African Refugee and Immigrant Health Needs and Barriers: Report from a Community-Based
House Meeting Project
Linda Boise, PhD, MPH
1,2
, Anais Tuepker, PhD
3
, Teresa Gipson, MD
4
, Yves Vigmenon, MD
5
,
Isabelle Soule, PhD 6 , Sade Onadeko, BA,MA 7
1
Portland State University, School of Community Health;
2
Oregon Health & Science University,
Department of Neurology;
3
Oregon Health & Science University, Department of Internal
Medicine & Geriatrics;
4
Department of Family Medicine, Oregon Health & Science University;
5
Oregon Health & Science University, Department of BioMedical Informatics and Clinical
Epidemiology;
6
Oregon Health & Science University, School of Nursing;
7
School for
International Training (SIT), Washington DC
Abstract
Background: As in other communities in the U.S., information is lacking about the health needs of Africans refugees and immigrants living in Portland, Oregon. In 2008, the African
Partnership for Health coalition (APH) was formed to carry out research, advocacy and education to improve the health and wellbeing of Africans in Oregon. This was APH’s initial project.
Objectives: The purpose of this study was to (a) gather data about the perceived health needs and barriers to health care Africans encounter, and (b) lay the foundation for a program of action to guide APH’s future work.
Methods: Community-based participatory methods were used to collect data on how to improve the health of the African community in the Portland area and define an agenda for future projects. Popular education principles guided the engagement and training of African community members, who conducted nine house meetings with 56 Africans from 14 countries.
The results were analyzed by African community members and researchers and prioritized at a community meeting.
Results: Three themes emerged: the stressfulness of life in America; the challenges of gaining access to health care; and the pervasive feelings of disrespect and lack of understanding of
Africans’ health needs, culture, and life experiences by health providers and staffs.
Conclusion: Using CBPR methods, we identified and prioritized the needs of the African community. This information provides a framework for future work of the African Partnership for Health and other service and advocacy groups.
Keywords: African refugees and immigrants, health care barriers, health needs, mental health, community-based participatory research
Submitted 26 May 2012, revised 16 February 2013, accepted 7 March 2013
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Since the 1990s, many African refugees arrived in the U.S. from war-torn countries, including Burundi, Ethiopia, Somalia, Rwanda, Liberia, Eritrea, Sierra Leone, and the
Democratic Republic of Congo. Additionally, many immigrants from Africa have come to the
U.S. outside of an organized refugee resettlement program. Available research
1,2 and anecdotal reports suggest that African refugees and immigrants are an especially vulnerable group. Nearly every aspect of life in the U.S. – climate, dress, food, housing options, work, social networks, laws, and normative values – may be dramatically different from their home environments.
3
In
Portland, Oregon, as in other communities in the U.S., basic information about health needs of
Africans is lacking. A key reason for this is the lack of census, county, state, and federal health data on African population groups as the data that does exist concerning them is embedded within data from the more numerous population group, African Americans. Members of the
African community, service providers, and policy advocates, who formed the African
Partnership for Health (APH), a non-incorporated coalition, in 2008, recognized the need to better understand the health concerns of Africans living in Portland, Oregon. While most of the non-African members have professional experience with the health care system as clinical providers or researchers, African members include health care professionals as well as "lay people" without clinical expertise but rich experiences interacting with the healthcare system. At the time this project was conducted, APH was in its early stage of development and its members were becoming acquainted with each other and with the processes of community-based research.
APH successfully applied jointly for grant funding with Lutheran Community Services
Northwest, who hired and supervised staff and administratively managed the grant. This paper describes the resulting community study. The purpose of this study was to gather information
2

about the perceived health needs and barriers to health of Africans living in the Portland metropolitan area and to lay the foundation for a program of action to guide APH’s future work.
METHODS
We used community-based participatory research (CBPR) principles as described by
O’Fallen & Dearry 4
to carry out this study. The community of interest was defined by community members themselves as African-born individuals, whether refugee or immigrant, and their US-born family members living in the Portland metropolitan area.
5
APH recognized that cultural differences exist for different African nationalities and subpopulations as well as religious groups. However, APH was interested in exploring the extent to which Africans with diverse backgrounds, both refugees and immigrants, and those from different countries and regions have similar experiences in seeking health and health care in the U.S. Identifying these common concerns would support APH’s hopes to build a coalition to work on issues of relevance to the broadly defined “African community.”
