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© 2009 American Public Health Association
DOI: 10.2105/AJPH.2008.154054
ANALYTIC ESSAY FORUMS |
Benedict I. Truman is with the Office of Minority Health and Health Disparities, Centers for Disease Control and Prevention, Atlanta, GA. Bryan K. Kapella is with the Division of Global Migration and Quarantine, Centers for Disease Control and Prevention, Atlanta, GA. Timothy Tinker is with Booz Allen Hamilton, McLean, VA. Elaine Vaughan is with the University of California, Irvine. Marta Brenden is with the Division of Refugee Assistance, Office of Refugee Resettlement, Administration for Children and Families, Washington, DC. At the time of the study, Celine V. Woznica was with the Heartland Alliance for Human Needs and Human Rights, Chicago, IL. Elena Rios is with the National Hispanic Medical Association, Washington, DC. Maureen Lichtveld is with Tulane University, New Orleans, LA.
Correspondence: Reprint requests should be sent to Benedict I. Truman, Office of Minority Health and Health Disparities, Office of the Chief of Public Health Practice, Office of the Director, Centers for Disease Control and Prevention, 1600 Clifton Rd, NE, Mailstop E-67, Atlanta, GA 30333 (e-mail: btruman{at}cdc.gov).
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ABSTRACT |
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Some immigrants and refugees might be more vulnerable than other groups to pandemic influenza because of preexisting health and social disparities, migration history, and living conditions in the United States.
Vulnerable populations and their service providers need information to overcome limited resources, inaccessible health services, limited English proficiency and foreign language barriers, cross-cultural misunderstanding, and inexperience applying recommended guidelines. To increase the utility of guidelines, we searched the literature, synthesized relevant findings, and examined their implications for vulnerable populations and stakeholders.
Here we summarize advice from an expert panel of public health scientists and service program managers who attended a meeting convened by the Centers for Disease Control and Prevention, May 1 and 2, 2008, in Atlanta, Georgia.
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INTRODUCTION |
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IN APPLYING PREPARATION and response guidelines for pandemic influenza, providers of health and social services to immigrants and refugees must help them to overcome obstacles typical of migration histories and circumstances in the United States. As defined in US immigration law, an immigrant is a person who enters the country as a lawful permanent resident or who is granted that status after arrival.1 A refugee in the United States is a person living outside his or her country of permanent allegiance (nationality) and unable or unwilling to return there because of persecution or a well-founded fear of persecution arising from the refugee's race, religion, nationality, membership in a social group, or political opinion. Although the criteria for assigning asylee and refugee status are similar, most asylees apply for and acquire legal status after entering the United States, and most refugees negotiate the process before entry.
Foreign-born persons composed less than 5% of the US population in 1970 and 12% in 2005; they are projected to reach 15% in 2015. In 2005, of the approximately 37.4 million foreign-born persons in the United States, 31% were naturalized citizens, 30% were unauthorized migrants, 28% were legal permanent residents, 7% were refugees who arrived after 1980, and 3% were temporary legal residents.2 Compared with persons born in the United States, the foreign born are more likely to live in poverty,3 less likely to have a high school diploma,4 and less likely to have health care coverage.5 Although the relative disadvantage varies by nativity and immigration status among foreign-born cohorts,4,6,7 access to care barriers are most severe for undocumented persons. These individuals may avoid contact with public officials because of fear of detention and deportation; this leads to higher risk of adverse consequences of pandemic influenza than is faced by citizens and by other immigrants and refugees.2,8–11
We describe the implications of available guidance on community mitigation and related strategies12–29 for these vulnerable populations and their stakeholders and provide advice from an expert panel of public health scientists and service program managers convened by the Centers for Disease Control and Prevention (CDC) on May 1 and 2, 2008, in Atlanta, Georgia. Their advice is tailored to the interests of public health practitioners and service agencies addressing the special needs and circumstances of immigrants and refugees living in the United States.
