Running Head: PATIENT EDUCATINO FOR REFUGEES

Stress
By definition, a refugee is someone that has been displaced from home (Williams, 1986).
In addition to challenges that accompany displacement, many refugees face challenges that can
compromise their mental health. Therefore, refugees often have increased levels of stress related
to issues such as identity and belonging (Hollifield, Fullilove, & Hobfoll, 2011). Furthermore, in
resettlement, refugees are faced with many difficult tasks such as finding employment,
overcoming language barriers, and creating community in a foreign place. This only adds to the
stress that refugees may have experienced as a result of life events such as political or religious
oppression, war, and migration (Refugee, 2011).
Despite the high incidence of stressful events that refugees endure, most refugees are
incredibly resilient and do not suffer from a psychiatric disorder (Refugee Health, 2011).
However, distress takes many different forms and all people experience stress differently.
Therefore, it is important to recognize that a large majority of refugees do need help to cope with
the stressors they have experienced in the past and those that accompany resettlement. It is
critical that health care providers conduct screening for stress and mental health conditions when
proving care to refugees. One mental health-screening tool that is widely used to screen refugees
for mental health disorders is the Refugee Health Screener-15 (RHS-15). This tool is designed to
be both short and effective and can be used by any provider caring for refugees (Hollifield et.al.,
2013). In addition to using mental health screening tools in order to identify and refer individuals
who may have a mental health disorder to a psychologist, health care providers can provide
valuable education to refugees on how to minimize and manage everyday stress experienced
during resettlement.

PATIENT EDUCATION FOR REFUGEES

Health care providers can help patients create a stress management plan that includes
simple tips to minimize stress. According to the CDC and the U.S. Committee for Refugees and
Immigration (USCRI), this may include: effective self care behaviors such as eating healthy
well-balanced meals, promoting a healthy sleep pattern, and exercising; talking to friends or
family about feelings and coping; avoiding drugs and alcohol; and finding simple things that
bring joy such as reading a book (CDC, 2015; USCRI, 2015). Furthermore, health care providers
can help patients identify signs and symptoms of depression or more serious mental health
disorders that require more specific management and therapy.
Oral Health
Oral health is a vital aspect of personal care. Oral abnormalities are among the most
common health conditions in refugees that arrive in the United States (Cote et.al., 2004). Prior to
resettlement, many refugees have poor oral health as a result of an inadequate diet, lack of access
to resources and education on dental health, and in some instances cultural practices that result in
trauma to the teeth (Sing et.al., 2008). During resettlement in the United States many refugees do
not have knowledge or access to dental care, which can potentiate poor oral health. Furthermore,
according the U.S. Department of Health and Human Services (USHHS), lack of financial
resources and language barriers may prevent many refugees from seeking oral health care
(USHHS, 2005). In addition to these barriers, poor oral health in the refugee population is often
attributed to dietary changes that accompany living in the United States. For example, people
may eat more refined sugars because of easy access, which in return can cause an increased
number of dental caries (Marino, Stuart, Wright, Minas, & Klimidis, 2001).
The U.S. Committee for Refugees and Immigrants (USCRI) advises health care providers
to promote proper oral hygiene by educating refugees on the importance of daily tooth brushing

PATIENT EDUCATION FOR REFUGEES

and flossing. Teeth should be brushed two to three times per day with toothpaste. They should
also floss daily to remove food that remains in between teeth (USCRI, 2015). In addition, the
Mayo Clinic encourages annual professional cleanings and evaluations (Mayo Clinic, 2013).
Furthermore, it is crucial that providers educate patients who are refugees about the
consequences of consuming a large amount of sugar in their diets. Patients should be educated to
avoid drinks high in sugar such as sodas and to rinse their mouths with water after drinking
sodas, coffee, and teas (USCRI, 2015).
Nutrition
According to the CDC, approximately 1 in 3 adults are obese in the United States (CDC,
2015). In addition, obesity is more prevalent in lower SES populations, such as refugees (CDC,
2015). Lack of physical activity and proper nutrition can eventually lead to other health problems
such as heart disease and diabetes (CDC, 2015). These health problems only magnified in
vulnerable populations. When refugees arrive in a new country, two main concerns include overnutrition and under-nutrition (Rondinelli et al., 2010). Excessive weight gain is a real problem
when refugees arrive due to social pressures, unhealthy food choices, and a more sedentary
lifestyle. On the other hand, under- nutrition is also a problem due to poor diets and lack of food
resources (Rodineli et al., 2010). In addition, lack of certain vitamins and foods can lead to other
health problems such as anemia, in the refugee population. In fact, up to 75% of African refugees
can be affected by an iron deficiency that leads to anemia (Seal, et al., 2005). Vitamin A
deficiencies are also common among the African refugees, leading to other health concerns
(Seal, et al., 2005). The nutrition of this population is crucial to the status of their health and how
well they are able to flourish as they begin the process of resettlement.