At each phase of the project, we sought to engage members of the African community to participate in equal partnership with service providers and researchers and maintain an atmosphere of co-learning. African and non-African members of the group were present throughout the project's evolution, including the initial selection of research priorities for this project and the identification of future projects at its conclusion. The project coordinator (SO) was a young woman whose parents were Nigerians and who had lived much of her childhood and adult life in Africa. Early in 2009, she held a series of conversations with leaders from the
African community (including organization office holders, pastors, imams, and prominent community elders) in order to gain understanding of the health concerns of Africans. These
3

conversations were used by APH to develop questions to be posed in data gathering "house meetings." The house meetings, most of which were held in facilitator's homes, were decided upon as a culturally appropriate way to collect qualitative data, similar to a focus group. Once the house meetings were held, a community action board (CAB) was formed with Africans and researchers to jointly review the notes and interpret the findings. These findings were then presented at a community meeting both to provide "meaningful dissemination" and to elicit further input from the community in setting the agenda for APH future projects.
The house meeting project took place within the context of both learning about Africans’ health concerns and helping to build the capacity of the community to take action to improve their health. Popular education was a useful tool for preparing for and conducting the house meetings. Popular education is an educational method designed to empower those who are disempowered due to economic or social marginalization. Popular education recognizes that everyone has valuable knowledge and uses strategies to promote equal participation and power in charting the course of activities being pursued. Ultimately, the objectives of popular education are to connect people’s personal experiences to larger social and political realities; increase people’s belief in their ability to bring about change; and empower, build leadership, and enhance social capital.
6,7
In the spring of 2009, the project organizers introduced the project at a community meeting with approximately 25 community members and service providers. The goals of the project were described followed by an open discussion about the health needs of Africans.
Invitations were extended to community members to serve as facilitators for the house meetings.
From this meeting, through flyers posted in community centers and markets frequented by
Africans, and through further networking twelve African community members were recruited to
4

be facilitators. They were diverse with respect to gender, education, country of origin (from West and East Africa), and refugee/non-refugee. Several worked in nonprofit organizations, several were physicians, and others were leaders in African social organizations. Eight members of APH council agreed to serve as note-takers. House meeting facilitators were paid a small stipend for organizing and leading the discussions and a small amount of funds was provided to purchase food.
Training of the house meeting facilitators was conducted by a Somali immigrant who was director of a local civic engagement organization and skilled in popular education. At the fourhour training, the facilitators were oriented to the processes for the house meetings by engaging them in a discussion of the challenges of maintaining health and getting health care that African immigrants and refugees face in Oregon. The concept of “root causes” was also introduced so that the facilitators could meaningfully discuss these in the house meetings. The protocol for the project, approved by the Portland State University Humans Subjects Research Review
Committee (IRB), was explained, including the process for obtaining consent and the importance of documenting the thoughts shared among participants.
The house meeting facilitators were asked to bring together Africans they knew either as friends or from their work or social connections in their homes or another comfortable location.
Upon arrival, participants were offered food. The consent form was read aloud (signed consent was not required to preserve confidentiality and encourage open discussion) and participants were asked to respect the confidentiality of others by not discussing comments made during these meetings with others. They were also asked to complete a brief anonymous written survey that gathered information about their age, gender, length of time in the U.S., country of origin, and ethnicity. Following the meeting, the facilitator and the note-taker met to review the notes,
5

which were then emailed to the project coordinator. The notes were forwarded on to the project researchers for analysis.
The discussions at the house meetings focused on three main areas:
1. The health care-related concerns of African immigrants and refugees
2. Barriers Africans face in getting their health care needs met
3. Perceptions about the root causes of these barriers to health and health care
Data collection and analysis
Data from the written surveys were entered in Excel and frequencies and means were calculated. Notes prepared by the note-takers were printed for manual review and entered by the principal investigator (LB) into NVIVO for qualitative analysis. Using content analysis, the notes were reviewed by the project coordinator (SO), research associate (AT), and principal investigator (LB) to obtain a preliminary assessment of the themes. The Community Action
Board (CAB), composed of three researchers (LB, AT, TG), the project coordinator (SO) and three community members who had participated in community meetings but were not active members of APH, met over three meetings to review the notes and refine and clarify the themes.
