1. Arizona Department of Health Services – August 7, 2013 Zachary Holden, MPH Refugee Health Coordinator (Photo by UNHCR/ F. Noy) REFUGEE WOMEN & CHILDREN’S HEALTH

2. A refugee is a person who is outside his or her home country and is unable or unwilling to return due to persecution, or well-founded fear of persecution on account of  race,  religion,  nationality,  membership in a particular social group,  or political opinion. WHO ARE REFUGEES? (United Nations 1951 Convention Relating to the Status of Refugees) (Photo by Reuters)

3.  10.5 million refugees worldwide  47% of refugees are in a protracted situation GLOBAL CRISIS Flee home country to country of asylum Live in refugee camp or other accommodation Voluntary Repatriation (return home) Local Integration (in the country of asylum) Resettlement (to a third country - United States, Canada, Australia, Sweden, Norway, etc.) <1% (United Nations High Commissioner for Refugees, 2011)

4.  Every year the United States accepts 50,000-80,000 refugees  Resettlement location factors  Family  Community  Availability of services  2012 – state of Arizona received the 5th largest number of refugees, with 3,324 arrivals  YTD – 1,900 RESETTLEMENT IN THE U.S. (Office of Refugee Resettlement, 2012)

5.  State Refugee Resettlement Program is federally funded  Bureau of Populations, Refugees, and Migration (PRM)  Office of Refugee Resettlement (ORR)  Each state that accepts refugees has:  State Refugee Coordinator  Charles Shipman, Department of Economic Security  Refugee Health Coordinator  Zachary Holden, Department of Health Services  Refugee Resettlement Agencies provide direct services  Reception & Placement  Case Management RESETTLEMENT IN ARIZONA

6. REFUGEES IN ARIZONA Top 10 languages: 1.Arabic 2.Nepali 3.Spanish 4.Burmese 5.Somali 6.Karen 7.Kirundi 8.Farsi 9.Swahili 10.Tigrinya 60,000 arrivals since 1980 from 106 countries speaking 115 languages and dialects

7.  Refugee Resettlement Agencies  Finding a house  Enrolling in school  Finding a job  Job training  Service enrollment  Navigating health  ESL RESETTLEMENT IN ARIZONA ArrivalYear 1Year 2  Community Support  Family, friends and neighbors  Ethnic Community Based Organizations  Faith-based Organizations  Public and private client support services SELF RELIANCE

8.  Phoenix  Tucson RESETTLEMENT AGENCIES

9. ETHNIC COMMUNITY-BASED ORGANIZATIONS  Phoenix  Somali American United Council  Iraqi American Society for Peace and Friendship  Bhutanese Community in Arizona  Arizona Burma Organization  The Lost Boys Center for Leadership Development  Liberian Association of Arizona  Burundi Arizona Heritage Organization  Association of Afghans in Arizona  Many more  Tucson  Tucson International Alliance of Refugee Communities (TIARC)  Horizons for Refugee Families  Noor Women’s Association

10. REFUGEE HEALTH

11.  Lack of formal education  Lack of language access  Pre-literacy in native language  Inability to make decisions  Superstitions, traditional beliefs  History with torture in clinical setting  History with institutional corruption  Lack of understanding of the healthcare system, health specialties and health insurance  Lack of money or insurance  Transportation difficulties BARRIERS TO CARE (Photo by IRC Phoenix/ Natalia Winberry)  Fear of deportation  Cultural insensitivity  Lack of gender-matched providers  Frustration

12.  The National Assessment of Adult Literacy reports that health literacy is lowest in immigrant populations, low income populations, minority populations, and poorly educated populations.  Ergo, health literacy among refugees is generally very low.  Often lack of basic knowledge about:  Body physiology  Disease transmission  Nutrition  Hygiene  When to access healthcare  How to access healthcare HEALTH LITERACY

13.  Cultural Orientation  Preventive Health Screening  Refugee Women’s Health Clinic MIHS  PCP  Community  Internet  WIC OPPORTUNITIES FOR HEALTH EDUCATION

