Cultural Competence in the Refugee Context

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Cultural competence is a defined as a set of congruent behaviors, attitudes and policies that come together in a group of people to work effectively in cross-cultural situations such as an evaluation of programs and services provided to immigrants and refugees The word 'culture' is the integrated pattern of learned human behavior that includes thoughts, communications, actions, customs, beliefs, values and institutions of a social group.1 The word 'competence' implies having the capacity to function effectively as an individual and as an organization with the context of cultural beliefs and behaviors1.

Stages of the Migration Process

According to migrants, migration is defined as an act loaded with a negative connotation (escaping political oppression) or with positive connotations (seeking a better living). The other major reasons for migrations are economical, parental migration, familial reasons, etc. It is accompanied by a significant change in the cultural set up of both the migrants and the host community members. The process of migration is divided into the following discrete stages. Each step has unique features that trigger different types of family coping mechanisms and showcases different kinds of conflicts and symptoms.2

Carlos Sluzki’s Model of Migration

1.Preparatory Stage

The first stage begins with the decision 'to move' made by the members of the family. It involves the exchange of letters, a request for visas application, or any other act that substantiates the intent to migrate. It has a varied time frame. The stage is marked by a course of ups and downs, a short period of euphoria followed by a brief period of dismay. The poor performance of individuals seen in this stage is due to the result of efforts, tensions, and emotions.

2. The Act of Migration:

The migrant undergoes a painful journey with little or no celebrated custom upon arrival. The act of migration may take a considerable amount of time. War-displaced people may have to stay in transient camps in various countries before making it to their final destination. The mode of the migratory act may also vary considerably.

3.Period of Overcompensation

The stress following the migratory act is generally not seen in the weeks or months following the migration. Most of the time, the participants are unaware of the stressful nature of the entire experience and its cumulative influence.

In the period immediately following migration, the priority of the family is absolute survival, i.e., the satisfaction of the basic needs. The new immigrant may show a clear focus of attention-of-consciousness, but the overall field of consciousness may be blurred or clouded. Many families manage to establish a relative halt on the process of acculturation and accommodation for months, so the conflicts tend to stay dormant in this period.

4.Period of Decompensation or Crisis

The reshaping of the new reality, identity, and compatibility with the environment takes place in this phase. This stage is marked by conflicts. There is frequent need to retain certain family habits though they differ from the new context while letting off other traits as they differ from the original culture. This phase is delicate and often challenging but is unavoidable. It creeps into the family leading to clashes. The family coping effects express themselves in the course of the months, sometimes years, after the migration.

5. Transgenerational Impact

Delay in the adaptive mechanism becomes evident in the second generation of migrated families. Environment similar to the country of origin generally slows down the adaptive changes, and no consequences are seen if the second generation socializes in this secluded environment. However, if the process of socialization occurs in diverse habitat, then whatever has been avoided by a first-generation will appear in the second one, which is generally expressed as a clash between generations called an intergenerational conflict of values.

Influence of Migration on Refugees’ Health

Refugees are the survivor of persecution and multi-violence (war/torture). The migratory experience has a profound effect on their overall well-being especially Mental Health.(reference to be added)

Everything related to the refugee changes-food, family, society, language, culture, and climate. But despite experiencing affective loss, initially, an excitement exists to find the first world paradise about which they know little. The migratory process results in a psychosocial process of loss and change, also known as grief.

Difficulties in expressing grief cause psychological problems. The challenges are more intense when migration occurs under adverse conditions like refugees fleeing their country for fear of being persecuted; this grief process is similar to the experience of loss rather than that of separation as they cannot return to the country of origin.

Post-Traumatic Stress Disorder (PTSD) is the most common mental health problem among refugees and asylum seekers. Other psychological problems experienced include: nightmares, hallucinations panic attacks, sexual problems, phobias, difficulty in trusting others and forming relationships and and depressive illness or anxiety.

Chronic and Multiple Stress Syndrome. Most immigrants suffer from Chronic and Multiple Stress Syndrome (or Ulysses syndrome), which manifest with depressive symptoms, anxiety, somatoform, and dissociative symptoms. The cause is linked to the harsh journey that immigrants pursue a better life.

