refugee health in minnesota carol berg, rn, mph public health manager, ucare [email protected]
TRANSCRIPT
Presentation Objectives
• Describe refugee and immigrant populations in Minnesota.
• Explain the MDH Refugee Health Program.• Cite the health needs assessed among new
arrivals.• Identify strategies to enhance culturally-
specific health care services for new arrival populations.
U.S.A.
U.S. Citizen
Non-Citizen
Persons fleeing from persecution
LPR
Immigrant
LTR authorized employment
Non-Immigrant
student tourist
refugee asylee parolee
undocumented individual
visitor on business
8/03
USCIS Definitions
What does it mean to be a refugee?
• Foreign-born resident who:• is not a United States citizen • cannot return to his or her country of origin because
of a well-founded fear of persecution due to race, religion, nationality, political opinion, or membership in a particular social group
• Refugee status is generally given: • prior to entering the United States• by the Bureau of Citizenship & Immigrant Services
(USCIS)• Eligible for up to 8 months of public assistance.
What does it mean to be an immigrant?
• Foreign-born resident who:• is not a United States citizen • is defined by U.S. immigration law as a person
lawfully admitted for permanent residence in the United States
• either arrives in the U.S. with an immigrant visa issued abroad, or adjusts their status in the U.S. from temporary to permanent resident
• may be subjected to a numerical cap
What does it mean to be an asylee?
• Foreign-born resident who:• is not a United States citizen • cannot return to his or her country of origin
because of a well-founded fear of persecution • due to race, religion, nationality, political
opinion, or membership in a particular social group
• Asylee status is generally given: • after entering the United States • by the State Department or USCIS
What does it mean to be a parolee?
• Foreign-born resident who:• is not a United States citizen • has been given special permission to enter
the United States:- under emergency conditions or
- when that person's entry into the U.S. is considered to be in the public's interest
Migrants to Minnesota
• Primary Migrants to Minnesota• Foreign-born persons whose primary state of
resettlement in the U.S. was Minnesota• Arrival notification from CDC
• Secondary Migrants to Minnesota• Significant movement of refugees/ immigrants
from state of primary arrival• Health information requested from primary
arrival state• If no information is available, baseline health
assessment should be done
• To control communicable disease among, and resulting from, the arrival of new refugees through:
• health assessment
• treatment
• referral
Refugee Health Program Goal
Functions of MDH Refugee Health Program
• Coordinate initial health assessments,
• Educate providers regarding screening protocols,
• Administer contacts with local health departments for refugee screening,
• Collect and disseminate health screening data,
• Collaborate with Volags, MAAs, and other community based organizations,
• Provide health resources for foreign-born populations and their health care providers.
Quarantine Station/CDCQuarantine Station/CDC
MDHMDH
Local Health Dept.Local Health Dept.
ScreensScreensForwards to
primary providerForwards to
primary provider
Primary providerscreens
Primary providerscreens
Screening formcompleted & returned
Screening formcompleted & returned
Refugee Health AssessmentInformation Flow
Volags (Volunteer Agencies): Local Organizations or Affiliates
• Catholic Charities (CC)
• Lutheran Social Services (LSS)
• Jewish Family Services or Minneapolis Jewish Family and Children's Services (JFS)
• MN Council of Churches (MCC)
• International Institute of Minnesota (IIM)
• World Relief Minnesota (WRM)
Mutual Assistance Associations (MAAs)*
• Amigos de las Americas• Association for the
Advancement of Hmong Women in MN
• Center for Asians and Pacific Islanders
• CLUES• Confederation of Somali in MN• Ethiopian Community in MN• Hmong American Mutual
Assistance Assoc.• Hmong American Partnership• Intercultural Mutual Assistance
Association
• Islamic Center of MN• Lao Assistance Center of MN• Lao Family Community• Oromo Community of MN• SEA Community Council• Slavic Community Center• Somali Family Services• United Cambodian Association
of MN• Vietnamese Social Services• West African Mutual Aide
Association *List not comprehensive
Refugee Arrivals to MN by Region of World Refugee Arrivals to MN by Region of World 1979-20101979-2010
