Wartime trauma paired with starting over in a new country make getting health care particularly challenging for immigrant refugees. Talking to a doctor or getting prescriptions filled in an unfamiliar language is hard enough. But for refugees, the physical and psychological scars of escaping war or genocide can complicate their health needs and getting them met.
I am a clinical pharmacist trained in improving medication safety and effectiveness in the outpatient setting. Starting in 2019, I was with a team of pharmacists serving Cambodian American patients in Connecticut and Rhode Island. I spent 15 months there studying the role of pharmacists and community health workers in helping disadvantaged immigrants get medications they need and learn to take them consistently and safely.
Many of them had fled the Khmer Rouge, a brutal political party and military force operating under the regime of Pol Pot in 1970s Cambodia. They had witnessed executions, survived starvation or suffered famine-related diseases.
As pharmacists, we learned that the best way to care for these patients was by listening to and learning from the community members they trusted. It’s a lesson for health care providers that could prove useful as the U.S. welcomes new refugees from countries like Afghanistan, Sudan, Myanmar and Ukraine.
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Unsafe medicine
As a traumatized population, Cambodian refugees might be wary of strangers. They may avoid anyone thought to be a government or other official. Consequently, they often rely on their own beliefs and assumptions, even about health.
Our research team learned that some Cambodians expect to receive medications for every illness. It reassures these genocide survivors that something is being done about whatever’s wrong.
If a doctor doesn’t give them a prescription, they might seek out one who will prescribe medicine. Still, they may take the medicine for only as long as they’re feeling sick. If side effects occur, they may decide the dose is too large and reduce how much they take. And medications are often shared among friends and family.
Limited English proficiency can keep immigrants from seeking medical care. When they do, language barriers make it difficult for health care providers to understand a patient’s symptoms and to prescribe the right medication, especially since interpreters are not always available. So, in immigrant communities, translating often falls to family members, sometimes children.
The presence of family members, especially children, can influence what patients and pharmacists say, particularly with sensitive subjects like mental illness or reproductive health. And translating in a medical setting can be a tremendous burden on children. During our research, we learned about a 7-year-old daughter who had been the one to translate her mother’s cancer diagnosis.
Established relationships
Locally based community health workers have been addressing these problems. With language interpretation skills and health information, they help residents in their own communities manage their mental and physical health.
Our research team of four pharmacists worked with five community health workers from Khmer Health Advocates, a West Hartford, Connecticut-based organization for Cambodian American survivors of the Khmer Rouge genocide and their families. After four decades in the area, Khmer Health Advocates knew its community best. That’s why we followed the organization’s lead as it directed recruitment for our study.
The health workers introduced us and our research project at churches, temples and events like the Cambodian New Year celebration. They also went to health clinics Cambodians use and put up fliers at Cambodian businesses.
The health workers also reached out to residents individually, connecting with people on a personal level. As genocide survivors themselves with training in trauma-informed care, they met patients in safe, familiar locations like their homes. They ate together and discussed not just the study, but familiar concerns like the financial hardship of restarting life in a new country and having to accept low-paying service jobs. In all, the community health workers helped recruit 63 patients to work with the pharmacists.
Photo courtesy of Khmer Health Associates
Cross-cultural problem solving
The health workers schooled us in Cambodian culture, which greatly values showing respect. The “sampeah” greeting, for example, consists of palms pressed together in a praying gesture while bowing the head. The higher the hands and lower the bow, the greater the degree of respect being shown.
We also learned idioms to help us understand the patients’ descriptions of their symptoms. For example, “spuck” is what they call neuropathy or nerve damage. It’s a common symptom among those who endured beatings during the conflict. Another phrase is “kdov kbal,” meaning “hot head,” to describe a feeling of heat in the brain interfering with thinking. And “phleu” refers to losing the train of thought, like with cognitive impairment.
Community health workers also helped the patients trust us pharmacists to help them manage their medications.
When it was time to meet with pharmacists, the health workers had already interviewed the patients to document the medications, herbal products, traditional Khmer medicines and dietary supplements they were taking. The patient would gather them all in preparation to talk with the pharmacist as the health worker sat with them.
When I met with patients over video from my office, the health worker held each medication to the camera. Then I talked with the patient about doses, side effects and any questions they had. I explained ways to take medicine to avoid side effects, and I noted possible drug interactions for my recommendations to their doctors. Through all of this, the health worker translated from English to Cambodian, from medical jargon to culturally appropriate terminology and back again.
We helped the 63 patients resolve more than 80% of their medication-related issues, a good resolution rate for any community, English speaking or not. Patients also got better at remembering to take medications, taking the correct doses and in taking them more consistently. Our study found that community health workers and pharmacists working together were crucial to these patients getting better at managing their medicines.
I saw up close how a cross-cultural team can effectively resolve medication-related problems in an immigrant community. With war and genocidal conflicts driving international migration, this model is applicable now when the health of the most vulnerable is increasingly at risk.
The funding for this work was supported by the National Institutes of Health and National Institute of Diabetes and Digestive and Kidney Diseases (Grant DK103663).