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DETERMINANTS OF PREPAREDNESS AND RESPONSE |
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The prepandemic physical condition and mental health status of individuals are important determinants of need and capabilities. Immigrants' overall health status begins to resemble that of US-born persons as duration of US residence increases.30 Foreign-born persons tend to have higher prevalence of diabetes, certain infections, and occupational injuries but lower all-cause mortality and prevalence of circulatory diseases, overweight and obesity, and certain cancers than do US-born residents of the same race/ethnicity.31–33
Some health indicators suggest increased vulnerability to infectious diseases and perhaps to pandemic influenza among some subgroups of foreign-born persons, including unauthorized immigrants. Compared with the native born, some foreign-born persons experience lower rates of certain routine immunizations6; lower utilization of preventive care34; significantly higher rates of certain infectious diseases, such as tuberculosis31–33; and, among unauthorized or undocumented immigrants, greater delays in seeking treatment of some infectious diseases.31–33
Regardless of visa status, the challenges of readjusting to a new country, finding employment, and learning a new language contribute to high stress levels and unique mental health needs. Refugees and asylees often arrive with a history of trauma, loss of social support, posttraumatic stress disorder, depression, or anxiety. These negative psychological states can be barriers to accurate personal risk assessment and initiation or maintenance of precautionary practices.35–37
Migration Status and Service Access
Refugees are resettled in the United States through federally sponsored programs that provide medical and monetary benefits for a specific period, subject to available funding.38 Single adults and married couples without children receive these benefits for 8 months from date of entry into the country. Families with children who are 18 years or younger might qualify for additional benefits, including temporary assistance for needy families and Medicaid for up to 5 years. Although immigrants who enter as legal permanent residents do not qualify for the majority of public benefits until after 5 years of legal residency, the State Children's Health Insurance Program, reauthorized in February 2009, enables increased access to health care for legal immigrant children and pregnant women.
Immigrants who enter the United States without legal status do not qualify for public benefits, except for certain services from the Department of Agriculture's Special Supplemental Nutrition Program for Women, Infants, and Children. Refugees are assisted by resettlement agencies with English-speaking professionals well versed in accessing health and social benefits, whereas immigrants are dependent on their families and neighborhood agencies and may be limited by language, unfamiliarity with available services, and difficulty in navigating the health care and social services systems.
Medical Screening and Other Health Services
Before coming to the United States, legal immigrants and refugees must have physical and mental examinations by US Department of State physicians to identify inadmissible health-related conditions. The CDC provides technical instructions to overseas physicians conducting these examinations and periodically revises the regulations that define inadmissible conditions to prevent disease threats to the United States.39 Pandemic influenza is included in the communicable diseases of public health significance as of October 6, 2008.
Applicants who meet all requirements for documentation of refugee status are eligible for Office of Refugee Resettlement (ORR) program services and assistance.38 Asylees Cuban and Haitian entrants, certified victims of trafficking and other crimes, and unaccompanied alien children are eligible for ORR services. ORR provides funding, and state governments administer refugee programs to ensure that all eligible clients receive medical screening services soon after they arrive in the United States or when they receive eligibility status. States often provide medical screening programs through agreements with departments of public health or through contracts with other health providers in coordination with voluntary resettlement agencies. In states without governmental involvement in medical screening, these agencies procure screening services from private clinics or physicians.
Voluntary resettlement agencies, based in local communities, receive support from the Department of State's Bureau of Population, Refugees, and Migration and ensure that refugees receive transportation, interpretation, and translation services related to medical screening. Government and private agencies and the services they provide to refugees, asylees, and other legal immigrants are shown in Table 1.
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Vulnerability to Pandemic Influenza
Although general statements about the social determinants of vulnerability to pandemic influenza and its consequences in migrant populations can make them seem homogeneous, immigrants and refugees are heterogeneous populations with differing risks for pandemic influenza and needs for preventive measures. Such needs vary between successive migrant cohorts from different parts of the world.
In general, causes of immigrants' and refugees' vulnerability to pandemic influenza include any combination of the following factors: high prevalence of chronic conditions that increase the risk for complications and death from influenza30; low rates of seasonal influenza vaccine coverage40,41; limited access to and use of preventive medical care42; social, linguistic, economic, and housing barriers to adoption and uptake of vaccines, antiviral agents, and nonpharmaceutical interventions promoted by public health officials40,41; cultural, religious, and traditional health care practices unfamiliar to Western-trained professionals40,41,43,44; and high risk of exposure to a pandemic strain of influenza through social networks extending beyond the United States. Disparities in preparedness, response, and recovery can be compounded by variations in exposure to pandemic influenza viruses, susceptibility after exposure, and treatment.45
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PARTNERS MEETING |
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To determine the utility of published guidelines, we searched the scientific literature, synthesized relevant findings, and examined their implications for vulnerable populations and their stakeholders. Guided by a conceptual framework (Figure 1), we selected keywords (immigrant, immigration, foreign born, refugee, influenza, and pandemic) to search the National Library of Medicine's PubMed online database and Internet sites (including http://www.pandemicflu.gov) for guidance documents, biomedical journal citations, and abstracts of articles published by July 31, 2008. We reviewed titles, abstracts, and reference lists of citations turned up by our search and assessed the available information for accuracy, source credibility, potential utility, and relevance to the information needs of immigrants, refugees, and related stakeholders.
