Teaching health professionals about the lives of immigrants

Dr. Evgeny Knaifel, Hebrew University of Jerusalem
Executive summary


In recent years, the Israeli healthcare system has seen an increasing number of empirical studies and culturally adapted interventions addressing the singular needs of immigrants. However, no systematic endeavor to train healthcare professionals in these fields has been made. The purpose of this position paper is to assist academic institutions and teachers in instilling future healthcare workers (physicians, psychologists, social workers, occupational therapists, nurses,
etc.) with unique knowledge and tools so that they might understand the experience of patients who immigrants, or asylum seekers, and provide a culturally-adapted response to their health concerns.
The overall recommendation is to expand training about health and illness among immigrants, from the subjective perspective of these patients and their families. Specific issues that ought to be considered are: physical and mental illness among immigrants, exercising the full scope of rights and access to treatment and services, developing and implementing culturally aware interventions, communication in cross-cultural treatment and so on. Below are specific recommendations for topics to be included in the training of health professionals.


Immigration, language and treatment

 

 In the context of immigration, acquiring a new language and sustaining the mother tongue are personal, familial and social issues that has wide-reaching and varied psychological, educational and cultural ramifications in the lives of immigrants and their children. These issues need to be addressed in the training program. It is recommended that the impact of language acquisition on the inner world of immigrants be addressed, including the barriers they encounter in this process. It is also advisable to give room to the linguistic patterns of different immigrant groups with special emphasis on the communication between healthcare providers and patients.


Health implications of immigration


The process of immigration has many health ramifications for immigrants. In recent years, professional and academic discourse has focused on how the process of adaptation inherent in migration influences health and how immigrants from different cultural backgrounds perceive and contend with illness. Numerous epidemiological studies report health disparities between immigrants and the local population and explore the social factors that create and perpetuate these disparities. These factors include a multiple stressful events, lack of adequate access to care, and structural discrimination in healthcare systems. However, a narrative-constructive perspective focusing on the personal experiences of patients from different cultural backgrounds in the health system has not been sufficiently explored. This is despite the fact that the experience of illness and the meaning attributed to its symptoms is a subjective experience that is directly influenced by culture: the “explanatory model” of the disease includes the individual’s understandings of the causes of the disease, ways of dealing with it, lifestyle changes that are required in order to treat it, patterns of seeking professional help, forms of treatment and projected results. It is therefore very important to convey to healthcare professionals the clinical and methodological significance of being attentive to patients’ narratives. In education for the health professions, it is advisable to incorporate courses that teach narrative tools, which facilitate an in-depth understanding of how people and families from different cultural backgrounds perceive and contend with health issues.


Management of stressful events among immigrant caregivers


Immigrant families caring for family members with a chronic illness have to deal with double stress associated with their role as caregivers and with the processes of adapting and as immigrants. This raises a number of important theoretical and practical questions: How is the concern and care given to a family member affected by immigration? What is the primary
factor that creates the experience of burden in immigrant caregivers: the illness, immigration or culture? What are the available resources to help alleviate some of the burden and help immigrants adapt to the new family circumstances? And what risk groups among immigrant caregivers are more vulnerable to immigration stressors? It is advisable to address these
questions when providing training for the healthcare and gerontology professions and to consider the double stressors that immigrant caregivers are subject to, as well as the psychological, social and linguistic-cultural challenges they face and their ways of contending with these challenges.


Patterns of help seeking behavior among immigrants, barriers and access to care


Immigrants encounter various barriers when they come into contact with the systems of a new country, including healthcare systems. It is no coincidence that immigrants apply for mental health services less frequently than the local population. In Israel, the National Health Insurance Law grants health insurance to every resident, but studies have shown that
immigrants employ these services less than local population. Researchers estimate that multiple social and cultural barriers – such as unavailability of information, linguistic barriers, lack of orientation in the new society, inexperience with the local healthcare system, stigma, suspicion and distrust in the system – all make it difficult for immigrants and their families to seek help, exercise the full scope of their rights and secure the desired services. It is therefore very important when training professionals that are to join the ranks of the healthcare system, to raise awareness of this disparity in healthcare services in the Western world and in Israel, and to the strategies that must be implemented to minimize these disparities.