14. REFUGEE WOMEN & CHILDREN’S HEALTH

15.  Common Health Challenges  Injuries from war, gender-based violence, torture  Domestic Violence  Chronic Diseases  Sexually Transmitted Infections  Breast & Cervical Cancer  Pregnancy Related Outcomes  Female Genital Cutting  Malnutrition  Tight Birth Spacing  Behavioral  Depression  Anxiety  Post-Traumatic Stress Disorder REFUGEE WOMEN

16.  Issues to watch for  Low birth weight  Low breast feeding rates  Malnutrition  Perinatal mortality  Disabilities due to birth complications  Heat / cold exposure  Lack of immunizations  HIV infection  Complications due to suboptimal factors during perinatal care  Socio-cultural pregnancy strategies  Lack of prenatal provider visits  Poor communication with providers REFUGEE CHILDREN

17.  Meeting language needs (Title VI)  Sensitive to cultural and religious beliefs  Build trust  Improve health literacy  Empower women  Involve husbands STRATEGIES FOR SUCCESS

18.  Know the language needs of your client before visiting with them  Provide interpretation  In-person is always better than telephonic  Provide translated documents MEETING LANGUAGE NEEDS

19.  Telephonic  Ensure that the client can understand the interpreter well  Speak directly to the client  In-person  Have the interpreter sit behind or to the side  Speak directly to the client  Gender-match the interpreter  Do not use family members  Hire multilingual staff  Speak clearly, not condescendingly  Do not use expressions INTERPRETATION

20.  Keep track of client’s language needs and report them to the state so that appropriate materials can be translated  Translated documents are important, but remember, not all clients are literate in their native tongue  Read documents through an interpreter if necessary TRANSLATION

21. CULTURALLY COMPETENT SERVICES

22. Cultural Sensitivity  Understanding what culture is  Having cultural self awareness  Respecting differences in appearance, custom, belief and opinion  Understand that culture influences communication SKILLS FOR WORKING CROSS-CULTURALLY Cultural Competency  Having knowledge and experience with a client’s culture  Knowing how to cultivate positive interactions with clients  Knowing how to adapt education to the client’s context  Evaluate your education tools for cultural relevance

23.  The “Okay Sign”  Summing with finger  Pointing with finger  Shaking hands across genders  Left hand shake  Punctuality, brevity and impatience  Complements can embarrass or obligate  Eye contact  Not accepting food and drink COMMON ACCIDENTAL OFFENSES Remember, it only takes one accidental offense to lose a client forever!

24.  Partner with local ECBOs, FBOs  Healthcare Chaplaincy  BRYCS.org  AZRefugeeHealth.org  Refugee Women’s Health Clinic  Resettlement Agencies  Local Trainings CULTURAL RESOURCES

25.  One-pager  Developed for healthcare providers  Basic cultural and health beliefs for a culture  Do’s and Don’ts  Common beliefs  Common conditions  Behaviors and customs you are likely to see.  Bhutanese, Burundian, Iraqi, Karen, Somali, Somali Bantu COMMUNITY PROFILES

27.  Take any opportunity to include refugee husbands in WIC outreach and education  Buy in / permission from the husband is often critical for positive behavioral change in many refugee cultures. DON’T FORGET THE HUSBAND

28. PIMA COUNTY BHUTANESE PROJECT

29.  Partnered with Pima County Bhutanese ECBO  Trained 11 community members as nutrition CHW  Held trainings in each of the Tucson Bhutanese neighborhoods on:  Healthy diets, including alternatives to traditional Bhutanese cuisine  Physical activity, including traditional dancing  Diabetes prevention and management  Breastfeeding awareness, dispelling myths about formula

30. THANKYOUTHANKYOU Zachary Holden 602-364-3592 Zachary.holden@azdhs.gov Refugee Women’s Health Clinic MIHS 602-344-1445 Crista.johnson@asu.edu