The themes and concerns from the house meetings were later prioritized through a series of conversations with APH and at a community meeting held in December 2009.
RESULTS
The final sample included 56 Africans from 14 countries (Benin, Burundi, Cameroon,
Chad, Democratic Republic of Congo, Eritrea, Ethiopia, Ghana, Kenya, Nigeria, Senegal, Sierra
6

Leone, Somalia, Togo) with a range of ages, gender, education, years in the U.S., and refugee/immigrant status (Table 1). Four meetings were conducted in languages other than
English; five were conducted primarily in English for a total of nine meetings. Six of the meetings were held in facilitator’s homes, two were held in community centers, and one was held at the hospital where participants worked as housekeepers. Three major themes surfaced during the house meetings: the stressfulness of life in the U.S. and associated mental health concerns, difficulties in gaining access to health care, and the lack of culturally responsive health care. Illustrative comments related to these themes are provided in Tables 2 – 4, with sub-themes identified and referred to below by number in the tables.
Theme #1. The stressfulness of life in America and mental health concerns
While mental health needs were discussed in the house meetings, participants generally spoke about them in terms of the stressfulness of their lives and the impact these stressors had on their health and wellbeing (Table 2). A recurring theme was the disappointment experienced upon arrival and establishing residence in a United States that did not live up to their expectations. Financial hardships (1) and the profound loneliness they felt (2), were often compounded by the emotional consequences of the traumas they had experienced in their home countries (3). Even for those who sorely missed family members living back home in Africa, they sometimes spoke about them with mixed emotion as refugees and immigrants were often expected to send financial support home (4). Some participants recognized the need for formal mental health services for some people in their communities (5); however, connecting people to mental health counseling was often difficult due to a lack of receptivity of those needing such support (6).
7

While much of the discussion focused on the stresses Africans experience in the U.S., participants also spoke about ways Africans coped with the challenges they faced (7). Some put emphasis on healthy lifestyles for maintaining mental wellness, including diet and exercise.
Others spoke of African religious faith and the importance of church and mosque for support. In one group of women, we learned about the “Mahber”, an informal group of friends who are the first line of support when needs arise. A running theme among groups was a perceived difference between Africans and their non-African American friends: “Americans”, they said tended to stress about the “little things” whereas Africans don’t dwell on the small stressors, though when multiple stresses pile up, this strategy was not always successful.
Theme #2. Difficulties in gaining access to health care
It was clear in our house meetings that many Africans faced a host of challenges in gaining access to needed health care (Table 3): knowing where to go for health services (1); unavailability of services (2); personal finances, lack of insurance, and the cost of health care (3
& 4); and confusion about how the U.S. health care system works. Many participants found the health care system frustrating, perplexing and often simply unavailable.
While there is variation in how African countries and regions deliver health care, 8 participants tended to contrast care here with that in their home country in similar ways. They spoke about a radically different set of principles, structures, and practices between the U.S. and
Africa (5). The participants told many stories about the confusion and shame that arose when people sought health care and were turned away either because they had no insurance or when they received huge bills following a trip to the emergency room or hospital. People shared stories of friends who would not go to see a doctor even for very serious conditions because they feared
8

the cost. The house meeting participants reported that these fears and concerns lead many
Africans to consider hospital emergency departments as their main source of care.
Language barriers were a significant problem (6) especially when speaking on the phone to an interpreter. Working through interpreters added to the complication of appointment-making an aspect of health care that was an unfamiliar for many. The necessity of using interpreters also deterred some Africans from seeking care because of their fear that private health information might be spread to the community by interpreters who lived in their neighborhood. The house meeting participants expressed a desire for education about a range of topics with the hope that they would be presented in ways that are sensitive to Africans’ culturally-grounded expectations and values (7).
Theme #3: Lack of culturally responsive health care
While house meeting participants spoke about their lack of knowledge about the U.S. health care system, they also frequently pointed to the lack of knowledge of and the insensitivity of doctors and other health system staff towards Africans (Table 3). Doctors often appeared to have minimal knowledge about common diseases in Africa like malaria that might still affect individuals after coming to the U.S. (1) and to be unaware of traditional health practices or patients’ culturally-influenced expectations regarding the doctor’s role (2).