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The May 2008 partners meeting further contributed to our efforts to tailor our report to the needs of our intended audience. The meeting participants, including the authors, represented a broad cross section of experts. The science and practice of pandemic influenza mitigation and the purpose, scope, content, and presentation of this article were discussed at the meeting.
We categorized possible interventions as household focused, provider supervised, or agency directed. For each pandemic-mitigating task or intervention prescribed in the published guidelines, we examined the implications for immigrants, refugees, and their service providers. We also examined the needs, obstacles, and potential solutions among the insights arising from the meeting and our research.
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PARTNERS' ADVICE |
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Household-focused interventions depend on the preparation and active participation of immigrants and refugees in their homes, workplaces, and other settings. Professionals who deliver public health, health care, and emergency services also prescribe, dispense, and apply provider-supervised interventions. Agency-directed interventions include monitoring to detect and respond to influenza clusters and, during a crisis, communicating effectively with public officials, responders, and laypersons about preparedness for and response to pandemic influenza.
Household-Focused Interventions
For pandemic-mitigating interventions to be successful, all households, including those of immigrants and refugees, will need to participate in planning, practicing, and acting effectively, with support and material assistance from service providers.
Remaining home while ill. Except for skilled migrants entering on H-1 visas, most migrants and refugees work in low-wage jobs that lack benefits (e.g., paid sick leave)46–49; therefore, they often choose to work while ill because of the real or perceived risk of losing pay or employment. Like other workers, they need information regarding influenza's symptoms and how to obtain medical care. Like other employers, employers of immigrants and refugees should consider instituting liberal leave policies, telecommuting arrangements, job security guarantees, and special pay incentives, even if government assistance is unavailable (Table 2).
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Voluntary isolation and quarantine. Immigrants and refugees sometimes live in crowded homes with their extended families.50–53 Implementing isolation and quarantine, which should be voluntary, might be difficult in a crowded household, especially when cultural or religious practices encourage physical closeness within families (e.g., praying and eating meals together). In addition, immigrants and refugees who live in households where isolation or quarantine is in effect might have to contend with the social stigma of being a presumed source of pandemic influenza in the community.54,55 Stakeholders should engage faith- and community-based organizations, cultural brokers, and other community leaders to work with families on how best to isolate and quarantine influenza patients and to help them cope with any related social stigma.
Personal protective measures. The CDC recommends that persons who cannot avoid close contact with an infectious person (e.g., an at-home caregiver of a family member with a respiratory infection) consider using respirators.14 Immigrants and refugees sometimes have experience with face masks and respirators in occupations where they are used to control dust-related diseases (e.g., construction, mining, and grain agriculture) or to prevent respiratory infection during outbreaks of severe acute respiratory syndrome and tuberculosis.54–56 In some Asian countries, wearing masks during respiratory illness is such a common practice that it is not stigmatized.57,58 For certain populations, however, experiences with stigma and discrimination associated with wearing face masks and respirators in public might act as barriers to their use.54–56 Moreover, cultural norms in their countries of origin (e.g., religious headwear), experiences in refugee camps overseas, and practical barriers to acquiring and correctly using face masks and respirators (e.g., fit testing) require providers to develop targeted educational materials for these populations. Cultural competency and understanding of connections between religious or cultural beliefs and health practices are critical in public health preparedness and response.
Stakeholders encourage public health practitioners to work with service providers to address availability, out-of-pocket costs, and correct fit and use of face masks and respirators, as well as sanitary disposal when they become contaminated. They encourage trusted community members to model and promote optimal cough etiquette and hand hygiene throughout the year. Practitioners should also encourage and subsidize use of inexpensive, readily available, and effective methods for cleaning and disinfecting environmental surfaces contaminated with influenza virus inside homes (e.g., bedside tables or lavatory surfaces). Morever, the use of vaccines, antivirals, and some personal protective devices (e.g., respirators) require supervision by health care providers to be effective
Social distancing among school children and adults. Countries of origin may have different school attendance laws, and immigrant children may attend religious schools that present barriers to adherence to local laws and policies regarding school attendance while ill. Stakeholders encourage officials and communities to use cultural and religious incentives to motivate adherence to school-related social distancing. Stakeholders should also recognize that schools are often both community gathering places and providers of breakfast and lunch for immigrant and refugee children (Table 2).