0
1000
2000
3000
4000
5000
6000
7000
800019
79
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Nu
mb
er
of
arr
iva
ls
Southeast Asia Sub-Saharan Africa Eastern EuropeFSU Middle East/North Africa Other
Refugee Health Program, Minnesota Department of Health
Lake
Cook
Le Sueur
RiceGoodhue
NoblesRock Jackson Martin Faribault Freeborn Mower Fillmore Houston
WinonaOlmstedDodgeSteeleWasecaBlue EarthWatonwanCottonwood
MurrayPipestone
Nicollet
Wabasha
DakotaScott
Wash-ing-ton
Chisago
Isanti
Brown
Sibley
Carver
Hennepin
WrightMeeker
Kandiyohi
Renville
Redwood
Sherburne
LyonLincoln
Yellow Medicine
Lac Qui Parle
Swift
Big Stone
PopeStevensTraverse
Chippewa
StearnsBenton
Carlton
Pine
Kanabec
MilleLacs
Aitkin
Crow Wing
Morrison
CassHubbard
Wadena
Todd
DouglasGrant
OttertailWilkin
BeckerClay
ClearWater
MahnomenNorman
Red Lake
PenningtonPolk
Beltrami
Marshall
Itasca
Koochiching
Lakeof theWoods
RoseauKittson
St. Louis
McLeod
71Anoka
Hennepin
Number of Refugees Arrival By Initial County Of Resettlement
2010 Primary Refugee Arrival 2010 Primary Refugee Arrival To Minnesota (N=2,320) To Minnesota (N=2,320)
Ram- sey
0
1- 20
21 - 50
51 - 100
101 - 300
301 – 1,000
1,001 – 2,000
Primary Refugee Arrivals, Minnesota2010
Haiti
1%Other
5%
Congo (DR)
1%
Eritrea
2%FSU
2%Laos/Hmong
2%Ethiopia
4%Bhutan
8%
Iraq
10%
Somalia
29%
Burma
36%
N=2,320
“Other” includes Afghanistan, Cambodia, Cameroon, China (incl. Tibet), Colombia, Cuba, Guinea, Kenya, Liberia, Mali, Mexico, Nigeria, Rwanda, Saudi Arabia, Sierra Leone, Sudan and Togo
Refugee Health Program, Minnesota Department of Health
*“FSU” includes Armenia, Belarus, Kyrgyzstan, Moldova, Ukraine and Uzbekistan
African Refugee Family Reunification Suspended
The State Department announced that the U.S. family-reunification program for African refugees has been suspended after DNA testing of applicants revealed widespread fraud. The suspension affects family members seeking to join East Africans, and some Liberians, already in the United States.
Minnesota only accepted through the family reunification program (P-3) until June 2008.
Source: Voice of America, August 20, 2008
“Free Cases” or “Families without U.S. Ties”
Def.-: Refugees who do not have family ties or anchors residing in the U.S. or the resettlement state
With the change in resettlement policy, Minnesota started accepting “Free Cases” in July 2008:– From July 2008 – Present: 849 (27%) of 3,166 arrivals
came as “Free Cases”• 2008: 44 (4%)• 2009: 178 (14%)• 2010: 959 (41%)
– Top Countries: Somalia, Burma and Iraq
Primary Refugees without U.S. Ties (Free Cases)Minnesota, 2010
Other1%
Ethiopia2%
Eritrea3%
Burma26%
Somalia43%
Congo (DR)3%
Bhutan10%
Iraq12%
Refugee Health Program, Minnesota Department of Health
N=959
‘Other’ includes Cuba and Sudan
“New” Refugee Populations
2008 to Present
Burma (Myanmar)
1948 - 1974
1974 - 2010
2010 -
Background
• Over 140, 000 refugees along Thai-Burmese border since 1984 (Temporary Protection) o Students with claims of political
persecution versus Ethnic Minorities
– U.S.A: Expected to resettle
in the US during 10 yrs starting FY2006
– Minnesota: Burmese started arriving in 2003; the KaRen/Burmese starting 2006
To date: 3,372 arrivals
Source: Human rights watch and US State Department
Fiscal Year US Arrivals
2006 1,612
2007 13,986
2008 18,139
2009 18,275
2010 16,693
2011 (Jul) 14,089
Bhutan
Background
• Over 106, 000 Nepali speaking Bhutanese (Lothsampas) refugees expelled from Southern Bhutan in the early 1990s; currently refugees are living in 7 camps in Nepal
• Cultural, linguistic expressions denied; Bhutan has denied their right to return to their country
• U.S.A: At least 60,00 are expected to resettle in the US - special humanitarian
concern
• Minnesota: Bhutanese refugees started arriving in May 2008 To date: 456 arrivals
Source: Human Rights Watch and US State Department
Fiscal Year US Arrivals
2008 5,320
2009 13,317
2010 12,363
2011 (Jul) 10,816
IRAQ
1991-2004 20081963-1991 2004-2008
Background
• Iraqi refugees (2.2 Million) Syria (~500,000) Jordan (~1.4 million) Other (~360,000)
• U.S.A: 30,000 referred
• Minnesota: Iraqi refugees started arriving in April 2008
To date: 445 arrivals
Source: Human Rights First and US State Department
Fiscal Year US Arrivals
2006 202
2007 1,608
2008 13,822
2009 18,838
2010 18,016
2011 (Jul) 7,544
Refugee Admissions Ceilings for FY2011Refugee Admissions Ceilings for FY2011
Europe/Central Asia
3%Latin America/Caribbean
7%
East Asia26%
Africa15%
Unallocated0%