The risk of illness and adverse health outcomes is higher in refugee groups coming from areas of poverty, conflict, or war. Also, the risk is higher in people with pre-existing medical conditions and the elderly.

Barriers in Accessing Healthcare

Accessing health care and social care support and services becomes a challenge for refugees. Number of barriers or difficulties in accessing health care include

  • excessive paperwork
  • lack of information on how to access services;
  • types of services available;
  • language barriers;
  • lack of cultural competency;
  • fear of persecution;
  • systemic issues associated with being ‘status less’ (i.e., the transitioning process from an asylum seeker to a refugee)

Refugee Status

Immigration status often plays a role in a lack of access to health services due to the fear of deportation and discrimination, resulting into  reduced utilization of health care services.

Lack of Familiarity with the Health Care System

The limited information on accessing primary health care services and not knowing whom to ask or where to go for health care, can result in frustration. It can also prompt to seek help from inappropriate sources. The refugee may experience difficulties; for example, immediate access to GP (General Practitioner) in the host countries follows a protocol that involves an appointment and wait-listed approach. It is contrasting to their homeland, where they get to see the GP immediately. It can be confusing as the refugee may think condition might resolve by the time, he/she gets an appointment. The problem with this approach is that it may prevent individuals with more severe illnesses from acquiring medical attention early in the disease process5.

Lack of Resources

Lack of availability of adequate resources to screen and provide specialized treatment programs for traumatized refugees and asylum seekers.

Financial Costs

Access to healthcare becomes an arduous task in the presence of financial constraints. Multiple factors like lack of livelihood, healthcare insurance, transportation costs affect health care access for new refugees. The financial capability of the refugee and lack of medical coverage for services that are chargeable presents as a barrier in seeking medical help.

Trust Issues

In working with different cultural groups, external intervention is seen as obtrusive, meddling into personal space. They may distrust the healthcare provider. It may be based on the fear of sharing sensitive information, divulging visa status, fear of deportation1.

Language Barrier

Research suggests that communication difficulties with service providers act as a critical barrier for asylum seekers and refugees seeking health and social services5. The majority of refugees have little or no English skills and have fear of and difficulty in expressing their medical symptoms. Mostly, the available services are in the majority language3. Therefore, people with a language barrier are unable to seek medical attention without an interpreter or translator. An interpreter helps in transferring the message from the health provider to the refugee and vice-versa. The role of interpreter is to hear concerns from both sides and provide accurate interpretation.

Even with interpreters, miscommunication can occur between doctors and patients due to the lack of proficient medical interpreters. This leads to inappropriate diagnosis, and devastating outcomes such as adverse drug effects, permanent disability, or even death5. Confusion might arise during a medical consultation with the use of complex medical terms providing information.5 The feelings of alienation and mistrust may continue to grow and may prevent the patient from seeking out future medical care.

Problems associated with an interpreter8:
Family or individual refuses
Male interpreter is present for a female client
Interpreter imposed his view
Family does not want to disclose sensitive information
Interpreter is not efficient
Added financial costs
Availability of a suitable interpreter

Health Literacy

Health literacy is the ability to get, process, understand and apply health information and services in order to make appropriate health decisions. 1 It involves the application of a wide range of skills, including reading, listening, numeracy, analytical, and decision-making skills, to health situations. Health literacy relies on general literacy skills, and has been described as “the bridge between literacy (and other) skills and abilities of the individual and the health context.” 2 However, even people with average general literacy skills might find health information too complex or technical. Inadequate health literacy hinders adherence to prescription and treatment instructions. 3 Also, people with low health literacy tend to be less healthy and are less likely to utilise disease prevention services and information. 4 They also have higher hospitalization rates and worse health outcomes. 5 Poor health literacy leads to increased health care costs, thus posing an economic burden to societies. Low health literacy has been found to be a major financial drain on the U.S health care system, costing the economy between $106 billion and $238 billion annually. 6

The refugees with low health literacy are less likely to understand written or verbal information from their healthcare providers, to follow medications or appointment schedules, or navigate the healthcare system to obtain medical care. Thus, leading to non-adherence to treatment. Low health literacy can have serious health consequences and puts additional demands on the healthcare system. According to the study, lack of health literacy resulted in difficulty in filling and refilling prescription medications, reading medicine labels, understanding the right dose, and taking medications at the right time12.