Mental health among immigrants and asylum seekers 


In recent years, the relationship between immigration and mental illness has been researched extensively in many Western countries and in Israel. Multiple epidemiological studies have found that, compared with the local population, immigrants are at a higher risk of developing psychotic, affective and anxiety disorders, suicidal behavior and addiction to psychoactive
substances. This is particularly characteristic of immigrant groups that are further removed from the local population in terms of their physical and cultural characteristics: for example, Afro-Caribbean immigrants in the United Kingdom or Ethiopian immigrants, migrant workers and asylum seekers in Israel. Over the years, many contributing factors have been proposed to account for the elevated risk of mental illness among immigrants: selective factors related to traumatic events and policies in the countries of descent, cultural factors influencing access to early treatment and diagnosis, and social factors related to economic adversity, discrimination, and racism in the destination countries. Therefore, when training health professionals it is important to address both the theoretical and empirical causes of these phenomena and the steps
that can be taken to minimize them.


Culturally-aware and context-aware mental health interventions with individual immigrants


In an age of globalization and global migration, and in light of the preference of many ethnocultural groups to preserve the culture of their country of origin even after their migration, cross-cultural encounters between healthcare professionals and patients who originate in different cultures are becoming rather frequent and commonplace. This requires healthcare
professionals and healthcare systems to acquire cultural competence and develop services and clinical interventions tailored to the needs of people from different backgrounds. The development of culturally aware interventions may affect processes of assessment, treatment, rehabilitation and recovery of people living with mental illness and their families. It would be
prudent to devote a significant amount of time when training healthcare professionals in general, and mental health professionals in particular, to culturally-aware interventions with people who cope with mental health problems in the global and regional context. It is also important to discuss with trainees the clinical and socio-political challenges that arise from the implementation of cultural competence in mental healthcare alongside the development and
popularity of evidence-based practice.


Culturally aware mental health interventions with immigrant families

The deinstitutionalization process that has been underway in mental health in recent decades, has led to a transferring the bulk of treatment for severe mental illness from psychiatric hospitals to the community. This shift has increased the responsibility and pressure upon and has made them a central, if not sole instrumental and emotional support system for those struggling with mental illness. But what happens when, in addition to caring for a family member with a serious mental illness, families are experiencing another life change - immigration? How is the concern and care given to a family member with a serious mental illness affected by immigration? And what are the implications of providing this care on the
immigration adjustment processes of the primary caregivers themselves? The cultural and contextual background of immigrant caregivers can have a formative impact on their perception of the family burden, on their emotional responses, and on their way of coping with mental illness in the family. It is important to present the particular needs of such families to trainees and educate them about culturally aware and context-aware interventions that need to be developed and implemented when working with them.


Immigrants in psychiatric rehabilitation in Israel


The field of psychiatric rehabilitation is relatively new, having evolved over the past two decades with the goal of helping people with serious mental illness reintegrate into society. In Israel, the field of psychiatric rehabilitation developed rapidly thanks to the Rehabilitation Law for Persons with Mental Disabilities (Rehabilitation Law, 2000). The law stipulates an array of services (“rehabilitation package”) in the fields of housing, employment, education, and leisure, to which people with serious mental illness are entitled. Following the legislation, rehabilitation-oriented practices and interventions were developed and assimilated among psychiatric rehabilitation service providers, with emphasis on illness management and
recovery, improving social skills, contending with stigma, and boosting strengths, skills, and hopes. Immigrants in psychiatric rehabilitation in Israel encounter the combination of these processes and they bring to this encounter their unique cultural background and their immigrant status. Their dual labelling as immigrants trying to integrate into Israeli society and as patient with mental illness trying to integrate into normative society turns them into a group of risk that may be pushed to social marginality. Because of the high rate of mental illness among immigrants on the one hand and the potential role of psychiatric rehabilitation in reducing hospitalizations and encouraging the recovery process, it is important to expose trainees in healthcare professions to the issues described above.
 

 


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