Challenges of Migration and Culture in a Public Health Communication Context

Migration and public health

In recent years, issues related to migration and culture loom large in public health discourse due to the upsurge in migration (with one billion migrants) and forced population displacement (with 65 million displaced people), ¹ compounded by factors such as conflict, oppression, violence, environmental disaster, human trafficking, among others. ² From a public health perspective, the health and wellbeing of migrants, either as visitors, tourists, international students, migrant workers, refugees and uprooted people, asylum seekers, irregular or undocumented migrants, and victims of human trafficking, ² have taken on a particular urgency. Compared to other population groups, existing evidence documents a higher prevalence of communicable diseases, chronic diseases, and mental health problems among migrant and refugee populations. ³ This triple burden of diseases is further jeopardized by a combination of harsh social and economic conditions, unfavorable political systems, and cultural differences that migrants and refugees experience through their divergent migratory routes (from country of origin via the transit country to the country of resettlement), resulting in barriers to essential health care services. ³ The continuing influx of refugees and declining health services make the Syrian public health crisis a case in point.

Health care experiences of Syrian refugees

The conflict in Syria has resulted in millions being displaced to neighboring countries, resulting in an increase in health care needs among these Syrian refugees that are too often unmet due to practical barriers to basic health care services and lack of access to culturally responsive care. With growing numbers of men, women, and children having been displaced and often having suffered trauma, it is imperative that health care providers are aware of their beliefs and experiences in order to provide culturally competent and sensitive care to this already vulnerable population. Factors that affect experiences and beliefs of Syrian refugees in terms of health care services include: attitudes/perceptions of health care providers (which is often negative), familial structures, literacy levels, language, and other social barriers. ⁴ Refugees in refugee camps often state that their health care services are insufficient, and that their health conditions will likely exacerbate in the future. ⁵

Much of the existing research has focused on the specific needs that Syrian refugees may have, and how health care providers and health care systems can better accommodate their needs. These studies have primarily been concerned with Syrian refugee population in Lebanon ⁴ and Jordan. ⁵ There remains very little, if any, research specific to Syrian refugee health experiences and practices in countries in Western Europe or North America.^6,7 Moreover, existing research has generally focused on the health of women and girls (e.g., antenatal care, reproductive and family planning, and so on) and on mental health (e.g., rates of PTSD, depression, and so on).^8,9

The role of technology vis-a-vis digital divide, health literacy, and cultural competence

The growing use of social media in health care has created a dichotomy concerning the role Information and Communication Technologies (ICTs) play in health care contexts.^10,11 On the one hand, research suggests that ICTs play an important role in providing health care, reducing health care cost, and extending the reach of health care. Conversely, research also suggests that integrating ICTs into health care is complicated and a daunting process to improve health care quality and create a health care system that is effective and accessible.

Syrian refugee youth are often found to rely on Google Translate to facilitate everyday communication, especially with their sponsors and at school. ¹² Therefore, it would seem as though technology can be leveraged to facilitate medical consultation. And, indeed, researchers have underscored the potential benefits of using machine translation during cross-cultural clinical consultation, but they have also cautioned that machine translation be used when patients are literate, physicians possess cross-cultural communication competence, and with utmost attention specifically during mental health consultations. ¹³

Growing research indicates that Syrian refugees in rural Lebanon relied on digital technology such as WhatsApp to augment their access to prenatal care. ⁴ However, there are also limitations that ICTs face in the health care sector. ICTs cannot be automatically considered to be beneficial to health care given their capability to help people in remote areas and spread health information like never before; there are complications. For example, there is digital divide – differences in access to, and knowledge and use of ICTs that exists among different demographic groups (e.g., the elderly, people with lower levels of education and who have lower social, economic and work status, and minority populations). ¹⁰ In some developing countries, policy makers and health officials have been reluctant to implement e-health (employing ICTs to deliver health care at distance) systems, and to the uptake and utilization of e-health services. ¹⁴ Even in developed countries that have adopted telehealth or e-health, and telemedicine, there is still the issue of equal access to and learning to use the information and communication technologies and overcoming economic, social, cultural, educational, and linguistic barriers that determine the effective utilization of ICTs for quality health care. ¹⁵

Notwithstanding its limitation, there is an underlying belief in ICTs role in augmenting the health status, well-being, and the quality of life for women and women of color. Considering that migrant and refugee women and girls experience barriers to necessary and culturally responsive sexual and reproductive health services,^3,16 embracing opportunities afforded by ICTs for public health communication is increasingly important to promote gender equality and empowerment of the women and girls in the flow of migration and forced displacement. It is important, however, to also recognize the role ICTs can play in designing interventions to improve health outcomes for women with limited health literacy skills (the inability to access, understand, evaluate, and communicate information required to manage health on a daily basis in a variety of settings across the life course). ¹⁷

Take the case of Canada, where health literacy is a social determinant of health. An estimated 60% of Canadian adults have low health literacy skills, ¹⁸ with older adults, members of the Aboriginal population, new immigrants, people with lower levels of social-economic status, including women, especially who are foreign-born, having lower levels of health literacy skills. Limited health literacy has been linked to adverse health outcomes. ¹⁰ This reality is likely graver for Canadian women, especially for those who are from an Aboriginal or immigrant background, because they remain at the lowest two levels of literacy. ¹⁹ Nonetheless, health literacy is a public health and social justice issue in Canada, and thus every Canadian has an equal right to accessible health information and understandable health services. The question then arises as to what programs and services are needed to work with diverse groups of women with low health literacy skills to improve their health-related outcomes and thereby enhance their empowerment in health care contexts.

Mental health

The unique experiences of refugee and migrant children and youth such as language barriers, experience of violence, trauma, loss, and separation from family and friends put them at risk for mental health issues that may vary by age, culture, country of origin, and the differing migration pathways.^20,21 Therefore, more than ever before, it is imperative to raise diversity awareness within host country health care settings, especially to advance understanding of the complex mental health care needs of disadvantaged and vulnerable migrant and refugee children and youth populations.

Call to action

There is no doubt that today's health care system depends greatly on ICTs. Technology, with its many uses, continues to flourish as society continues to develop and expand. There are numerous advantages as well as disadvantages to the use of these technologies in the health care context. Exciting research opportunities lie ahead to investigate how these technologies can help address important public health implications associated with the rapid increase of population movement.

Adopting a transdisciplinary approach, public health researchers, practitioners, policy makers, and relevant stakeholders should form partnerships and continue to debate and discuss where ICTs have taken health care in recent years and where it will be heading in years to come in terms of addressing the impacts of population displacement on migrant and refugee health and finding culturally appropriate solutions at the intersection of public health and human rights imperatives.