Working with immigrant and refugee populations: issues and Hmong case study.

ABSTRACT

There is a critical need to provide culturally and linguistically appropriate health information for immigrant and refugee populations. This article discusses the challenges related to providing health information for immigrants and refugees in the context of developing health education/ health literacy programs. It includes lessons learned from National Library of Medicine (NLM)-funded health information programs in Wisconsin, particularly the Hmong health projects funded by the NLM Specialized Information Services Division. Topics include special needs of immigrant and refugee populations; health care for immigrants and refugees; identifying and working with partner organizations; examples of successful efforts; and finding funding sources for health information literacy projects.

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For immigrants and refugees, finding useful health information is just one piece of the huge task of adapting and surviving in a new country. We need to "walk in their shoes" and listen to their stories before rushing into solutions based on our personal worldview of libraries and the World Wide Web as free sources of knowledge on a wide variety of topics, including health and disease. While we know that we need to take the time to learn about cultures other than our own, there is an immediate need to provide culturally and linguistically appropriate health information for immigrant populations. National standards require that most health care providers provide culturally and linguistically appropriate patient information. Those providing this health information and education are often frustrated in their search for appropriate resources. This is particularly true when working with refugees who have had minimal exposure to Western culture and health care systems.

This article will discuss issues related to health information for immigrants and refugees in the context of developing health education/health literacy programs for these underserved populations. When working with these populations, providing access to information via libraries and the Web is not enough--we need to work with consumer and patient educators to develop appropriate resources and programs that meet their information needs. The challenges involved will be illustrated with examples from National Library of Medicine (NLM)-funded outreach programs in Wisconsin. The focus will be on lessons learned from the Hmong Health Information Promotion (2001-2003) and the Hmong Health Education Network (2003-2004), both funded by contracts from the NLM Specialized Information Services Division. These Hmong health projects are partnerships managed by the Northern Wisconsin Area Health Education Center (NAHEC). The needs assessment process used to develop these projects is applicable to many populations. For more on needs assessment, review the community analysis advice offered in Consumer Health Information for Public Librarians (Baker & Manbeck, 2002).

The following topics will be addressed:

* Special needs of immigrant and refugee populations

* Health care for immigrants and refugees

* Identifying and working with partner organizations

* Examples of successful efforts

* Funding sources for health information literacy projects

Learning about the first three of these topics is the basis for the needs assessment that is the foundation for any health literacy program designed for a specific population. For immigrants and refugees, this process takes most of us out of our "comfort zone." Unless we make the effort to reach out beyond serving those who come to our libraries, and also take advantage of cultural competency learning opportunities, we miss the opportunity to serve those in greatest need. In other words, we need to learn from interpersonal networking and educational programs as well as the literature. In "Walk in Their Shoes," the keynote to the National Network of Libraries of Medicine Greater Midwest Region (NN/LM, GMR) Outreach Symposium of 2003, Dr. Kathleen de la Pefia McCook urged librarians to get involved in their communities (de la Pena McCook, 2003b). She used the example of sitting on a board looking at housing issues as her way of getting involved in the community. By networking with other organizations serving immigrants, librarians will come to recognize opportunities for health literacy partnerships. We need to contact local service agencies to find opportunities to work together on health literacy initiatives. For example, through networking with United Way, Dr. Suzanne Matthew, the Northern Wisconsin Area Health Education (NAHEC) director, learned of Wausau's Minority Interagency Group, which meets six times a year. Meetings include updates on various programs for minorities in Marathon County. While this group started some twenty years ago because of the Hmong refugees, the recent regional Hispanic population increase has expanded the group's focus.

Note that needs assessment and planning will continue as projects are implemented. By working with refugee and immigrant populations, you will continue to learn things about the culture and language that will change your perception of what works, so plans need to be flexible with room for changing methods and approaches. EthnoMed (www.ethnomed.org) is an excellent example of a librarian working with clinicians and educators to develop online resources to support culturally competent care and patient education for immigrants in the Seattle area. As Ellen Howard stated in her excellent NN/LM GMR Outreach Symposium presentation, "While we intended to develop EthnoMed in a systematic way, because of funding opportunities and the need for specific information, the growth and development of the site has been more opportunistic than systematic" (Howard, 2003). It is particularly important to address this issue when developing funding proposals for health literacy initiatives for immigrants and refugees. Timelines need to be as flexible as possible to achieve goals and objectives while maintaining the specificity required by grantors. Program implementation always seems to take longer than you think it should due to the complexity of the needs and cultural structures and the need to work with multiple partners to achieve goals. However, by working with populations instead of doing for them, the products--health education programs and information resources--will be more valuable for these groups.