Subdimensions of Health Literacy

The 2012 European Health Literacy Survey identified 12 subdimensions of health literacy that refer to the competencies required for obtaining, understanding, processing, and using in health care, disease prevention and health promotion settings. These have been used as a conceptual basis to assess health literacy, and to develop interventions to address health literacy limitations.Health Literacy is the ability of an individual to obtain, process, and understand necessary health information. Low reading skills and poor English language comprehension make it challenging for the refugee to navigate in the new environment. Study shows that refugee with limited English Proficiency are more affected by the health literacy barrier than native English speakers.11

The refugees with low health literacy are less likely to understand written or verbal information from their healthcare providers, to follow medications or appointment schedules, or navigate the healthcare system to obtain medical care. Thus, leading to non-adherence to treatment. Low health literacy can have serious health consequences and puts additional demands on the healthcare system. According to the study, lack of health literacy resulted in difficulty in filling and refilling prescription medications, reading medicine labels, understanding the right dose, and taking medications at the right time12.

Principles of Health Literacy

As the delivery of health care services becomes more patient-centred, clear communication between patients and health care providers is of utmost importance. Patients need strong health literacy skills to adequately utilize health information and services. Health workers also need health literacy skills to effectively communicate health information to patients. 9 Even health systems need to be health literate in order to provide easy access to health care services and information, and to empower patients to adequately utilize the range of available services. 10 The following principles have been offered to guide the writing and designing of health information to ensure that they are aligned with the skills and abilities of the users.

  1. Planning: start planning by defining the communication objective and the target audience. Determine the needs, interests, and behaviours of the audience, as well as how best you can engage them. Also plan to involve the target audience during the development and testing phases of your production.
  2. Content: Clearly state your specific objectives in the title, cover illustration and introduction; avoid vague or numerous objectives. Ensure that your content is accurate and relevant, and that the main action points are summarized or repeated. Use effective translations or interpretations where necessary, and ensure that your content is relevant to the culture and demographics of the target audience. Keep the content clear, simple, and positive, and include information such as references, publication dates, and websites or phone numbers for further information.
  3. Literacy Demands: ensure that your writing is easy for your target audience to read and understand, by using common, everyday words. Avoid using unnecessary abbreviations and acronyms, jargons or technical terms, and abstract words. Use short sentences and paragraphs, and write with an active voice. Use numbers simply and directly; avoid complicated statistics or calculations, use whole numbers, and choose frequencies over percentages.
  4. Organization: organize your information in a logical way that is easy to follow. Emphasise important information by placing them at the beginning and at the end. Group information in small sections logically, and give the sections simple and explanatory headings.
  5. Layout and Typography: Choose clear font types (e.g. Times New Roman or Arial) in easily readable sizes (preferably 12-16 point). Limit the variation of fonts, and use a mix of upper and lowercase letters. Also utilize white space by separating paragraphs with a line or two, and breaking up blocks of text with graphics. Use bulleted lists, underlining and bold to emphasise key messages. Use colour to highlight, add clarity, or differentiate sections. And direct attention to specific content with shading, boxes, or arrows.
  6. Graphics: Use engaging pictures that are attractive, easy to recognize, and which highlight your objectives. Choose action-oriented graphics that reinforce the key messages, and that reflect the culture and demographics of the target audience. Also, ensure that graphics are simple andnot too busy.

Increasing Health Literacy

Patient education is an important aspect of physiotherapy practice, particularly in the context of self-management of chronic diseases. Chronic diseases are associated with several modifiable risk factors; understanding these risk factors and effecting the necessary lifestyle changes is essential to preventing and managing chronic diseases. Patients with limited health literacy tend to have higher prevalence of health risk factors, lower participation in disease prevention activities, and poorer self-management skills. The 2012 European Health Literacy Survey found a strong association between higher health

literacy and frequent physical activity. 11 Effective communication is essential to enable patients make better and informed health care decisions. Thus, physiotherapists should ensure that they provide information to patients in ways that enable the patients to understand and use such information. Physiotherapists can help minimize the problems of low health literacy by identifying and supporting patients with low literacy.

