Pilot Study Examining the Impact of Acculturation on Refugees' Healthcare Satisfaction.

• Author: George, Saliyah J.

Refugees are individuals who are forced to flee their country due to violence, persecution, human rights violations, and/or war. (1) Not surprisingly, some refugees who experienced pre-migratory trauma arrive in their resettled countries with adverse health conditions, such as posttraumatic stress disorder. (2) The United States federal government is aware of the health disparities that impact refugee communities and offers assistance to help refugee populations become self-sufficient. During the first ninety days, and sometimes the first five years, of arrival in the US, refugees receive employment, food, housing, counseling, and healthcare benefits (e.g., Medicaid Refugee Cash Assistance and Refugee Medical Assistance) to help foster independence and productivity in their new setting. (3) Despite receiving these supportive services, refugees are disproportionately impacted by poverty, negative health outcomes (e.g., poor healthcare satisfaction), and have limited access to healthcare in their resettled communities. (4)

When refugees lack familiar support systems and experience extended periods of cultural shock, it can be difficult for them to quickly adjust to their resettled environment. (5) Although resources are provided to help refugees effectively adapt to their new environment, refugees often experience prejudice, discrimination, and exclusion while navigating in foreign social environments. (6) Differences in culture and misconstrued perceptions of refugees often cause refugees to yearn for their family members and friends who understand their customs and culture. (7) Acculturation can help refugees become familiar with a different and/or unfamiliar environment and overcome unexpected difficulties when they are resettled. (8)

Acculturation is a multidimensional phenomenon that focuses on the psychological changes that immigrant individuals experience when consistently interacting within new environments with dissimilar host cultural norms and individuals. (9) This dynamic definition of acculturation accommodates the different narratives and experiences of immigrants, asylum seekers, and refugees. (10) Berry describes four styles of acculturation (assimilation, separation, marginalization, and integration) based on a person's relationship to their original culture and host culture. (11) Immigrants and refugees may experience marginalization when they choose to reject the host country's traditions while struggling to maintain their own cultural identity. (12) Maintaining a strong connection with one's heritage culture while pursuing the least amount of connection to their host society creates separation. (13) The inverse, assimilation, occurs when the immigrant maintains low levels of connection to their heritage and cultural identity and connect to their host society. (14) Whereas, integration occurs when one has a strong connection to both the host culture and their original heritage and customs. (15)

Literature in the field of acculturation is inconsistent about acculturation's impact on health outcomes. Some studies suggest that bicultural (or integrated) individuals, who possess and perform cultural behaviors from their heritage culture and host culture, have better health outcomes when compared to their non-integrated counterparts. (16) Researchers conclude that bicultural refugees have lower prevalence rates of major depressive episode and higher rates of preventive oral health. (17) In contrast, the Immigrant Health Paradox suggests that immigrants tend to have better overall health outcomes than native-born residents. (18) Particularly in the US, nonimmigrant populations tend to have lower rates of chronic diseases and mortality than white individuals, who tend to have the best health outcomes in comparison to other racial groups. (19) Despite being adversely impacted by these social determinants of health, they have lower mortality rates and higher rates of substance abuse and cigarette use when compared to US-born individuals(.20) One possible explanation for the observed trend is that immigrants maintain cultural practices (e.g., mainly eating fresh produce) despite being in the US, which buffers against negative behaviors that are prevalent in their resettled community. (21) It is also important to note that maintaining cultural practices often diminishes as immigrants become more acculturated, obtain an education, and remain in the settled environment. (22)

Refugee Healthcare Satisfaction

Patient satisfaction is a type of health outcome that is often used to measure the quality of healthcare services a patient receives in a health system. (23) Patient satisfaction is impacted by patients' experiences, such as the quality of the interactions with doctors and specialists, which affects patients' retention rates. (24) The quality of the service that patients receive is often centered around the patient, doctor, and organization. (25) Patients tend to have greater healthcare satisfaction if health facilities/organizations offer effective and efficient services (e.g., human and electronic translators) and healthcare professionals listen and relate to patients' health concerns and provide high-quality care. (26) Patients' perceptions of quality healthcare services are related to their gender, age, severity of illness, and perceptions of the healthcare system in general. (27) However, refugee status is also a factor that impacts health satisfaction. (28)