The challenges of communicating across professional and cultural boundaries were everpresent. A number of participants expressed frustration in their efforts to understand and communicate with doctors due to language barriers as well as physicians’ inability to tailor their communication so that patients could understand them (3). Many comments were made about doctors as well as clinic staff who seemed to lack understanding of Africans’ lifestyles, history,
9

or values (4). Other culturally-based concerns included the expectation, based in religious laws and norms of gender interaction held by some African community members that may prohibit women from being treated by male health care providers. Several participants expressed their reluctance to share family medical history: reporting such information is considered routine in the United States, yet for participants this was regarded as a violation of a “family’s private business.” In several of the groups, concerns about poor communication were felt to cross over the line from a lack of understanding of Africans to racism and discrimination (5).
While there were many concerns expressed about poor and discriminatory treatment, some people offered suggestions for ways Africans can influence the way they are treated. These comments showed insight into communication and cultural adaptation as a “two-way street.”
The way we carry ourselves… we don’t always provide full communication….We need to educate people how to communicate fully…Accents can be a problem….[You and the doctor] need to develop a rapport.
We come from a culture where we place the doctor at a very high level….so we expect the doctor to know what the problem is….here we are expected to tell the doctor what our health problem is….we should change ourselves.
Root causes
In response to the second question, regarding the root causes for the problems they experienced, groups discussed them in somewhat different ways. Some focused on systemic problems with the health care system, such as the lack of jobs and health insurance and that “ the
U.S. health care system is driven by profits, not by the need to serve all people in need.
” Others discussed a multiplicity of factors they considered to be root causes, for example, language
10

barriers, stress, loneliness, and the lack of understanding of health care providers about African culture.
Setting priorities for action
About 20 people attended a community meeting in December 2009; about half were community members. Community members of the CAB reported on the themes from the house meetings by reading aloud selected comments. Discussion followed to clarify, validate, and prioritize the concerns of most interest to the community. Prioritized areas for future action included: addressing the stresses experienced by Africans, improving access to culturally competent health care, and domestic and family violence.
DISCUSSION
The conversations in our meetings suggest that there are many common experiences and perceptions across the diverse groups we interviewed. As has been found in other studies
8,9
they relayed how socio-cultural and economic conditions in the U.S., often superimposed on memories of past traumas, contribute to significant stressors that make immigrant life surprisingly hard. House meeting participants generally conceptualized these emotional challenges as stress rather than mental unwellness. The stigma of mental illness frequently resulted in a reluctance to seek formal mental health services though it was recognized by some as a critical need when stresses accumulate beyond the tipping point.
The gaps in services and the lack of financial access reported by Africans in our meetings reflect, at ground level, the discordance between the immigration and health care systems as
11

reported by one clinician
10
. Those new to this country found the system especially confusing and frustrating. Though it won’t solve all access problems, increasing Africans’ understanding about the processes and rules related to services and benefit programs should enhance their success in obtaining health care. Potentially beneficial topics suggested from our house meetings include making appointments, medications and prescriptions, hospital billing procedures, and strategies for effective communication with health providers. Additionally, cultural competency training appears to be needed to educate providers about African beliefs, values, expectations, and needs and to offer them guidance for engaging effectively with their African patients.
The third theme, the lack of culturally responsive health care was reported by a broad spectrum of both refugees and immigrants with varying language, literacy, and immigration status. Immigrants and refugees alike expressed a perception that systemic pressures, either alone or in conjunction with racist attitudes, lead providers and agency staff to treat them not as
“a whole person” but as poor minority newcomers at the bottom of the socio-cultural ladder.
These perceptions and experiences, consistent with other studies,
11,12,13
put Africans at a serious disadvantage in maintaining their health and wellbeing. Although Africans in our groups often expressed tremendous frustration in getting their health needs met, some participants suggested that Africans need to be more assertive in advocating for their needs.
STUDY LIMITATIONS
This study is limited by the relatively small number of participants, its non-random, convenience sampling, and recruitment through the social networks of house meeting facilitators.
