Karen People: Needs/Problems

Students and faculty at Baylor University Louise Herrington School of Nursing began serving and assessing the Karen community in Dallas in September 2007. Through a process of visiting refugees in their homes, meeting with refugees, providing care at the Agape Clinic, and interacting with refugee agencies, other health providers, community health workers and others we have identified some of the health needs and other issues of the Karen people in Dallas. These needs and issues include:

Access to health care

Access to health care is a multi-dimensional problem and includes (1) physical distance of where some refugees have been placed in relation to the location of health providers, (2) inabilty to make appointments at places that require appointments, (3) lack of understanding of health problems (especially chronic problems such as hypertension) and the treatment plans, and (4) difficulty utilizing the limited health benefits available to newly arrived refugees. 

Physical distance: Those refugees placed in the Vickery Park area are able to walk to the Holly Hill Refugee Screening Clinic operated by Parkland and the Dallas County Health Department. This is a walk-in clinic where new arrivals are screened for health problems, immunized, and treated for some health problems. This clinic also provides medical care for refugees for up to a year after arrival (adults on Monday and Tuesday, children on Thursday) - see Community Resources Guide for information on this and other clinics. Refugees placed in the Woodbridge area (New World Apartments) in far East Dallas and those placed on Northwest Highway have difficulty reaching this clinic. Interestingly, Parkland's Vickery Clinic (8224 Park Lane - see resources) seems to not be a significant resource for the Karen people living in the immediate area of the clinic.   

Other walk-in providers of care for the Karen include the Agape Clinic, which is open every Thursday, Friday, and Saturday, as well as Wednesdays except during Christmas and summer. Emergency rooms are also sources of care - as well as sources of crushing debt for those whose health benefits have expired. DISD students can access Youth & Family Centers at schools near Vickery and Woodmeadow. Please see Burma Refugees (Local) Resources Guide and the Agape Community Resources Guide for additional information

Except for those living in the Vickery Park area, refugees are dependent on caseworkers, volunteers or the DART bus and train system for transportation. There is a striking difference among the Karen in that young men tend to be very comfortable using public transportation, while young women and older women and men are reluctant to try riding the bus. This is probably consistent with most populations. Readers should be aware that the script used in Burma is completely different than English, so reading signs (or even which bus is which) is difficult.   

Current actions Agape: We have (1) hired a part-time outreach worker to assist students and volunteers in outreach to the more isolated refugees - especially New World, (2) increased outreach and related efforts, e.g., teaching people to ride the bus, (3) reserved five clinic slots every Thursday for Karen refugees (but are not limited to five), and (4) met and are continuing to meet with other providers (health and refugee services) to increase coordination among providers and hopefully develop additional resources. 

Inability to make appointments: Very few Karen have the English language ability to make appointments (estimate <5%). Almost all are thus dependent upon caseworkers (who have no medical training), community volunteers, or health workers such as at Agape or the Refugee Screening Clinic to make appointments. Unless the caseworker makes the appointment, in every case, transportation is a central issue.

Current actions Agape: We are increasing coordination with refugee and other providers and increasingour own capacity to provide care.

Understanding health problems and treatments: In the case of health problems that include signs and symptoms such as pain, fever and other problems, there is no difficulty in understanding that a problem exists. For those able to obtain care, there is a major problem in understanding treatment, e.g., how much acetaminophen or antibiotic and how often and long to give the medication(s).

Chronic illness such as hypertension (which usually has no signs) or asthma (which often is an intermittent problem) are problems in the patient's understanding of (1) the illness and risks and (2) the treatment, especially the ongoing (in the case of hypertension) or preventive (in the case of asthma) treatment. 

Current actions Agape: We have followed Parkland's lead in proving each refugee with a printed list of problems and actions, including the provider's assessment of the degree to which the patient understands the problem and treatment. We have also increased the one on one teaching and are utilizing the outreach worker, students and faculty in teaching. Patients started on a complicated treatment plan receive one or more home visits to evaluate comprehension and adherence. 

Difficulty utilizing limited health benefits: Repeatedly we have seen people with untreated health problems and expired Medicaid documents - people who thus could have been treated, but were not.

Current actions Agape: We are working to increase access as noted above. When a problem is identified, we are finding a source of care, assisting the patient into that source, and are assisting with financial aspects of care. We are hopeful that refugee agencies are no longer requiring refugees to to bring documents from Medicaid to the refugee office to initiate recertification (since the agency already knows when recertification is due).  

(Americans) understanding Karen people

For the most part, Dallas has little or no knowledge of the Karen people, their experiences and their health beliefs and practices. This website is an effort to address the issue - specifically we are targeting health providers, schools and others who have contact with the Karen. We believe that knowledge and understanding will improve the ability of the community as a whole to welcome our new neighbors.

Current actions Agape: The cultural and health profile included in this website includes information on background, history of immigration, culture and social relationships, communication, religion, health beliefs and practices and health problems and screening. Local and other (national/international resources are on separate pages.

(Karen people) understanding Americans ways

It seems obvious that communications would be a problem among people of different cultures. However, it cannot be over-emphasized that there are often enormous communication gaps between not only Karen and Americans, but also between Karen and refugee caseworkers - including in some cases, Karen caseworkers. American administrative or bureaucratic cultures are complete mysteries to virtually all people from the developing world. We have seen over and over again that Karen people have no idea who will do what when in terms of health care, social services, food, etc. Never mind why something will happen - if only the Karen can be told what will happen.