Immigrants and refugees from war-torn regions (e.g., Iraq or Sudan) might be accustomed to avoiding crowded areas to reduce their risk for injury from bomb blasts. Transfer of crowd-avoidance behavior learned overseas to influenza-avoidance behavior in the United States is unknown but should be explored. By contrast, cultural or religious traditions requiring attendance at crowded public gatherings (e.g., funerals and festivals) might present barriers to cooperation with such interventions among new immigrants and refugees. The feasibility and practical implications of postponing such events until after pandemic influenza risk has passed should be explored with religious and secular leaders.
Provider-Supervised Interventions
To prepare for and effectively respond to pandemic influenza, providers of health care, emergency, and other services who operate fixed or mobile clinical facilities with community outreach capabilities should work closely with immigrants, refugees, and the agencies serving them.
Immigrants and refugees, like other residents, will be assigned priority for receiving vaccines or antivirals before or during a pandemic on the basis of occupation, work setting, and other eligibility criteria. They might be underrepresented in high-priority job tiers for which US citizenship or a permanent residence visa is a requirement. Conversely, immigrants, refugees, and their health care providers are likely to be well represented among caregivers in different sectors of the heath care workforce, including home health care providers, nurses, and resident physicians in training, and these workers will also be assigned varying priority levels.
Immigrants and refugees are overrepresented in certain industries—construction, farmers' markets, retail sales, hospitality, restaurants and other food-serving establishments, child care, and poultry and meat packing—and compose most of the workforce of certain large employers in the United States. Ensuring that all population groups receive information on the rationale for priority groups as well as information on location and timing of distribution of vaccines and antiviral drugs is a critical aspect of planning. Planners should also ensure that distribution sites are easily accessible by all population segments. The advantages and disadvantages of having points of distribution in easily accessible community centers close to the homes of persons in isolation or quarantine should be considered; workplaces could serve as supplementary dispensing points. In their countries of origin, immigrants and refugees may have received vaccines, antivirals, and other health care supplies from pharmacies; therefore, the role of pharmacies in distributing vaccines and antiviral drugs during a pandemic should be explored.
Through effective communication, public health officials, employers, pharmacists, health care providers, and others involved in distributing vaccines should ensure that immigrants, refugees, and their service providers are aware of the priority tier to which they belong and how they can receive vaccination. Participants in the commercial drug distribution chain should work with immigrants, refugees, and stakeholders to ensure that they have fair and equitable access to antiviral agents during an influenza pandemic. Voluntary resettlement agencies, with funding from federal agencies and philanthropy, might serve as links to refugee communities. Obstacles to accessing vaccines and antiviral agents arising from immigration status should be removed. The Special Supplemental Nutrition Program for Women, Infants, and Children allows qualifying clients to access benefits without revealing immigration status; public health officials should consider this model. Increasing seasonal influenza vaccination among immigrants and refugees can be a key way to increase acceptance of a pandemic influenza vaccine.
Agency-Directed Interventions
In 2008, the World Health Organization issued guidelines for humanitarian agencies to use when planning for pandemic influenza preparedness and mitigation among refugee and displaced populations.28 The organization recommended that each agency serving such populations develop a pandemic preparedness plan linked to national and subnational plans within jurisdictions where refugees and displaced populations live. The Association of State and Territorial Health Officials, National Association of County and City Health Officials, and CDC have issued similar guidance for state and local health departments whose activities address preparedness and response to pandemic influenza, including activities that help immigrants, refugees, and displaced persons.13,25
Assessing community needs and response capabilities. Surveillance systems for seasonal influenza do not collect information about immigrants and refugees as a subset of the US population.59 Thus, planners and emergency responders might be unable to ascertain the pandemic's course and impact on immigrants and refugees separately from other subsets of the US population. Administrative systems that collect person-level service data from immigrants and refugees might be modifiable to fill this information gap.
Collecting such data might have both advantages and disadvantages. Advantages include greater ability to identify a population's special needs and more effective targeting of outreach programs. Disadvantages include lower use of services because of social stigma and fear of being identified and deported by authorities. Agencies that assess community needs and operate surveillance systems should work with immigrants, refugees, and their service providers to collect essential group-level or person-level data such as birthplace, language, literacy, education, income, and employment. The need for information to guide outreach programs should be balanced with efforts to protect vulnerable populations from social stigma and discrimination. Federal, state, and local health policies, laws, and regulations protecting privacy and confidentiality should inform data collection and use.