While we clearly did not reach all subgroups of Africans in our area, overall, we were pleased by
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the diversity of Africans included in the house meetings and found substantial consistency across groups on a number of concerns. However, cultural generalizations offered in this paper may be overly broad, especially given the small sample size and the sub-populations who were not reached. Also, we are unable to make definitive comparisons between important subgroups such as non-refugee immigrants versus refugees. Future research could explore whether the themes uncovered with our sample hold true in other segments of the African community of Portland that were perhaps underrepresented in our house meetings.
As is often the case with fledging community-based efforts, limited funding and limited staff time, our processes sometimes fell short of the ideal. At times, procedures were inconsistent and attention to detail was lacking. Participation sometimes flagged especially in involving community members in the interpretation of the results. This was possibly due to APH members’ inexperience with community-based participatory research as well as to the need for better training. One example was the inconsistency in how the notes were written, i.e., some summarizing the discussions and some including verbatim comments. We had decided not to tape record the sessions because we were concerned that community members would be uncomfortable with recording, but this decision may have inadvertently biased the results as the notes that included direct quotes may have been given greater emphasis than those that summarized the discussions. Also, limited discussion about the organizations and leaders currently addressing health concerns of Africans preclude drawing any conclusions about this question.
IMPLICATIONS FOR FURTHER RESEARCH AND ACTION
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In giving voice to the concerns of the African community about health and health care, this study offers APH and other organizations a useful frame for further research and advocacy.
The focus on the stresses Africans face as well as the attributes that fortify them to cope with these stresses suggest that programs that build on the strengths of Africans and that promote community support networks may be effective strategies for improving mental wellness among
African refugees and immigrants. Collaboration among African community groups and service organizations may have the added benefit of creating pathways for Africans to formal mental health services when appropriate.
The need for better understanding of the health system and for improved mutual understanding between providers and Africans surfaced in our house meetings as a critical need.
APH is currently focusing on addressing these concerns: in a collaborative project with county health providers, APH is promoting communication between Africans and health providers through dialogue sessions and is developing audio-visual and written tools to improve African refugees’ understanding of the procedures used during their initial medical visits.
In addition to education, empowerment strategies that engage them with other immigrants and underserved groups may offer Africans opportunities to learn about the health system, gain confidence in speaking out for their needs, and build leadership. One concern identified during the house meetings and of particular interest to APH is the need for better training for interpreters. While there is evidence from prior research that professionally trained interpreters benefit non-English-speaking patients,
14
our findings suggest that patients may fear that interpreters will stray outside of ethical boundaries and inappropriately divulge personal information to other community members. This may especially be a concern in small, close-knit communities such as with African subpopulations. Whether this concern is grounded in the need
14

for better training for interpreters or for better understanding by patients about the role of interpreters is worthy of further exploration. Undoubtedly, both are needed. As of the writing of this paper, the Oregon Legislature and the advocacy community are considering options for improving the training and regulation of interpreters. Our findings suggest Africans should be part of this conversation.
This study also offers insight into the challenges in building effective community-based research. At the time of this study, most members of APH were new to CBPR. One question related to best practice in CBPR arose in preparing for the community meeting at which priorities would be set for future work. One of the issues considered during that meeting was domestic and family violence. Although this topic was discussed in only one house meeting, it had often been mentioned in one-on-one meetings with community leaders. The fact that this topic was raised by community leaders and prioritized in the community meeting suggests that family violence was of great concern to the community despite its lack of attention in the intimate setting of the house meetings. Thus, an important question about the CBPR process was whether it is acceptable to stray from the concerns raised during the house meetings or should
APH have limited discussion only to the main concerns raised during them? While this might be considered a limitation of this study, it may be viewed as an acceptable, even a positive, adaptation that distinguishes CBPR from more traditional research methodologies. Knowing when to hold firm to a rigid methodology and when to adapt processes in order to achieve the goals of a community-based effort is an important challenge for CBPR.
Another challenge faced by APH was its relationship with its partnering service organization. At times, the coalition members found tension in APH’s affiliation with this organization since APH's focus on community capacity building and involvement in research
15

was distinct from the sponsor's primary focus. Tensions also sometimes surfaced around the competing interests among diverse groups within the African community, e.g., gender issues,
Christian/Muslim groups, immigrants versus refugees, and the various nationalities represented.
Nonetheless, APH’s work across these boundaries was mostly recognized as valuable and ultimately of benefit to the larger African community. Developing an identity that encourages even more widespread community engagement remains a challenge for APH as it grows.