Current actions Agape: We are acting as advocates and assisting individuals in understanding letters and appointments received.

Notes on problems and issues

The following was generated at a meeting with Karen people and community volunteers 10/2007. This is an initial list – something to work from and expand on. Please feel free to send ideas, additional needs, new resources, and anything else you think might help.

English as a Second Language (ESL)

Conversational as well as job oriented English are important. ESL classes are currently being taught by Kerry and Carl Lorey. However, more volunteers are needed as these two missionaries become more and more overwhelmed by the growing numbers of new Burmese refugees in the DFW area.

Establish a specific “curriculum”-how to read a calendar, how to call 9-1-1, how to say address, and how to say what is wrong with them (e.g., pain, body parts, etc.)

Brief laminated pocket guide to Burmese/English translation. Some of the refugees have large dictionaries that they do not frequently use. If we could narrow it down to some pertinent words and phrases…for example “Burmese pain scale”, how to introduce yourself, yes, no, etc…

Sick Care

The Karen people desperately need sick care! Getting the refugees to the clinic as well as making home visits is important. (Also see transportation)

Include a brief section on Karen refugees in the student folder. Sections may include introduction/history of Burma, religious/cultural traditions related to healthcare, how to communicate with Karen people, culture shock, what to expect on a home visit, and common Burmese illnesses and their assessment findings, cultural practices/ courtesies (taking shoes off when entering the room etc.).

Diseases should include PTSD, depression, hepatitis, parasite infections, malaria, and GI disturbances.

Baylor students will see refugees at least once weekly as routine and when students see the Karen people, open a chart, treat/teach/or assist them into the clinic or other source of care. From these and other encounters, generate a community problem list. In addition the student may teach on American culture and practices. This not only may help with culture shock, but just as it is important for use to understand their practices, they need to understand ours… this will help with communication and understanding!

Anxiety r/t lack of income and long-term stability

After just four months of being in the US, government aid is no longer given and the refugees are expected to pay rent and bills using money that they have earned by working. The only problem is they cannot speak English and have no job training or preparation in how to get a job. Some are given “match grants” which may extend the assistance for one month. However, not all refugees receive this and even for those who do, it does not last very long.

• Again, ESL-job related
• Preparation and assistance in how to get a job, filling out applications, obtaining work permits from the refugee agency, etc… what kind of jobs are the Karen able to have?
• Job training
• Class on Medicare/Medicaid and how it applies to the Karen people.
• Find other groups of Karen people who have established jobs, and were able to settle down) so they may get tips on what jobs to get, and how to acclimate to the country (use the refugee clinic for help finding past Karen people that the new Karen people can talk to) this might also help with culture shock as well!

These are issues primarily addressed by the refugee agencies, but we should be aware of them.

Transportation

If refugees were provided with jobs in their communities, how would they get there? Refugees must utilize the DART system/ bus system. However, many Karen people do not know how to get anywhere on the bus and even if they did they often do not have money for a bus ticket.

• Refugees should learn (through demo/return-demo.) how to get to the Refugee Agency, Agape, Parkland, and their local grocery store and pharmacy.
• Maps that they can read may be provided.

This is an issue that Caroline can assist with.

Communication

Refugees often do not have the resources to communicate with themselves much less the outside world. Each refugee needs a support system. One answer may be a “To-Go-Phone” from Target with prepaid minutes. Perhaps one phone for each household/apartment for emergencies and to contact other refugees. Teaching how to use the “To- Go- Phone” important. Many of the Karen people are given resources that they are expected to utilize, however have little understanding of how to actually use these resources.

Signing legal documents

Often the case workers will ask the refugees to sign documents in English that they do not understand. Should the Karen people sign the document or refuse to sign the document until proper translation is given?

Encourage the refugees to allow those outreach people they trust to read and translate the meaning of the documents for them to sign.

Simple statements like a scheduled doctor’s appointment often come in the mail and are typed in English.

Appointments have been missed because they cannot read English. This should not happen. In addition, when getting paperwork from the doctor’s office after a visit is important. Often time the doctors give instructions about treatments, and follow up appointments, many of the Karen people have stated that they do not have such documents, and they need them in case of an emergency.

Walking to school with small children vs. riding the school bus

Karen mothers are concerned that their children cannot get on a bus to go to school but must walk. Some say they need an ID card to be permitted to ride the bus.

• Ensure that those in need of school ID cards can get them.
• All moms and kids know which bus to ride.

Hygiene

Some refugees report they are not given hygiene products and if they are provided with these items, they are not instructed on how to properly use them. Possible actions include:

• Class on hygiene and self-care. Products are provided and demonstrations are given. Topics that may be included are shampoo, conditioner, oral/dental care, feminine hygiene, etc…
• Teaching on dental care very important. Their dental care practices are different than ours and many arrive to the states with multiple dental caries

Secondary Prevention Classes

Actions include (this list should surely be expanded):

• How to take a temperature.
• Buying generic instead of name brands.
• Teaching signs/symptoms of common illnesses among the Karen people
• When to call or go see the practitioner.
• Treating and monitoring your child for dehydration.

Fear and anxiety r/t culture shock

Classes specifically designed for Karen people who have only been in the US for approximately 3-4 weeks. These refugees will be able to obtain names and numbers for future support. This will provide the new refugees an opportunity to communicate within the realm of familiarity.