One of the authors of this post (Dr. Breckenridge) recently arrived at the airport to board her flight and was surprised to find it packed with people. It seemed strange, since she hadn't seen packed flights for several months due to the COVID-19 pandemic.  As she oriented herself to her surroundings, she realized she was standing in line with hundreds of Afghan nationals.  Images from the recent news about the Taliban overtaking the country flashed in her head.  She felt an overwhelming desire to welcome these people to the US. She wanted to thank those who had assisted our troops; but as she started to speak to the people next to her in line, she quickly became aware of the language barrier. She found herself frustrated and emotional. She wanted to be able to communicate with them. Her thoughts caused her to reflect further. How would she care for these families in her clinic? She also realized that she needed to learn more about their culture. These thoughts prompted her to write this piece to help other NPs who may encounter patients newly resettled in the US from Afghanistan.

Over 95,000 Afghan refugees are expected due to the recent crisis, and many began their US resettlement process in September 2021. What does the influx of Afghan refugees mean to our healthcare system and communities? What do we need to know about the health needs of this group of refugees? How can we integrate cultural sensitivity into our care for these individuals? What health issues should NPs be aware of when caring for these families and individuals? These are just some of the questions we must ask ourselves as we prepare to support this people group.

Life in Afghanistan 

Understanding the Afghan cultural environment is critical. Most of Afghanistan is rural countryside where farming is the primary source of income. It is a place where what you do as an occupation carries a lot of weight.  A teacher is held in high regard whereas being a barber is considered  less prestigious.   It is a place of ethnic diversity.  There are over 20 different ethnic groups living in Afghanistan.  Most people are Muslim, both Sunni and Shia.  Healthcare is sparse, especially for those who live in rural Afghanistan. The average lifespan is 51 to 54 years old, and the majority of the population is under the age of 15. Clean water is a privilege in much of the country. Land mines are not uncommon and frequently injure those not aware of their presence. Education in Afghanistan is different from the US. Public elementary school is available for children in urban areas but may or may not be available in rural settings. Middle and high schools are not common, so there is a high rate of illiteracy, though this does not reflect among  refugees.  Most refugees are educated and have worked with the U.S. Government as support staff and interpreters.  The role of women in Afghanistan has changed over the years. Some are now allowed to work, but all women continue to be required to dress conservatively with head coverings (hijab) or other “typical" Islamic dress.  Most men have a beard.  At one time men were jailed if they trimmed or cut their beard. The Afghan families live intergenerationally, often caring for older parents in their home.  Families are typically patriarchal.  Entertainment includes kite flying, soccer, and television (if you are privileged to have electricity).

Transition to US healthcare

Because the medical system in the US is different, Afghan patients may be reluctant to seek medical care as they are unfamiliar with healthcare environments.  Standard clinic routines we take for granted may need explanation.  Language barriers, cultural differences, and lack of relationships with medical providers are additional obstacles.  An example of cultural differences in medical care may be the presence of the husband at a woman's medical visit. The male will often do the talking for the woman. Providing proper interpretation services during a medical visit is essential. Although two primary languages (Pashto and Dari) are spoken in Afghanistan, many dialects exist. Additionally, lack of trust in the government is not uncommon. NPs must be sensitive to body language that could be misinterpreted such as a thumbs up sign and winking. Additionally, these families may struggle with punctuality since it is acceptable to show up unannounced or late in Afghanistan.

In the usual refugee resettlement process, refugees have a medical screening exam prior to leaving their home country and are screened upon arrival in the US with another special screening exam according to guidelines from the CDC and immigration services.  Because of the urgency to leave Afghanistan, many of the new arrivals did not have the usual pre-departure medical screening.   Each person receives a physical exam including mental health screening, communicable disease screening, immunization evaluation, and illicit drug use testing.  Communicable disease screening includes but is not limited to evaluation for tuberculosis and sexually transmitted illnesses. All are treated for parasites. Communicable illnesses that are common in Afghanistan are measles, cholera, smallpox, and respiratory infections such as Covid-19. 

In addition to healthcare needs, we must consider food insecurity among Afghan refugees. Refugee status provides 6 months of medical insurance and financial support from the US.  Changes to immigration regulations have provided these benefits to refugees whose applications are in process (known as “parolees" - an immigration term for an individual whose application for refugee status is in process), but there may be delays in getting the benefits established.  Despite support from the US government and refugee settlement organizations, refugees may find it difficult to overcome relocation barriers. Financial constraints, food preference, and anxiety are some of the concerns hindering food security.  Reluctance to seek mental healthcare is a common problem. Many experience trauma prior to immigrating. Anxiety, depression, and PTSD are frequently encountered; yet NPs may find that refugees are reluctant to seek treatment due to cultural stigma.

As access and cost are two additional significant hurdles to immigrant health, NPs can play a very beneficial role in providing healthcare to this vulnerable population.  Furthermore, immigrants report high satisfaction rates for those receiving care from NPs. 

Important tips for the NP

1. Stay alert for symptoms and signs of illnesses not often seen in the US but that may be present in refugees, particularly tuberculosis, measles, mumps, rubella, rabies, typhoid, pertussis, diphtheria, cholera, polio, chicken pox, Hepatitis A, Hepatitis E, scabies, malaria, leishmaniasis, and lead poisoning.
2. Although an initial screening is completed in the immigration process, chronic diseases are not addressed and may have gone untreated for long periods of time.
3. Routine healthcare recommendations may be unfamiliar or met with hesitancy. Being patient with refugees and being willing to educate them is crucial.
4. All patients should be evaluated for malnutrition.
5. Dental assessments should be included in physical exams.
6. Female patients should only be seen by female practitioners. Males can be evaluated by either male or female.
7. If caring for these refugees, verify their vaccination status.  Vaccines are part of immigration health services including COVID-19, flu, hepatitis, MMR, and Varicella vaccines.  
   

NPs strive to provide patient-centered and family-centered care to each patient they encounter.  To do this for Afghan refugees, they must understand their cultural environment.  Due to poverty, an unstable environment, and a lack of resources in Afghanistan, many refugees are at risk for illnesses that are not commonly seen in the US.  Many have endured trauma without access to mental healthcare resources.  NPs should adjust differentials to include communicable diseases, malnutrition, exposure to lead, and the effects of trauma.  As NPs seek to provide care to all members of an ever-changing community, this will include providing culturally sensitive care to Afghan families who have arrived in the US under the hardest of circumstances.