Cultural Competence in the Refugee Context
- 1 Introduction
- 2 Stages of the Migration Process
- 3 Influence of Migration on Refugees’ Health
- 4 Barriers to Accessing Healthcare
- 5 Overcoming Barriers
- 6 Providing Culturally Sensitive Care
- 7 Providing Legal Status
- 8 Access to Health Care Service
- 9 Language and Information Services
- 10 Cultural Competence in Physiotherapy
- 11 Summary
- 12 Resources
- 13 References
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. The word 'competence' implies having the capacity to function effectively as an individual and as an organization with the context of cultural beliefs and behaviours.
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. 
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 survivors of persecution and multi-violence including war and torture. The migratory experience has a profound effect on their overall well-being especially Mental Health. 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. Many also experience 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 migrants pursue to gain 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 to Accessing Healthcare
Accessing health care and social care support and services becomes a challenge for refugees. 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)
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. 
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. 
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 deportation. 
Research suggests that communication difficulties with service providers act as a critical barrier for asylum seekers and refugees seeking health and social services.  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 language.  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 death. Confusion might arise during a medical consultation with the use of complex medical terms providing information.  The feelings of alienation and mistrust may continue to grow and may prevent the patient from seeking out future medical care. 
Problems Associated with Interpreter 
- Family or individual refuses
- Male interpreter is present for a female client
- Interpreter imposes own view
- Family does not want to disclose sensitive information
- Availability of a suitable interpreter
- Interpreter is not efficient
- Added financial costs
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. 
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 time. 
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.  There is a need to improve language and information services and create close links with community-based organisations. Health services should engage in community-level interventions focusing on more culturally congruent services with the communities’ health constructions.
Providing Culturally Sensitive Care
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 patients. 
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. 
- 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.
There 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. 
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 group.  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 system. 
- Increasing eligibility for Health Insurance may provide assistance. 
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. The 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). 
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. 
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.
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:
- Ability to communicate without language barriers;
- Open reciprocal dialogue with providers;
- Provider professionalism; and
- Accurate diagnosis and treatment. 
Providing qualified translational services will assist newly arrived refugees in accessing healthcare services.  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. They 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 they need a break, or are okay to continue the sessions. 
Education and Information
Physiotherapists should educate the client about their condition and treatment options. 
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 immediately. 
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? Physiotherapists 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 client. 
Facilitating Access to Physiotherapy Center
Many refugees may not be aware of Physiotherapy management options. Providing information about the services available through posters, images.
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. 
- Designed for humanitarian response, Translation Cards is an app for Android devices that allows for tap-and-play audio translations, even in the most remote bandwidth-constrained locations. Each card contains an audio translation, optional text translation, and works across multiple languages. Any organisation can rapidly create a deck of cards catered to their own specific use cases. Translation Cards is available on the Google Play Store for free. The app comes bundled with a default deck designed by UNHCR Innovation for humanitarian refugee crisis response in Europe.
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