Near East/South Asia
49%
Africa East Asia Europe/Central Asia
Latin America/Caribbean Near East/South Asia Unallocated
N=80,000
Source: US Department of State
Types of Medical Exams
Overseas Visa Medical ExaminationU.S. Public Health Service
Domestic Refugee Health AssessmentMinnesota Department of Health
Adjustment of Status Medical ExaminationFrom temporary to permanent residentNeeded to obtain a green cardUS Citizenship and Immigration Service
Adjustment of Status Exam(Green Card Exam)
Immigrants: exam done by Civil Surgeon required
Refugees: immunizations only (unless arrived with Class A condition); local Public Health can act as Civil Surgeon
Forms are found at www.uscis.govCall MDH for more guidance
Health Status of New Refugees, Minnesota, 2010‡
Health status upon arrival No of refugees No(%) with infection screened among screened
TB infection* 2,086 (95%) 570 (27%)
Hepatitis B infection** 2,160 (98%) 112 (5%)
Parasitic Infection*** 2,106 (96%) 471 (22%)
Sexually Transmitted 1,765 (80%) 28 (2%)
Infections (STIs)****
Malaria Infection 234 (11%) 0 (0%)
Lead***** 833 (87%) 16 (2%)
Hemoglobin 2,151 (98%) 437 (20%)
Refugee Health Program, Minnesota Department of Health
‡ 2010 Preliminary results for arrivals between 01/01/2010 and 12/31/2010Total screened: N=2,193 (98% of 2,242 eligible refugees) * Persons with LTBI (>= 10mm induration or IGRA+, normal CXR) or suspect/active TB disease** Positive for Hepatitis B surface antigen (HBsAG)
*** Positive for at least one intestinal parasite infection
**** Positive for at least one STI
*****Children <17 years old (N=954 RHAs)
Health Status of New Refugees, MinnesotaImmunization Status, 2002-2010
0102030405060708090
100
Per
cent
2002
2003
2004
2005
2006
2007
2008
2009
2010
Year
Overseas
Domestic
Refugee Health Program, Minnesota Department of Health
Health Status of New Refugees Upon Arrival to MN, 2010*
Screening rate 98% (2,193/2,242)
Immunizations 91% (2,003/2,193) started or continued age-appropriate vaccinations after health screening
Tuberculosis 27% (570/2,086)
Latent TB infection or suspect/active TB case
Hepatitis B 5% (112/2,160) HBsAg positive
*Preliminary Results
Health Status of New Refugees Upon Arrival to MN, 2010*, cont’d
Parasitic infection 22% (471/2,106) Tested positive for at least one intestinal parasite(common: Strongyloides, Giardia, Schistosoma, Trichuris, E. histolytica)
Lead level (<17 y.o.) 2% (16/833)
Hemoglobin 20% (437/2,151) less than 12gm/dL
ReferralsPrimary Care (51%), Pediatrics (43% of <18 yrs), Dental (37%), Public Health Nurse (13%), Vision (8%)
*Preliminary results
39%
14%
16%
20%
40%
27%
0% 10% 20% 30% 40% 50%
13/33
201/1,004
N=2,086 screened
*Diagnosis of Latent TB infection (N=568) or Suspect/Active TB disease (N=2)
Refugee Health Program, Minnesota Department of Health
Tuberculosis Infection* Among Refugees By Region Of Origin, Minnesota, 2010
320/803
570/2,086
32/221
4/25
*Preliminary results
Hepatitis B infection Among Refugees by Region of Origin, Minnesota, 2010
0%
0%
4%
7%
4%
5%
0% 2% 4% 6% 8% 10%
Europe
North Africa/Middle East
Latin America/Caribbean
SE/East Asia
Sub-Saharan Africa
Overall Hepatitis BInfection Rate
Refugee Health Program, Minnesota Department of Health
N=2,160 screened
112/2,160
37/834
74/1,039
0/32
0/227
1/28
*Preliminary results
Intestinal Parasitic Infection* Among Refugees by Region of Origin, Minnesota, 2010
9%
16%
47%
26%
18%
22%
0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50%
Europe
North Africa/Middle East
LatinAmerica/Caribbean
SE/East Asia
Sub-Saharan Africa
Overall ParasiticInfection Rate
* At least one stool parasite found (including nonpathogenic)Refugee Health Program, Minnesota Department of Health
471/2,106
149/812
271/1,025
3/33
*At least one type of pathogenic intestinal parasite
N=2,106 screened
15/32
33/204
*Preliminary results
Infectious Disease – Infectious Disease – TB, parasites, hep BTB, parasites, hep B
NutritionalNutritional Deficits – poverty, diseaseDeficits – poverty, disease
Immunizations – Immunizations – required for schoolrequired for school
Mental Health – Mental Health – loss, fear, adjustmentloss, fear, adjustment
Access to care – Access to care – how, why, when, wherehow, why, when, where
Interpreters – Interpreters – language/culturallanguage/cultural
Costs –Costs –insured, under-insured, no insuranceinsured, under-insured, no insurance
Source: MDH Refugee Health Program
Health Concerns: Immediate
