Refugee Populations

Each year, the Kansas resettles approximately 350 refugees annually. The majority of refugees being resettled currently include people from three main groups. They are Iraqis, Bhutanese and Burmese. Somali refugees are coming to Kansas in secondary resettlement, primarily to work in the meatpacking industry. For the current and past fiscal year refugee admissions to the United States go to http://www.cal.org/co/refugee/statistics/index.html. Following is cultural and historical information that may be helpful in providing services to these refugees.

Bhutanese

The Bhutanese refugees are coming from refugee camps in Nepal. They are almost all ethnic Nepalis from Southern Bhutan who have been living in the camps for more than 16 years since being expelled from Bhutan. Despite living in Bhutan since the 1800s they retained their Nepali language, culture and religions. Nearly all speak Nepali as a first or second language and about 35% have a functional knowledge of English. Sixty percent are Hindu, 27% are Buddhists and 10% are Kirate, an indigenous religion similar to animism. The percentage of Christians varies from 1-7%. The Nepalis divide themselves into a caste system which separates people into different social levels and influence the choice of marriage and other social relationships. For more information go to
http://www.cal.org/co/pdffiles/backgrounder_bhutanese.pdf.

Burmese

Burma, also called Myanmar, is one of the most ethnically diverse countries in the World with more than 130 distinctive subgroups. The largest ethnic group is the Burmans or Bamar at about 68% of the population. They tend to be valley dwelling people who are Buddhists and mostly literate. The remaining other ethnic groups include Chin, Kachin, Karen and many others. They are mostly hill people who are largely non literate spirit worshippers or animist. . Myanmar has been under military rule since 1962 and has more than half a million refugees in their neighboring countries of Bangladesh, India, Malaysia and Thailand. Around 150,000 people, mostly Karen and Karenni are living in designated camps in Thailand, some for more that two decades. Another 22,000 are in camps in Bangladesh that date back to 1992. The United States is resettling Karen and Burmans from refugee camps in Thailand and Chin from Malaysia. For more information refer to http://www.cal.org/co/publications/cultures/burmese.html.
Burmese Refugees Powerpoint (.pdf)
| Keeping Track of Refugees from Burma Powerpoint (.pdf)

Iraqi

The United States have begun to resettle refugees that the UNHCR has determined are at greatest risk for returning to Iraqi due to the Iraq War. The new Iraqi arrivals join previous groups of Iraqi refugees resettled in the Unites state after the 1991 Gulf War and the 1996 Iraqis linked to the U.S. sponsored coup attempt. Iraq includes a number of diverse ethnic groups, religions and languages. Iraq’s population is approximately 75-80% Arab, and 15-20% Kurd, with smaller numbers of Armenians, Assyrians and Turk omen. Islam is the predominant religion, practiced by 97% of the population. Of the Iraqi Muslims, 60-65% are Shi’i Arabs and 32-37% are Sunni Arabs or Kurds. A small number of Iraqis are syncretic Muslims. Christians make up 3% or the population. Arabic, the national language, is spoken with some level of proficiency by all Iraqis. For more in-depth information regarding people from Iraq go to http://www.cal.org/co/publications/cultures/iraqis.html

Somali

Somali’s population is mostly rural. Nearly 80% of people are agriculturalists or pastoralist or camels, cattle, sheep and goats. The nomadic way of life is celebrated. Most of the population is urban dwellers especially in the past few years as civil war and famine have led hundreds of thousands have poured into the cities seeking sanctuary and relief. Ethnically and cultural, Somalia is one of the most homogeneous countries in Africa, though the people Bantu from the south and Arabs from the costal cities are important minority groups. The great majority of the people is ethnic Somali and they speak dialects of the same language and practice Islam. Clans are the heart of Somali society and people often have greater allegiance to this lineage than to the nation. See http://www.cal.org/co/somali/somtxt.html For more information about Somali refugees.

Health Education Information in Various Languages

Kansas is becoming a more diverse with each new group of immigrants and refugees settling in the state. It is important to provide meaningful health services that are linguistically appropriate and culturally competent. In order to support providers in serving to immigrant populations the following sources of cultural beliefs, medical issues and health education information may be helpful:

Ethnomed at http://ethnomed.org/
Healthy Roads Media at http://www.healthyroadsmedia.org/
NSW Multicultural health Communication Service at http://mhcs.health.nsw.gov.au/
Refugee Health Information Network at http://www.rhin.org/
Vaccine Action Information at http://www.immunize.org/vis/
Health Information Translations at http://www.healthinfotranslations.com/
U.S. Committee for Refugee and Immigrants at http://www.refugees.org/
Medline Plus at http://www.nlm.nih.gov/medlineplus/languages/languages.html
Multilingual Health Resources Exchange at http://www.health-exchange.net/

Notification of Refugee Resettlement

When the State Office of Refugee Health receives notification of refugee arrivals from the USPHS quarantine station, a copy of the document is forwarded to the local health department of the community in which the refugee(s) will be resettled. The referral is discussed with the health provider and appropriate instructions, cultural information and fact sheets are forwarded at the time of mailing the notification. Usually the VOLAG/sponsors make appointments for the new refugees within days of arrival. The health departments and VOLAGs, as a team, follow-up new arrivals to assure initial health screenings are performed.