There is limited research that examines acculturation's impact on refugees' healthcare satisfaction. Refugees are more likely to face discrimination at health facilities from healthcare providers than native-born Americans. (29) Due to factors such as a lack of culturally competent doctors and a lack of effective translation services, refugees often report low rates of healthcare satisfaction. (30) In 2011, Ramin Asgary and Nora Segar conducted a qualitative study to evaluate healthcare barriers faced by refugee populations, most of which were from African countries. (31) They concluded that refugees tend to mistrust healthcare providers because they perceived doctors' interactions as impersonal and focused on making money without comprehensively treating their health condition. (32) In studies where refugees report being satisfied with the healthcare services they receive, they also report feeling uncomfortable during visits due to the lack of access to interpreters and infrequent continuity of care. (33) However, when refugees receive care from refugee treatment units they tend to be more satisfied with the care they received. (34) Therefore, higher rates of healthcare satisfaction may be related to health professionals in these facilities receiving evidence-based cultural sensitivity training and having readily accessible interpreters. (35)

Study Purpose and Significance

In order to address the gap in literature, this study attempts to understand the impact of acculturation on refugees' health satisfaction by examining refugees who come from many national and ethnic backgrounds. (36) In addition, to better tailor healthcare services and expand high-quality and accessible healthcare services to this vulnerable population, it is crucial for healthcare providers to understand the complex psychological process that refugees experience and the barriers they face while in the healthcare sector. Ultimately, this study's findings can reveal gaps within Lancaster's healthcare system and the healthcare system as a whole and offer feasible policy recommendations to improve refugee healthcare satisfaction. Methodology

The purpose of this study is to explore the potential relationship of acculturation on refugees' health outcomes and healthcare satisfaction. The primary researcher conducted semistructured interviews to capture refugees' past and current experiences accessing healthcare services in Lancaster and gauged how acculturation influences refugees' daily experiences. A qualitative, as opposed to a quantitative approach, is used to understand the feelings, values, and perceptions that underlie and influence refugee health outcomes. The complex relationship between acculturation and health satisfaction is explored when refugees elaborate about their experiences and how external factors affect their health outcomes. This study employs semistructured face-to-face interviews with refugees living in the City of Lancaster in Pennsylvania. Lancaster's population is approximately 59,265, with 40 percent identifying as non-Hispanic White, 17 percent Black or African American, and 25 percent of the population living under the federal poverty level. On average, for every 327 residents, one refugee is resettled in Lancaster. (37) Four of the largest resettled refugee populations in Lancaster are from Somalia, Burma, Bhutan and the Congo. (38) In addition, since 2003, Lancaster has taken refugees at a rate of twenty times per capita, which is one of the reasons why Lancaster is called the "Refugee Capital."(39) All protocols for this study are approved by the Institutional Review Board (IRB) from Franklin and Marshall College (#R_3MnXAYBYPo1TTic).

The participants in this study included nine Lancaster refugees who racially and ethnically identify as Asian (3), non-Hispanic Black (3), White (1), and Hispanic-White (2). The participants' countries of origin include: Bhutan (3), Ethiopia (2), Cuba (2), the Democratic Republic of the Congo (1), and Iraq (1). Three participants identify as female and six as male. All participants are between 18-55 years old and have lived in Lancaster for at least two years.

Participants were recruited using purposive snowball sampling. The primary researcher used non-probability homogeneous purposive sampling because she only contacted and recruited participants who are refugees and were resettled in the City of Lancaster. (40) Only recruiting this specific type of participant allows the primary researcher to...