Chronic Disease – Chronic Disease – diabetes, hypertension, diabetes, hypertension, obesity, work hazards, TB in frail and elderlyobesity, work hazards, TB in frail and elderly
Mental Health – Mental Health – family role and self family role and self
definitiondefinition adjustment, isolation, lack of adjustment, isolation, lack of supportsupport
Access to care – Access to care – misunderstanding and misunderstanding and mistrust of systemmistrust of system
Interpreters – Interpreters – language/culturallanguage/cultural
Costs –Costs –insured, under-insured, no insuranceinsured, under-insured, no insurance
Health Concerns: Long Term
Limitations of Domestic Screening
• Elective on parts of both state and refugee
• Wide variation in quality and comprehensiveness across states
• Funding sources may be limited• Clinics’ and clinicians’ experience/
expertise in working with newly arrived refugees &/or tropical medicine varies state to state
Areas of Need in Resettlement• Applying for Social Security number, public
assistance, photo ID• Education; English language classes• Employment services• Housing, food, furniture, clothing
(www.211unitedway.org)• Health care services: physical, mental, spiritual• Ethnic-specific support services (MAAs or other
community agencies); www.iimn.org (ethnic resource directory)
• Legal Assistance
Strategies to Enhance Culturally Competent Care
• Cultural Assessment (incorporate tool, results in medical record)
• Other considerations: – interpreter services (Interpreting Stakeholder
Group)– bilingual/bicultural staff– appropriate education resources (www.health-
exchange.net)• Appoint staff as cultural resources
(www.culturecareconnection.org)• PHN and community-based follow-up
Interpreting Stakeholder GroupISG works to improve the quality and delivery of spoken language and interpreter services in Minnesota, and to promote the professionalization of the interpreting industry as a whole.
http://www.isgmidwest.org
Strategies to Enhance Culturally Competent Care
• Cultural Assessment (incorporate tool, results in medical record)
• Other considerations: – interpreter services (Interpreting Stakeholder
Group)– bilingual/bicultural staff– appropriate education resources (www.health-
exchange.net)
• Appoint staff as cultural resources• PHN and community-based follow-up
Stratis Health – Culture Care Connection
An online learning and resource center aimed at supporting health care providers, staff, and administrators in their ongoing efforts to provide culturally competent care.
www.culturecareconnection.org
Diversity In Minnesota – Information Sheets
Somalis in Minnesota Hmong in Minnesota
http://www.culturecareconnection.org/matters/diversity/somali.html
Know Your Community: County ProfilesCounty profiles detail pertinent demographic, socioeconomic, and health
status data, with information about vulnerable populations. County Profiles offer providers and administrators an in-depth view of the communities they serve. This information can be used in strategic planning to ensure the provision of culturally and linguistically appropriate health services. http://www.culturecareconnection.org/navigating/mncountyprofiles.html
Minnesota Health Literacy PartnershipMHLP, a program of the Minnesota Health Literacy Council, was formed to help coordinate health literacy efforts across the state. The partnership is comprised of health care organizations, consumers, and literacy groups, as well as the state’s health and social service agencies, and has worked with a number of local organizations to develop health literacy training, patient education materials, and toolkits.
www.healthliteracymn.org
• Radio shows• ESL• Ethnic press• ECHO TV• Global Brown bags (for staff)• Metro Refugee Health Task Force• Community health forums• Etc!
Community Health Education
L Listen with empathy to the client’s perception of the problem
E Explain your perceptions of the problem
A Acknowledge and discuss the differences and similarities
R Recommend treatment
N Negotiate agreementBerlin, E. A. and Fowkes, W.C., 1983
LEARN
• Improve access to care• Data collection and analysis• Equitable payment for immigrant health services• Develop clinical guidelines• Diversify workforce• Use trained interpreters• Use CHWs• Train providers and educate new immigrants.
MN Immigrant Health Task Force, MDH, 2004
Immigrant Health Task Force
Contact Information - 2011
• MDH Refugee Health Staff:
651-201-5414
• MDH Refugee Health Program:
www.health.state.mn.us/refugee
• Metro Refugee Health Task Force
Sara Chute: [email protected]