CDC Technical Instructions

The Centers for Disease Control and Prevention, Division of Global Migration and Quarantine has released new Technical Instructions in the following areas:

Technical Instructions for Civil Surgeons for Tuberculosis became effective May 1, 2008. The Health and Human Services (HHS) Memo, Technical Instructions and Frequently Asked Questions provide important background for assisting refugees. Further guidance released on October 1, 2009 is found in the CDC Immigration Requirements: Technical Instructions for Tuberculosis Screening and Treatment: Using Cultures and Directly Observed Therapy.

Technical Instructions to Civil Surgeons for Vaccination requirements were introduced and made effective July 1, 2008. The HHS Memofor vaccination, Technical Instructionsfor vaccination and Frequently Asked Questionsfor vaccination will also help to guide those providing services to refugees. Vaccination instructions are based on Advisory Committee on Immunization Practices (ACIP) for Adult Immunizations Recommendations, Child and Adolescent Immunization Recommendations and the 2008 Immunization Catch-up Schedule.

Technical Instructions for Medical Examinations of Aliens were released on October 6, 2008. These technical instructions CDC Technical Instructions for Medical Examinations of Aliens only apply to the overseas examination and do not apply to the refugee health assessment after arrival. Never the less, this information and the Questions and Answers information will be helpful in providing an understanding of how communicable diseases of public health significance are defined and how they are treated before U.S. arrival.

The Centers for Disease Control, Global Migration and Quarantine are in the process of creating Refugee Health Guidelines for Immigrant, Refugee and Migrant Health and include both domestic and overseas guidelines. They include general guidelines, lead screening guidelines, intestinal parasites guidelines and malaria guidelines and can be found at http://www.cdc.gov/ncidod/dq/refugee/rh_guide/index.htm.

Refugee Health Screening, Referrals and Follow-up

The health history and physical examination is performed by a physician, physician assistant, nurse practitioner, or public health nurse certified for Kan-B-Healthy (EPSDT). Referrals for medical care are made to local physicians, clinics and specialty services (i.e., dentist, optometrist, etc.) for definitive diagnosis and treatment. The components of the screening are:

1. a health history that includes recent symptoms of illness, general health history, for women, an OB/GYN. review, and for children, a review of birth and childhood diseases.

2. laboratory and screening including: TB skin test, hemoglobin/hematocrit, urinalysis (dip sticks that includes glucose, blood leukocytes/nitrates), ova/parasites, Hepatitis B. (HbsAg), hearing, and vision.

3. physical examination performed by a physician, physician assistant, a nurse practitioner or a public health nurse certified for Kan B Healthy that includes weight, height, blood pressure(five years and older) and general physical (including gross dental evaluation, EENT, heart, lung, abdominal, skin) and other age/sex appropriate evaluations (i.e., breast exams, inguinal hernia, pap smears, scoliosis, etc.).

4. immunizations, including history of past immunization, administration of vaccinations, education and outlining of vaccinations schedules as appropriate for age.

5. referrals into community primary and public health care services for treatment and follow-up.

6. education about the availability of health services, expectations, and appropriate utilization.

An orientation to the health care system and basic health information is provided during the screening. On the first visit, each refugee family is encouraged to go to the local SRS office to apply for Medicaid if not previously done. It usually takes three clinic visits to complete all the testing, immunizations, physical examination, and follow-up care in the health department.

Health care providers can refer to Health Care for Immigrants: Evaluating New Arrivals and Addressing Health Disparities - download slides for more indepth information on health assessments for refugees.

Networking and Coordination of Services

An informal system of case management to ensure Medicaid/RMA enrollment and managed care was developed between the KDHE refugee health coordinator and the Kansas Department of Social and Rehabilitation (SRS) Medicaid offices. A person in SRS has been assigned to coordinate and be a resource for Medicaid Refugee enrollment issues. SRS and KDHE coordinate on system and individual issues affecting refugees, including the administration and reimbursement of immunizations required by the (USCIS) United States Customs and Immagration Services for change of immigration status. The refugee health manual reflects current Standards of Practice and Procedures and has been distributed to all the health departments, clinics, and agencies/VOLAGS participating in the Refugee Health Program.

Recordkeeping Requirements for Local Health Departments

A state refugee health record (Click here for the Refugee Health Assessment Form) is completed on each client and a copy of the form is sent to the State Refugee Health Coordinator. The county health departments receive $400 per complete health assessment, which includes the laboratory screening [TB skin test, hemoglobin, urinalysis, ova and parasite test, hepatitis B screen, hearing and vision screens], health history, immunizations, physical examination performed by a physician, ARNP, or certified Kan-B-Healthy (EPSDT) RN with physical examination skills, referral and follow-up. All clients with positive PPDs are referred to the health department TB program for complete clinical evaluation, prophylaxis, and follow up. A quarterly report of the status of TB testing and follow-up are sent also to the TB program. Other health department referrals are made as appropriate, e.g. WIC, family planning, STD, maternity, and child health.

Click here to contact the BLRH staff member responsible for this program.