Bridging  Barriers  to Care for Refugees and Immigrants

Annette Holland, Refugee Health Program Manager, Seattle and King County Public Health | Roda Scego, CNM, ARNP, Franciscan’s Highline Medical Center

The world’s population is increasingly on the move, a trend that has implications  for healthcare providers in the U.S. and abroad. Globally, nearly one in seven people is a migrant. According to the World Health Organization (WHO), around one-quarter of the world’s one billion migrants move across international borders. 

Some 68 million people are refugees, forcibly displaced from their homes and communities. With some 46 million immigrants (as of spring 2019), the U.S. is home to just under one-fifth of the world’s migrant population, more than any other country. 

The shifting nature of international immigration poses complex challenges to healthcare providers in the U.S., who may care for patients from diverse backgrounds with complex, rapidly changing healthcare needs. Refugees are often in general good health, according to the WHO, but experience higher rates of diabetes, work-related injuries, posttraumatic stress disorder, depression, and anxiety than the general population.

Children and those who have experienced torture are particularly vulnerable to PTSD and depression. The Center for Victims of Torture reports that 44 percent of refugees living in the U.S. have experienced torture, making them 2.5 times more likely to experience depression.  
By bridging common barriers to healthcare, providers can better serve newly arrived patients and help build stronger, healthier communities.  



Effective communication between patients and providers is foundational to quality healthcare. When patients and providers don’t speak the same language, important details may be missed or misinterpreted. “The biggest barrier [for refugees accessing healthcare] is language and communication,” says Annette Holland, Refugee Health Program Manager, Seattle and King County Public Health.
When friends or family members are used as interpreters in a healthcare setting, patient privacy may be compromised and complex medical terminology may be easily misunderstood. “In Public Health,  we work with qualified, certified interpreters who are experienced and have a good working knowledge of medical terminology,” Holland says. Newly arrived refugees may not know that they can request an interpreter during a medical visit and may not be in a position to advocate for one, she notes. 

High-quality interpretation is becoming more common in hospital and primarycare settings but is less common in smaller clinics, Holland says. “Physicians may not all know how easy it is to access an interpreter,” she says. “If you receive Medicaid funding, you are obligated by law to provide equal access to your medical services, and interpretation is part of that access. For instance, Washington State will pay for an interpreter involved in a Medicaid-covered visit, and signing up to access the interpreters is just a little hurdle for the physician or clinic on the administrative side.”

Digital tools, like Martti’s video-based interpretation platform and call-in interpretation services, can help make interpretation more accessible for providers and patients. “I would urge all providers who deal with patients with a language barrier to offer the opportunity for language interpretation, because even when patients say they understand, they may not understand the impact of the deep discussion that needs to take place,” says Roda Scego, CNM, ARNP, certified nurse midwife at CHI Franciscan’s Highline Medical Center  in Burien, Washington.



Healthcare providers who serve refugee and immigrant populations must navigate varying beliefs and preferences around nearly every aspect of care, from vaccinations and preventative care to end-of-life decisions. “A lot of people come from countries where you only go to the doctor when you’re sick, so one of the challenges is the idea of preventative care,” says Holland. 

Often, providers can mitigate these  challenges by simply taking time to ask patients about their background, she notes. “Sometimes, for example, a physician will suggest a dietary regimen that isn’t a good fit culturally,” she says.

Physicians need to think outside the box when caring for refugees and immigrants; thankfully, Holland points out, many providers already do, but there are always exceptions. “Someone from another country may be susceptible to different illnesses or diseases,” she says. “The average physician here might not think to screen for malaria, parasites, or certain vitamin deficiencies.” 

“I wish providers would take a little more  time with these types of patients,” says Scego. “Remember, these patients are  in a unique situation and need a little  more time and support.” 
Group medical appointments for refugee families can help providers navigate cultural differences and language barriers, says Holland. “If a physician sees a family of four or six together, as we do during refugee health-screening appointments, there are multiple benefits, including being able to spend more time with the family learning about their history and culture, and possibly using one interpreter instead of having to schedule all of these appointments separately,” she says.



Refugees and immigrants may be experiencing prolonged separations from loved ones that strain their physical and emotional health, says Scego. As a certified nurse midwife, she cares for many such patients through pregnancy and early parenthood. “I have multiple pregnant patients under my care who are separated from their spouses or partners and family members,” she says. “We’re talking about a woman who is forced to go through pregnancy and childbirth without the support of her loved ones.” 

This ongoing strain can lead to physical symptoms and trigger an emergencydepartment visit, “I see them coming into the emergency departments with psychosomatic symptoms, because the emotional symptoms have become physical problems,” she says. “We know from research that constant stress during pregnancy negatively impacts the health of the pregnant mother, as well as of the unborn baby. We also worry about the emotional connection between the mother and the child when the mother is so worried about her husband or partner in another country.” 

Expanding  Access to  Transportation

“Transportation can be a huge barrier to healthcare, and learning to navigate public transportation in a new country takes time. In King and Snohomish counties, we have a contract with HopeLink to provide transportation to health screenings for all newly arriving refugees. A publictransportation orientation program provides free guided tours that can help refugees and immigrants learn how to use public transportation and grow their confidence.” 


Connecting newly-arrived patients to services such as community groups, post-partum support, care navigators, and doulas can help create a network of support for these patients, Scego says.

And physicians who aren’t familiar with resources for refugees and immigrants can seek out a local resettlement agency, says Holland. “I would advocate for anyone who works with refugees to be familiar with the different local resettlement agencies,” she says. “They can be a lifeline for refugees when they arrive, and they can also be a resource for physicians.”


Sources: PIIS0140-6736(19)30035-2/fulltext SurvivorNumberMetaAnalysis_Sept2015_0.pdf