Building a smoothly functioning collaboration among community members, researchers, and service providers holds promise but requires a strong commitment to the CBPR process and to the long-term goals of supporting the African community as it seeks to improve the health and well-being of its members.
Acknowledgements
The authors wish to express their appreciation to the members of the African community who contributed to this project in many ways, including participating in African Partnership for
Health meetings and deliberations, serving as house meeting facilitators and note-takers, reviewing and helping to interpret the results of the house meeting discussions and participating in the community meeting at which priorities were established for future action. We also thank
Lutheran Community Services North West for its administrative and program support for this project and North West Health Foundation for its financial support.
Ms. Onadeko was Project Coordinator for this House Meeting Project. In 2012, she received a
Master of Arts in Sustainable Development (International Policy and Management) from School for International Training, Washington, DC; Dr. Vigmenon, originally from Togo, conducted two house meetings; all authors were members of the African Partnership for Health.
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Table 1. Characteristics of House Meeting Participants
(N=56)
Characteristic
38 (14-67) Age (mean, range)
Gender (number, %)
33 (59%) Men
Women 23 (41%)
Education (number, %)
Grade school (8 th grade or less) 11 (27%)
9 (22%) Some high school or high school graduate
Some college or college graduate 10 (24%)
11 (27%) Post college or graduate degree
Immigrant status b (N, %)
18 (34%) Refugee
Non-refugee immigrant 35 (66%)
7 (1-30) Years lived in U.S. (mean, range) a
Data on education missing for 15 participants b
Immigrant status missing for 3 participants c
Years lived in U.S. missing for 3 participants
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Table 2. Stressfulness of life in the U.S.
Concern Sample quote or summary note
Direct quotes are italicized; summary statements non-italicized.
(1) Economic challenges and their impact on wellbeing
We expect when we come to America, everything is going to be easy, very easy to get, the land of resources.
But we soon find out we are struggling to make ends meet, just to make enough money to fulfill our basic needs, such as eating, dressing up, and supporting our family here and in Ethiopia. So to go beyond that and worry about our health, and how to navigate the bigger world outside is quite overwhelming and frightening.
Sometimes I wonder why I even come. I have a degree but I can’t get work with it here. You go through racism, people look at you funny here. In my country, I am a big man, the head of my house but here, I am nobody, even my wife and children have more power than me.
(2) Disappointments and loneliness of
America
I had a child and there was nobody by my side. I cry all the time ‘cause I miss my mother, my grandmother, my aunty, my community. I was part of groups at church, in my community, at the market place. Every week I went to at least 2 parties. I never had time to think of problems or be sad. I never cry. I came here because people that come back home from America look like America is this great place because they spend a lot of money, they look rich. I sold everything to get visa and ticket. Now that I am here, it is only suffer headaches.
There are benefits but life is stressful and lonely.
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(3) Trauma from experiences in Africa Somali refugees have been resettled in Oregon due to civil war and instability in Somalia. As a result most families have gone through traumatizing life experiences and are in need of mental health services due to post traumatic stress disorder.
(4) Responsibilities to support family back Our primary problem is stress. We come from a poor country. Our family back in Ethiopia are very poor and home in Africa they expect us to help them. So even though we have to run our own family here doing minimally paying jobs, we still have to provide for our extended family in Ethiopia. This is the story of every Ethiopian person. So this is very stressful.
(5) Recognition of mental health impact of One big issue is mental health: ‘the shock of being here’ and the stress of being in a new country which can the stressfulness of living in America lead to something else like depression.
(6) Reluctance to seek help My brother recently got laid off from his work. He has three children. He is distressed and is going into depression. Because culturally we don’t talk about depression issues, this is very difficult for him to get help.
(7) Ways people cope with the stressors of [Wellness is maintained by] the African diet with its emphasis on fresh, instead of processed foods and living in the U.S. cooked at home with healthy oils.
Good health is exercise. People must be physically well to be happy.
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…African faith in God
In our Mahber, there are 6 families. Two of us belong to this Mahber, as we were friends in Ethiopia and I came to Portland because of my friend. We contribute money every month so that we have a group saving in Mahber. This money can be used when something bad happens to one of us
(family death, sickness, etc.). When adversities come to one of our families, the first people to arrive are the group in our Mahber…
We don’t really talk about the small stressors in life, but these are things that build up and become unbearable. But since we don’t like to admit it and we are nervous about discussing this, sometimes it becomes too late by the time you try to seek care.
