assist in understaffed services. In addition, a study on 15.2 million migrants in 92 countries concluded that migrants had lower mortality rates for cardiovascular, respiratory, digestive and endocrine disease compared to the host population. Migrants are at higher risk for tuberculosis, hepatitis, and diabetes (WHO).
Migrants and refugees are faced with various mental health stressors during the different stages of migration. The WHO outlines different triggers that can lead to mental health issues during pre-migration, migration, post-migration, and settlement. It is crucial to understand the gravity of the migration process and the hardships faced to understand the cause of many mental health issues migrants develop.
This section will describe the various stressors faced during the migration process.
Pre-Migration: exposure to armed conflict, violence, poverty, and/or persecution
Migration Travel and Transit: exposure to violence and detention, lack of stability, lack of services to cover basic needs
Post-Migration: barriers to accessing healthcare, poor living conditions, separation from family and friends, lack of a support system, worried about legal status and finding employment and other resources and supports
Integration and Settlement: difficulties assimilating or integrating, unemployment, racism, social isolation, worried about being deported, poor living and working conditions
Given all of these stressors, we can conclude that the prevalence of mental health disorders such as PTSD, anxiety, and depression may be higher among migrants and refugees. However, migrants often face barriers in accessing mental health services such as language difficulties, discrimination, high cost of care, and cultural differences.
Mental health is a taboo topic among immigrant households which I have experienced personally among my own family and from hearing the stories of others. We often tend to bottle our feelings up and use it as fuel to work harder to achieve our goals. The National Alliance on Mental Illness (NAMI) released an article written by Katherine Ponte, who was raised in a large Portuguese immigrant community in Canada before moving to the U.S. She elaborates on how mental health was stigmatized in her community because of what others might say or think. However, this can be very detrimental to our overall health in the long run because our mental and physical health go hand-in-hand and affect each other. Poor mental health can often exacerbate chronic physical conditions and vice versa. This is why it is pertinent to integrate mental health care into primary care so we do not assume that one is more important than the other and so we realize that they are connected. This can also be a strategy to identify mental health conditions in migrants that may go unnoticed otherwise as well as make mental health services more accessible and affordable.
To address the stressors migrants face during the last stage of migration, there is a lot that the host country can and should be doing to socially integrate migrants into their population. The opportunity to find a sense of community and belonging in a new country can lead itself to preventing and improving many mental health conditions. Befriending people that have a similar background as you and share similar experiences can alleviate many of the stressors associated with the settlement process because you have people to talk to that will understand you. Since communication is necessary to provide effective mental health care, host countries should focus on addressing these language barriers between migrants and mental health providers. This can be done by providing interpreters and translators and giving migrants verbal and written information in a language they can comprehend. Oftentimes, migrants and refugees do not even know where to go to receive mental health services, so this information should be clearly accessible.
Connection between Domestic Violence and Mental Illness In the United States, 1 in 4 women and 1 in 10 men experience some form of domestic violence which includes sexual violence, physical violence, intimate partner violence, and/or stalking. These statistics are exacerbated for migrants, especially migrant women, because they face unique challenges such as the fear of deportation, fear of losing their temporary visa or losing custody of their children. Abusers will often use the victim's immigration status as a threat to call Immigration and Customs Enforcement (ICE) if the victim tries to report the violence. In addition to the various stressors during the migration process listed above, domestic violence can rapidly deteriorate one’s mental health as victims can experience post-traumatic stress disorder (PTSD), anxiety, depression, and substance abuse.
It is crucial for migrants to know that undocumented victims and survivors of domestic and sexual violence have the right to access domestic violence services and go to the court. Domestic violence shelters and services can not refuse to help someone based on immigration status. In the U.S. Constitution, due process is required for every “person” in the United States, not just every citizen. Therefore, legal recourse is available to ALL domestic violence survivors. It is understandable for migrants to still not trust the U.S. court system and sometimes it may not be safe. Domestic violence organizations and shelters are a great outlet to turn to in these situations. These organizations can help migrants by ensuring they can obtain a restraining order without being detained and also support them in safely getting a divorce or obtaining custody of their children.
Massachusetts-Based Organizations Providing Mental Health Services to Immigrants or Refugees
Behavioral Health Network: provides behavioral health services to children, adults and families struggling with mental illness, substance use, and developmental disabilities
Salasin Project: provides individuals and families who have experienced domestic violence with a supportive community to heal
REACH Beyond Domestic Violence: offers an emergency shelter program for survivors of domestic violence by providing housing and other resources. They create solutions to end domestic violence through community engagement, educational programs, and community-based advocacy.
Rian Immigrant Center: offers counseling, support, and referrals free of charge to immigrants who have limited access to health insurance
Refugee and Immigrant Assistance Center (RIAC): offers a wide range of counseling, psychotherapy and psychiatric services to immigrants and refugees who experiences mental illness, trauma, and domestic violence. Counseling available in English, Somali, Arabic, Spanish, French and Farsi.