Communication during public health emergencies. Emergency communication and education objectives during a severe influenza event are similar for different populations. However, immigrants and refugees might have specific beliefs, experiences, and cultural orientations that should be considered,60,61 such as distrust of public health officials or their messages about influenza. In addition, they might have more fear during a severe influenza outbreak tied to their immigration experience, adaptation to a new sociocultural environment, past discrimination, or previous encounters with government or medical institutions.61 Therefore, during a crisis, communicators might need to modify planning and communicating approaches in these communities to address unique concerns.
In certain countries, experiences with severe acute respiratory syndrome containment and HIV risk reduction have demonstrated that persons who are perceived by the public to be typical of infected persons are usually at greater risk for experiencing stigma and discrimination during infectious disease outbreaks.62 This risk is greater if media stories repeatedly associate the origin of an outbreak with specific or well-defined ethnic, geographic, or cultural profiles.63 Persons whose culture or country of origin are identified as the source of a pandemic episode might fear these psychosocial outcomes as much as the physical consequences of the illness.63–65 Stigma and fear have critical implications for managing infectious disease emergencies: they can encourage illness concealment, delay early detection and treatment, increase distrust of health authorities, lower the likelihood of compliance, and prolong recovery.63
Other, broader concerns and cultural beliefs among immigrants and refugees can be barriers to the adoption of certain health-protective behaviors during an influenza crisis. Undocumented immigrants might worry that their immigration status precludes them from receiving appropriate medical care and that coming forward could have negative consequences, including discrimination or deportation.61,64 Early communications and public education outreach that openly address these challenges before and during an influenza crisis may avert stigmatization, discrimination, and fear of reprisals related to immigration or refugee status.
Populations filter messages and risk information through their already existing belief and value systems. Thus, maximizing public health communication effectiveness for immigrants and refugees can depend on whether health messages reflect fundamental cultural values. Values most likely to be influential include family and community ties (familism), equity or fairness, and the definition of self in relation to others.66–68 For example, identifying oneself in reference to relationships with others (i.e., interdependent self-construal) is often a dominant cultural orientation within Asian American and Hispanic American communities.67,69 Recent research demonstrates that, depending on country of origin, emergency messages intended to motivate precautionary behaviors might be more effective for immigrant and refugee communities if they are framed as protection of loved ones rather than only of the individual.61 More research is needed that explicitly evaluates the effectiveness of different multicultural communication strategies.70
Public health officials and other stakeholders should address immigrant and refugee communities' unique concerns when developing messages that outline public health recommendations before or during an influenza outbreak or pandemic. They should encourage use of bilingual, bicultural community health workers, develop low-literacy and culturally appropriate health education materials, and use all forms of ethnic and mainstream media, including print, audio, audiovisual, and podcasts.
Engaging target audiences. Adherence to key principles of community engagement promotes effective and successful influenza preparedness and response among immigrants and refugees. Language, literacy, and cultural appropriateness of local public health education and control efforts are important in areas where new arrivals from uncommon sources of migration (e.g., Nepal and Bhutan) are beginning to settle.
Several key principles should guide public health practitioners and other officials: (1) engage members of the target audiences in developing and delivering messages through existing trusted, effective channels; (2) include appropriate institutions and sources of authority in affected communities (e.g., churches, community centers, shamans, and religious or other acknowledged community leaders); (3) address community concerns, even those not directly related to pandemic influenza preparedness, to build credibility and trust; (4) strive to improve the cultural competence of providers who serve immigrants and refugees; (5) integrate pandemic influenza preparedness into everyday activities to the extent possible; and (6) use positive approaches when assessing needs and vulnerabilities and when employing community assets to overcome barriers to preparedness and response.
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Human Participation Protection |
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No protocol approval was necessary because no research involving human subjects was conducted.
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Footnotes |
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Peer Reviewed
Note. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. Moreover, this article includes statements made by individuals at a meeting convened by the CDC for the purpose of obtaining their input. Such statements also do not necessarily represent the views of the CDC.
B. I. Truman originated the article, searched and reviewed the literature, wrote and revised each draft, reconciled contributions from coauthors and reviewers, and chaired the meeting of stakeholders. B. K. Kapella, M. Brenden, and C. V. Woznica wrote the "Migration Status and Service Access" and "Medical Screening and Other Health Services" sections. T. Tinker and E. Vaughan wrote the "Communication During Public Health Emergencies" section of the article. E. Rios provided important insights that guided the article's content regarding undocumented immigrants. M. Lichtveld wrote the "Engaging Target Audiences" section. All authors conceptualized the article's scope and content, interpreted the findings, reviewed and revised drafts of the manuscript, and approved the final version.
Accepted for publication March 28, 2009.
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References |
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