SPECIAL NEEDS OF IMMIGRANT AND REFUGEE POPULATIONS

As reflected in Mary Pipher's book title, our newest refugees and immigrants are in "The Middle of Everywhere" (Pipher, 2002). Actually, we are a nation of immigrants, with every generation dealing with a different mix of cultures with their own health practices and beliefs. While the backgrounds of Western European immigrants are closer to mainstream American culture, those from developing countries--particularly refugees--often are quite different from our personal experience. Legal immigration includes those admitted for humanitarian reasons (refugees, asylees). The numbers in this category declined substantially to approximately 27,000 in 2002 and 2003, although as many as 70,000 are authorized. Refugees are here because they must leave their homes, and the requirements for refugee status are very specific. An Urban Institute presentation to the National Association for Bilingual Education highlighted three U.S. immigration trends (Fix & Passel, 2003):

1. High sustained flows: More than 14 million immigrants entered the United States during the 1990s--more than any previous decade--and this trend continues into the twenty-first century. This is at the same time that the number admitted for humanitarian reasons declined. Immigrants account for 11 percent of the U.S. population and 25 percent of low-income workers. Children of immigrants represent 20 percent of all children and 25 percent of low-income children.

2. Growing geographic dispersal: Prior to 1995, 75 percent of the nation's immigrants lived in six states (California, Florida, Illinois, New Jersey, New York, and Texas). This declined to roughly 67 percent in the 1990s, and some twenty-two additional states are now defined as "high-growth." Even this list does not include states like Wisconsin, where communities like Wausau have seen huge increases in immigrant populations. Twenty-five percent of the Wausau School District enrollment is Southeast Asian, and small rural farm communities are seeing similar enrollment levels for Hispanic students.

3. Increase in undocumented immigration: The flow of undocumented immigrants to the United States more than doubled between the early and late 1990s. Like legal immigrants, they are far more dispersed than in the past. This places a particular burden on health care services, particularly for urgent care needs.

Who Are the Hmong?

Since the Hmong population is not represented in many states, we will begin with some background information. For additional information and photos, see "Hmong Health Information: Lessons Learned; Future Directions" as presented at the 2003 NN/LM GMR Outreach Symposium (Allen & Matthew, 2003). Hmong refugees represent members of a culture that has never enjoyed a home country. Hmong means "free people." Over the centuries, the Hmong migrated from northern China into Laos. In Laos they were an agrarian society living in the hills, maintaining a culture separate from the Laotian people. Many of those in Laos joined what they refer to as the "Secret War," working for the U.S. Central Intelligence Agency (CIA) before and during the Vietnam conflict. They fought for the United States in the jungles and the air, even serving as pilots. Histories of the era speak of their high intelligence and ability to learn to use technology. The Hmong fled Laos in 1975 following the Communist takeover. They do not support the Laotian government, and one faction continues to work toward regaining their home territory in Laos, which creates ongoing dissension within the Hmong community. During and after the war many escaped to Thailand and lived in United Nations refugee camps prior to resettlement in other countries. The U.S. government followed a policy of dispersal, allowing no more than eight family members to emigrate as a group (Cha, 2003). This placed the Hmong and other new immigrants in smaller communities that were not at all diverse. These dispersal policies were contrary to the cultural values of the Hmong, who emphasize family and clan affiliations--support systems that could have helped the Hmong deal with many of the adjustment difficulties that followed. Another consequence of these dispersal policies was a high level of secondary immigration, where many Hmong moved to be with their extended families. Many left California for communities like Wausau, Wisconsin, and Minneapolis/St. Paul, Minnesota, where education, health, and social services were perceived as more responsive to their needs.

Thailand never welcomed the Hmong as permanent residents. In the 1990s the official United Nations refugee camps were closed, with the Hmong expected to return to Laos or emigrate to other…