Organizations Operating Nationwide that Provide Mental Health Services to Immigrants or Refugees
United We Dream: provides webinars, a mental health directory of resources by state, and a mental health toolkit under their UndocuHealth & Wellness section
Mental Health America: provides education and outreach, research, advocacy, and mental health referral services
Coalition for Immigrant Mental Health Resources: offers a mental health directory of organizations in English and Spanish, a map to find mental health support, crisis counseling hotlines, and an Illinois Welcoming Center (IWC) for immigrant and refugees which are linguistically and culturally sensitive
Inclusive Therapists: provides therapy for individuals, families, children, teens, as well as medication management and low cost, non-profit services
Therapy for Latinx: find Latinx therapists in you area for individuals, couples, families, and groups
In the year 2021, about 150,00 unaccompanied minors came into the United States through the U.S.-Mexico border alone. This number has continued to rise during the Biden administration in recent years. This is solely the number of unaccompanied minors, and the total number of children arriving to the country is much higher. Many children come to the United States either to escape violence and poverty in their home country or reunite with family.
The use of scaremongering is commonly utilized to present migrant children as a disease threat in the United States. For example, Representative Morris Brooks from Alabama was quoted saying, “I don’t think there is any health care professional who has examined the facts who can honestly say that Americans have not died because of the diseases brought into America by illegal aliens who are not properly healthcare-screened as lawful immigrants.” However, this is proven wrong by scientific evidence because the vaccination rates of many childhood diseases in Latin American countries such as El Salvador, Guatemala, Mexico, and Honduras compared to the United States are similar or higher than vaccination rates in the United States.
Instead of pointing fingers at other countries for their poor healthcare systems, we should be focused on providing culturally responsive pediatric care for migrant children that come into the United States. Migration often prevents timely vaccinations or over-immunization because medical charts and patient history are not transferred over from the country of origin to the host country. It is important to first understand the factors that affect the health status of migrant children which the Migrant Clinicians Network states on their website. These conditions include:
Overcrowded or Substandard Living Conditions
Poor Sanitation Facilities
There is also a fear of deportation and being separated from family that can lead to trauma and chronic stress throughout the migration process. This fear may also prevent unaccompanied minors or migrant parents from seeking health insurance for themselves and children.
Massachusetts-Based Organizations Providing Children’s Health Services to Immigrants or Refugees
Migrant women are adversely affected by the lack of or poor access to healthcare when they travel to their host country. Unique health needs such as reproductive health, pregnancy, intimate partner violence, and incidences of breast and cervical cancer all disproportionately affect women. Detention centers often put women, particularly pregnant women, at a higher risk for health complications oftentimes ignoring their request for treatment and cries that they are in pain leading to many miscarriages while in detention. Immigrants and refugees' stories may help us to better understand the seriousness of these situations. The story of Juana Villegas demonstrates the many health challenges and traumatic experiences that women specifically may face.
During the first five years migrant women are lawfully present in the United States, they may be eligible to enroll in Medicaid or the Children’s Health Insurance Program (CHIP). Undocumented immigrants are NOT eligible to enroll in Medicaid, CHIP or obtain coverage through the Affordable Care Act (ACA) Marketplaces. Although some states now have exceptions to this rule, this lack of affordable coverage for migrant women means late screenings for cancer that could have progressed in that time period, limited/no access to contraceptives to prevent pregnancy, and late STI or STD testing. These preventative services are important to prevent the negative outcomes that can arise from these conditions. In some scenarios, especially with many refugees fleeing violence or persecution, migration can sometimes be a better opportunity to obtain care than in a collapsing healthcare system back home. This is why it is crucial to recognize the unique vulnerabilities and health problems women face throughout migration and uphold their sexual and reproductive rights.
An intersectional perspective is also important, as migrant women face compounding discrimination as both women and migrants and may come from other marginalized backgrounds in terms of ability, class, religion, and more. These forms of discrimination can ultimately lead to sexual harassment or violence in the workplace or while migrant women are seeking services such as housing, healthcare, education, or transportation. For more information on domestic and sexual violence, see the Migration and Mental Health section above.
Massachusetts-Based Organizations Providing Women’s Health Services to Immigrants or Refugees
Centro Presente: a non-profit Latin-American immigrant organization in Boston that advocates for immigrant women through their Women's Rights Center Brazilian Women's Group: a community-based organization providing free immigration clinics, legal assistance, know your rights trainings, ESL classes, and women's empowerment gatherings
Organizations Operating Nationwide that Provide Women’s Health Services to Immigrants or Refugees
Caribbean Women's Health Association: assists in applying for health insurance under Medicaid, Child Health Plus and Family Health Plus. Offers free and confidential rapid testing for HIV/AIDS along with counseling as well as an immigration lawyer to help with citizenship, green cards, and other assistance.
Migrant farm workers are a huge population that face various health issues due to the conditions they work in and the strenuous labor they do. Some of these health problems include pesticide or chemical poisoning, heat stroke, malnutrition, respiratory conditions, dental diseases, and poor child health to name a few. Many children work alongside their parents or find employment as unaccompanied minors where they work in hazardous work environments with limited or no access to healthcare.
There are many clinics in the Massachusetts and Connecticut areas that serve the migrant farm workers of the Connecticut River Valley. These clinics provide workers, including children, with yearly medical check-ups, dental care, chronic disease management and mental health services. I have linked a few migrant farmworker clinics and organizations operating in Massachusetts specifically as well as those in the Northeast.