*4.1.2 Refugees' barriers to use of available healthcare services*

The Burmese point of view (on barriers to use of health services) was that refugees not only have challenges with transportation, but also with inadequate health insurance coverage. It is safe to say that most Burmese refugees favored proximity in the use of healthcare services.

*"Most refugee [according to my experience/observation] do like to go to the doctor nearest to them"*

He also added that language could be a barrier [2]:

*"The greatest problem of most refugees from Burma arriving in Bowling Green, is language. Most of them have not gotten the chance to learn English. A person without a sound knowledge of English surely would face many difficulties in communication. Therefore, the first important thing is education. The necessary organization should provide opportunities or programs so that refugees could learn English until they can speak and write English, so that what they say could be easily understood by an American listener or speaker".*

Views expressed by the two Congolese refugees on barriers were that not only was transportation a challenge, but also the affordability of public transportation.

*"We need transportation, it's really a big problem in our community because most of us don't have transportation, we've (refugees) missed so many doctor appointments. Therefore, we decided to start the association ARIKY (Association of Rescue and Intervention of Kentucky), because of this kind of issues"*

They also added,

*"I think we still have more challenges as refugees. One is transportation, even if we call 911, some people cannot afford the ride. Another is getting a driver's license because of the language barrier. So current challenges include transportation, interpretation, and translation.*

Similarly, the Iraqi interviewee identified transportation and language barriers as the two main limiting factors to accessing available healthcare services [2],

*"The first thing I would talk about is the transportation – it is very important to the patient. S/he is ready to stay at home and stay sick [without transportation], plus it is linked with the language barrier. So, if s/he cannot speak English and has no means of transport that is a big problem, just like it happened for one of the refugees"*

Another reason he gave was the feeling of camaraderie with the healthcare professional,

*"For example, most of the Iraqis go to Morgantown city because there is a doctor there that speaks Arabic. They feel that they can communicate and understand the doctor well".*

### *4.1.3 Perceptions on physical and psychological state of health*

Through the interview questions, the refugees provided insight about perceptions of their physical and psychological state of health. The 78-year-old Burmese immigrant presented age-related diseases such as cataracts, hypertension, and a case of hyperuricemia as his main health concerns. However, the Congolese viewed their health concerns in a different manner. According to them, before arriving in the U.S., they passed through screening and health checks and were cleared of all forms of chronic or infectious disease. Thus, they came into the U.S. with a clean bill of health. However, having lived for a few years in the U.S. and beginning to work in different factories, they began to develop some health concerns, such as eye infections, earaches, or headaches. The Iraqi refugee, as a certified medical interpreter, noticed that most refugees have high cholesterol levels and complain of joint and back pains [2].

Regarding the difference in men and women experiences with healthcare providers, the Burmese immigrant remarked that there is a clear difference:

*"Men prefer men doctors, and the ladies prefer lady doctors in Burmese culture". He added that religion played a role… "It's also a concern with the religion Buddhism. Even among Burmese Christians, women should be treated by women doctors only, men likewise"*

The Iraqi claimed it was about culture:

*"In our culture, it is not acceptable that a female, if pregnant or with other medical concerns sees a male doctor" He continued: "She needs to see a female doctor [like a gynecologist]. They prefer that because it is part of our culture"*

The Congolese participants indicated a different perspective, and thought religion was based on the individual, whether male or female. Both genders may have personal preferences and religion may not play a significant role in their choice of healthcare provider.

#### *4.1.4 Issues of cultural competency of the healthcare system regarding knowledge about foreign disease conditions, presentations, or ailments*

This theme sought to examine the issue of cultural competency of the healthcare system regarding knowledge about foreign disease conditions or ailments presented by immigrants, such as the case of Ebola in the U.S. or the current outbreak of the Zika virus. Also noted was the availability of services such as interpreters toward which refugees would naturally gravitate [2].

The Burmese interviewee said…

*"The health departments should provide basic health education pamphlets and occasional health education talks translated in Burmese language on certain topics that are important to refugee health".*

The same views were shared by both Congolese refugees, with practical examples [2]:

*"An example of language barrier - there was a pregnant lady, we took her to the hospital, and the health professional said, "No you're not ready to deliver now, you can go home". She could not argue, and she went home. After 2 hours, she delivered at home. I think the problem was an existing language barrier, so we need interpreters"*

The Iraqi believed interpreters are needed; however, effective interpreters must fully understand the culture of that patient:

*"An interpreter that understands the patient and can communicate the same to their health care provider bridges an important gap, due to differences in culture and beliefs. The interpreter should be an expert in the patient's culture and can aid to avoid many points of misunderstanding between the health professional and patient"*

Generally, the interviews ended on a note of admonition, motivating refugees to learn the English language, obtain a job, encourage others in the community to do the same and make an appeal to the health care system to improve its quality of service to accommodate the increasing influx of refugees.