  • Use of screening tests to aid health providers in identifying patients with low health literacy12.
  • Creating a more readable health information12.  Physicians or staff can give health information cards/pamphlets to increase health literacy.10
  • Use communication tools in the form of pictures, audiotapes, interactive computer programs to convey health information12.
  • To compensate for poor reading skills, the patients depend on their listening skills, so the health care provider should speak clearly and slowly, avoiding medical jargon. It is essential to verify the patients' understanding and comprehension by making him repeat what they have understood regarding the diagnosis and treatment. 12
  • Educate children and adults about health issue12.

Overcoming Barriers

Overcoming Barriers to accessing care and providing guidance for navigating the healthcare system. Understanding of refugees’ expectations of the healthcare system and challenges faced by them is essential to improve and provide required healthcare services to the refugees. New roles should be developed for the health care staff for addressing diverse refugee groups who have dealt with exceptional life situations like war, separation, and death.5 There is a need to improve language and information services and create close links with community-based organizations.

Health services should engage in community-level interventions focusing on more culturally congruent services with the communities’ health constructions.5

Providing Culturally Sensitive Care Health Literacy and Cultural Competency video

Cultural sensitivity is essential in cross-cultural medical treatment. There is a need for more cultural health service providers. Strategies to support refugees should be developed. Increasing cultural awareness, cultural sensitivity, cultural education, and cultural competence among health professionals is extremely essential to provide quality care to culturally diverse patients8.

Formalising training to health care staff about understanding the health care needs of refugees is a must along with providing special treatment programs to traumatised refugees and asylum-seekers.

Healthcare providers must address cultural factors during initial assessments and investigations8,9. For example:

  • Taking a detailed medical history and conducting a physical exam. Cultural values inform the patients’ definition of health, the body and its functions, and the perception of the problem and cause
  • Inquiring about traditional treatments practiced. Alternative approaches exist in various cultures (like for reducing fever, hygiene, and beautification) and a wide range of practices and customs are practiced during major life events (childbirth and death)
  • Assessing care needs that often require the provider to view illness in a broad social context, rather than as an individual concern
  • Differentiating between cure and treatment, sharing information on health and wellness, and involving the patients’ family and community in care and medical decisions.

In the area of mental health, a broad continuum of mental health services including, psychosocial assessments, advocacy, home visits, case management, counselling, psychopharmacology, and asylum evaluations needs to be provided to refugees.  Agencies should encourage all of their staff to consider social adjustment issues from intake and throughout the refugee experience. Social adjustments and mental health issues must be included in the thinking of support staff working with refugees in order to serve them better. Employment counsellors should be trained to observe clients over a longer period to note difficulties that may arise and refer the candidates for counselling and other social services.9

There here is a need to engage in more community-level interventions with a focus on cultural congruence with the communities’ health constructions.

Culture-blaming issues is another issue that needs attention. It should be avoided and focus should be kept on developing strategies to support marginalized groups. Cultural safety requires genuine efforts to understand cultural barriers through community engagement and working with community members in addressing these barriers 5.

Providing Legal Status

It is necessary to address sanctions that situate stateless people in the host country. Migrants with legal documents have better access to health care.

It is important to invest and develop effective strategies that allow the provision of primary and preventive health services such as screenings, health promotion, and disease prevention for the vulnerable group21.

Increasing medical insurance coverage for refugees can help in getting access to health care facilities.

Access to Health Care Service

Lack of knowledge about how to navigate the complex health care system results in poor access to healthcare service.

  • Providing education about navigating the healthcare system9.
  • Increasing eligibility for Health Insurance may provide assistance9

Fast track schemes to integrate refugees

  • New public-private partnership for health surveillance,
  • delivering information about health promotion,
  • phone-based incentives and
  • sign-posting of essential health services.