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Table 3. Health Care Access Barriers
Concern Sample quote or summary note
Direct quotes are italicized; summary statements from note takers are non-italicized.
(1) Not knowing where to Want information about where there are walk-in clinics, not just ER. go for health care
The little information we get is simply by talking to friends who have been here before us.
Well, I just don’t know much about the health care system here.
(2) Lack of service availability
No, I never go to the dentist. I worry about it but I don’t have one I can go to.
(3) Lack of insurance or Since we are here to talk about health care, how do we get it? I have a part-time job that don’t affordable health care give insurance. I am so afraid of getting sick.
What health care? We don’t have health care. They give our children and women health care but we have nothing.
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My doctor told me that I have to wait till I have insurance before I can get some of those tests.
(4) Cost of health care …we are supposed to have decent health benefits [from our jobs], but even with this, it is expensive. We are stressed about these using these systems because we are worried we will get stuck with a large bill that will mess up your credit.
How can you have insurance and still get stuck with such a huge bill? This is something we just don’t understand and because we don’t understand it, most immigrants are choosing not to access care to begin with unless it is an emergency.
(5) Lack of understanding When you are in Africa and you get sick, you know you can go to the hospital and get treated of the U.S. health care system. Different set of for minimal cost. Payment is on a cash basis. You know ahead of time how much you will pay and they don’t send you a bill 2 to 3 months later. principles, structures, and practices between
In Africa when you arrive at the hospital you get served. Here my mom was sick. We arranged the U.S. and African health care systems all the transportation to the hospital, but when we arrived they turned us away because we didn’t have an appointment.
(6) Language barriers Information is often available but not in the right language though – that is important too.
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(7) Need for culturally sensitive education
Cannot trust the translation services, they don’t work on the phone and sometimes they don’t want the services of the available translator (since they are often of the community and there is a privacy concern.
Many refugees feel isolated and lack the necessary navigational skills to access the care they need. They often have not learned preventive health care, often do not get proper treatment, and have a different set of beliefs and expectations about health care, which may inhibit their ability to properly access health care for themselves and their families.
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Table 4. Lack of culturally respectful and responsive care.
Concern Sample quote or summary note
Direct quotes are italicized; summary statements from note takers are non-italicized.
(1) Doctors unfamiliar with illnesses affecting Africans
Some of the diseases that we have over there are not the same, and they [the doctor] are deducing from what he thinks rather than what you are telling him...
(2) Doctors in Africa are considered as providers of urgent and acute care
The doctors in Africa will do what you need to survive and prevention is not stressed. People don’t go to the doctor for prevention, or even for treatment: many people will first pray or go to an herbalist. In contrast, in the US, the doctors will perform every test and service for which they can possibly get money.
(3) Communication between doctor and patient
You’re trying to explain what is happening to you…English may be your 4th language…the doctor needs to take the time to review, make sure communication is clear, but that doesn’t often happen.
They talk so fast to you or they talk to you like you are a baby. It’s so annoying!
(4) Lack of cultural understanding and sensitivity of clinicians and clinic staff
They have to send us to a doctor who understands how Africans live…they have to recognize they have the limitations.
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(5) Racist attitudes
Some people do get mean if you don’t have insurance.
One person told a story about a friend whose doctor commented that he seemed depressed. The man took this remark to be offensive and then became angry; the doctor then became concerned the man might have some kind of psychosis.
You are African, you are Black, you are considered not to have money, you are considered not to understand…this is what we need to consider here….there is an underlying factor here that says, because of who she was, it was more easy for them to send her out without consideration… you are from
Africa….they are going to assume you don’t have the money…they are going to try to give you the minimum.
I think one of the root causes is the lack of training for receptionists, the ones who are taking the information…the lack of cultural sensitivity….[when they think of Africa], all they think of is animals.
Before they are even halfway through, they [the doctors] are thinking about the people waiting in the next room….the system itself is what is pushing this on us…and we are in the lower pool.
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It [the system]’s putting pressure on you, the professionals, and you have a dog to step on, and we are the dog.
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