### **5. Discussions**

The study provides a better understanding of the role culture plays in health service use. In addition, the study gives useful information about the expectations or needs of these refugees as consumers in the healthcare system of the U.S. and highlights cultural patterns in their knowledge of preventive health and healthseeking behaviors [2]. The results of the study relate to the literature on behavioral patterns in the use of healthcare services by refugees.

The study results revealed a significant relationship between nationality and the number of times refugees have visited a healthcare facility to visit a friend or family member. The frequency of healthcare service use is essentially independent of refugees' native language and religion with an exception to refugees' nationality which was significant. This influence is like other research findings [7]. Findings on language and religion can be viewed from the perspective that ethno-medical approaches, such as the use of spiritual folk healers and folk remedies, affect the health outcomes of refugees [8]. In addition, some immigrants and refugees prefer spiritual healers rather than physicians to treat culture-bound syndromes because it is their belief that the physicians do not possess the knowledge or the understanding to treat foreign disease syndromes. Therefore, a need exists to create more awareness through interpreters, communication experts, and translated health bulletins about the effectiveness of evidence-based clinical practice [2].

The length of stay in the host country influence refugees' use of healthcare services including visiting/scheduling appointments. Besides, possession of health insurance is related to ER visits. This is another similar finding which suggests that trust in Western medicine also appears to be influenced by acculturation level (Number of Years in the U.S.), indicating that greater levels of acculturation are related to greater trust in modern medicine [9]. It has been observed that in the U.S, access often is synonymous with health insurance and to some degree equality in the utilization of healthcare services [10].

Although no age or gender differences were observed in the use of health services, one would expect there to be a significant difference, i.e., more vulnerable populations (women, children, the elderly) would be expected to use services more than others (men, teenagers) in each community [2]. Demographic indicators of health status (i.e., age, gender) are among the strongest predictors of those who use healthcare [11].

Regarding cultural competency of services from the refugees' perspective, the *t*-test for presence of interpreters at a health facility was only significant *(p = 0.05) for D1 – I have visited the emergency room for a life-threatening medical condition.*

However, from the healthcare providers view, identified barriers were reported as, lack of funding, and supports to meet the language and cultural needs of refugee patients, uncertainty about refugees' entitlements to healthcare, uncertainty about continuity of care, and difficulties with making appropriate referrals [12].

The results from the interviews depict what has been echoed that lack of language supports, difficulties with accessing specialty care, unfamiliarity with referral procedures, limited information on finding services, confusion about the roles of different health professionals, and overall challenges with navigating the healthcare system are all reported healthcare barriers from the perspectives of refugees [12]. Language barriers can reduce the quality of care, while the use of trained interpreters can improve access, quality, and patient satisfaction [13]. Moreover, to date, published research has indicated that immigrants face significant challenges regarding healthcare access [14]. It has been suggested that such challenges include lack of health insurance, lack of interpreters, discrimination based on race or accent, and lack of understanding on the part of doctors regarding immigrant or cultural perspectives on illness [14].

## **6. Strengths**

The use of a mixed study design helped in gaining an in-depth understanding of health seeking behaviors among refugees. For example, these participants openly shared and expressed their feelings about each interview question. At times, there were laughs, sighs, and long thoughtful pause, before reasonable responses or perspectives were given. Even though some of their thoughts and feelings mirrored responses received from participants who completed items on questionnaires, other opinions or suggestions represented new insights or ideas [2].

### **7. Limitations**

Despite the information provided, the study was not without limitations. The sample of refugees is only representative of the general refugee population in southcentral Kentucky. Hence, there is inadequate generalization and transferability with the study. Also, an inability to compare the use of Western healthcare services to informal alternatives to medical care i.e. a case of whether informal alternatives affected the numeric strength that used available services (because they had local alternatives at home). More so, researchers have suggested that refugees use local or herbal remedies (Complementary, Alternative and Integrative Therapies - CAI). Some studies have portrayed the substantial effect of legal status, service use, and interactions with service providers by refugees. This study overlooks the issue of legal status (e.g., refugee versus asylum-seeker; refugee versus resident alien) which could be used to identify to what extent one's duration of stay is due to legal status and how much of this status helps in reducing fear encountered in contacting a physician or utilizing services at their local health facilities [2]. Response bias was also a limitation to the study due to the tendency of a respondent to answer questions on a survey untruthfully or misleadingly.

#### **8. Recommendations**

a). Refugees are less likely to access healthcare than citizens, regardless of insurance status; therefore, studies comparing uninsured citizens and uninsured *Health Seeking Behaviors among Displaced Populations/Refugees DOI: http://dx.doi.org/10.5772/intechopen.97403*

refugees are needed to further understand differences. b). Healthcare cost is a growing concern within the U.S, the presence of free community clinics is both cost- and resource-saving. Studies are needed to accurately determine the cost-saving benefit of free community clinics or county health departments in the setting of a literacy center, e.g., the International Center. Such studies may help address the pressing issues of health cost and language barriers in healthcare delivery [2]. c). Providing potential access to the healthcare system, however, does not guarantee utilization. Therefore, the relationship between a regular source of healthcare and utilization of healthcare services varies and should be further studied