Language and Information Services

In the absence of linguistically and culturally accessible care, refugees and immigrants may have difficulty developing trust and respect for, physicians and western medicine. There is a need to improve language and information services.

Access to language services, cultural awareness, and education of both provider and patient will remove misunderstandings among the patient and the health care provider.

Following should be implemented:

  • Language-assistance services should be provided at no cost to the patient, at all points of contact, promptly, and during all hours of operation;
  • Verbal and written notices informing patients of their right to receive language assistance should be made available
  • Unless requested by the patient, family members or friends should not serve as interpreters; and,
  • Patient-related materials and signage must be provided in the commonly encountered patient language group(s) 9.

Confusions during a medical consultation due to complex medical terminology used for providing information need to be corrected. There is a need to address cultural differences concerning symptomologies, diagnoses, and medical terminologies.5

Role of Interpreter Interpreter facilitates communication during the consultation and builds interpersonal trust. As discussed earlier, interpreters accompanying refugees need to be competent in interpreting medical language to prevent any errors. Interpreter should be trained to work with culturally diverse groups. In some cases, interpreters from the same community may involve fear of leaking personal information in their society; so, the interpreter should assist on request. In the absence of an interpreter, health providers can make use of non-verbal communication skills to express themselves adequately. Hand signals, visual cues, gestures, simple words slow speech, friendliness (approaching with smile/being calm/humor) can be used to communicate better.8

The use of telephone interpreters increases the availability of interpreters at any time of the day. Remote telephone interpreting services provided rapid access to various languages, and patient feels comfortable about confidentiality with a remote interpreter.

According to a pilot study evaluating the quality of care available to refugees, four themes reflected a ‘good doctor visit’. They were: 1. Ability to communicate without language barriers; 2. Open reciprocal dialogue with providers; 3. Provider professionalism; and 4. Accurate diagnosis and treatment.14

Translational Services

Providing qualified translational services will assist newly arrived refugees in accessing healthcare services9. Providing written cross-cultural health promotion material is required. Speech-to speech translation systems that convert speech in the source language to another speech in the target language can be developed and used for communication.

Cultural Competence in Physiotherapy

Physiotherapists should be aware of their own cultural identity. They should have cultural knowledge of common health beliefs and behaviors and should display culturally-sensitive behaviors (e.g., empathy, trust, acceptance, respect). They are required to use this knowledge and skills to modify their approach to meet the culturally-diverse needs of their clientele. Therefore, the ability to work with clients from diverse cultures is considered as a skill for improving clinical outcomes.

Brief Interventions for Physiotherapists working with refugees

Physiotherapist should identify the functional capacity of the client along with the functional deficits. The main focus should be on resources and current situation and future life opportunities.

Building a Therapeutic Relationship

The physiotherapist should create a working relationship with the client and establish trust and rapport.

The physiotherapist should show an attitude of understanding and interest to the client and should listen with empathy and face the emotions that the client wishes to express.

Confidentiality of the client's information must be assured.

Pay attention to how the client feels: whether he needs a break, or is okay to continue the sessions19.

Education and Information

Physiotherapists should educate the client about their condition and treatment options19.

Create a Safe Environment

A safe environment, so the client feels comfortable enough to express himself should be provided. The therapist should acknowledge the client’s present situation and past experiences. The physiotherapist should adapt to a pace that is tolerable for the client. Anything which triggers traumatic memories should be addressed immediately19.


Respect should be given for the client ́s boundaries during the physiotherapy session. For example-body positioning between the client and therapist and at what distance does the client feel comfortable?

Physical therapists should ask for permission from the client and explain the necessity of touch to the client before conducting the physical examination. A respectful contact, such as a firm handshake, establishes excellent rapport with the client19.

Facilitating Access to Physiotherapy Center

Many refugees may not be aware of Physiotherapy management options. Providing information about the services available through posters, images. Developing Diversity in Physical Therapy: The Importance of Cultural Competence video


The development of cultural competence is a developing learning process. The teamwork and collaboration among healthcare providers is essential. The refugee populations will benefit more from a culturally competent interaction.