PATIENT EDUCATION FOR REFUGEES

As health care providers, it is important to address the nutritional needs of this population
and educate them on the importance of a healthy and well-balanced diet. Making sure that they
know what they put in their mouths affects the way they feel each day. Some nutritional
knowledge that this population should know include: increasing the amount of fruits and
vegetable to make sure the body gets enough vitamins and minerals, consuming whole grains to
prevent certain diseases and maintaining a healthy digestive tract, decreasing the amount of fats,
salts, and sugars in your diet, and staying physically active (USCRI, 2015).
Sleep
Although a critical part of health, sleep is often overlooked. In fact, sleep or lack of sleep
is considered a determinant of health status (Luyster et al., 2012). About 37% of adults, or every
1 in 3, are getting less than the recommended 7 hours of sleep, and the percentages increase
when looking at children and adolescents. Lack of sleep causes molecular, immune, and neural
changes that can lead to development of diseases, impairment in cognitive and motor
performances, and even a shortened lifespan (Luyster et al., 2012). The effects of lack of sleep
are only magnified when dealing with a vulnerable population such as the refugee population.
In addition to the daily stress effecting sleep and sleeping patterns, the refugee population
has other circumstances that are also contributing to a disrupted sleeping pattern. For example,
some Cambodian refugees experience a sleep paralysis that may produce hallucinations or night
terrors that can dramatically interrupt sleep (Hinton, 2005). In addition, many refugees
experience PTSD that can produce nightmares or increase anxiety, both negatively affecting the
quality of sleep (Hinton, 2005). The lack of quality sleep can lead to negative health outcomes
for this population and an overall negative effect on flourishing.
As future health care providers, it is crucial that we address the concerns of this
population. Refugees may have multiple issues in which they are seeking health care for, but it is

PATIENT EDUCATION FOR REFUGEES

important that we do not overlook their amount and quality of sleep. It is also just as important, if
not more important, to educate this population on how critical sleep is to their health outcomes
and appropriate sleep hygiene techniques that help improve amount and quality of sleep. Some
key sleep hygiene tips that can be given to this population include: create a regular sleep
schedule and routine, avoid caffeine, use bed only for sleeping, exercise regularly, and eat a
healthy, balanced diet (Centre for Clinical Interventions, 2008)
PTSD in the Refugee Population
Refugees are one of the most vulnerable groups in terms of experiencing trauma, stress,
instability and violence (Keller et al., 2006). Often times refugees are victims of coercion, rape,
torture and death threats repeatedly and both in their past and present (Keller et al., 2006). These
experiences in conjunction with their general instability in daily lives can lead to exacerbations
of anxiety as well as Post Traumatic Stress Disorder (PTSD) (Keller et al., 2006). PTSD is
associated with anxiety, depression, and suicidal ideation that can severely inhibit their daily
lives (Keller et al., 2006). The vast majority of refugees display significant depressive symptoms
and most of them do not have access to treatment plans (Keller et al., 2006).
This is a population for which mental health is of particular importance. There are
significant and life-altering sequelae of experiencing repeated trauma and of prolonged stress
(Refugee, 2011). There are potential therapies that can be employed to combat the symptoms of
PTSD such as a Torture Treatment Program (Keller et al., 2006). Providers need to be cognizant
of cultural and language barriers when dealing with PTSD, as it is easy to miss signs. One tool
that is used to determine the degree of emotional distress is the Refugee Health Screener (RHS15) (Refugee, 2011). There are various resettlement interventions that can be utilized by
providers when dealing with a traumatic history such as community-based therapy and

PATIENT EDUCATION FOR REFUGEES

psychosocial and pharmacological interventions (Murray, Davidson, & Schweitzer, 2010). These
interventions seek to encourage personal growth and a secure sense of community with goals of
reducing anxiety and depressive symptoms (Murray, Davidson, & Schweitzer, 2010). In order to
address the needs of this vulnerable population rapid identification through early screening and
consistent treatment are instrumental in the improved mental health of trauma survivors (Keller
et al., 2006).
Response to Sexual and Gender based Violence in Refugee Populations
Refugees are at an alarming risk of experiencing gender-based violence (GBV) such as
domestic violence, rape, trafficking, and sexual violence (Ward, 2002). In war torn areas rape is
employed as a weapon of war and the ensuing aftermath and instability is incredibly dangerous
for refugees who often have no security whatsoever (Bott, Morrison, & Ellsberg, 2005).
Emotional dependence on top of physical instability and adds another layer of complexity to an
already challenging issue to address (Bott, Morrison, & Ellsberg, 2005).
In the event that this violence cannot be prevented through provision of adequate safety
measures such as lights and basic human needs it is imperative that victims have access to
medical services, emergency contraception and psychosocial support (Ward, 2002). The most
three commonly measured types of GBV against refugee women are intimate partner violence,
physical violence and rape (Stark & Ager, 2011). With these significant, traumatic and life
changing examples of violence against women it is pivotal that providers are aware of these
issues and cultural situations so they can appropriately screen for past and current violence and
hopefully educate in order to prevent future violence.
Not only is an immediate response pivotal but the continuation of programs and therapies
is instrumental in the coping capabilities of the victims of gender based violence (Ward, 2002).

PATIENT EDUCATION FOR REFUGEES

GBV needs to be addressed in a preventative capacity through programs and in the field and then
valid assessment tools should be employed to help the victims (Ward, 2002). There is also a great
need for training materials related to GBV in all aspects from preventative programs and
assessments to psychosocial therapies (Ward, 2002).

PATIENT EDUCATION FOR REFUGEES

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