High Prevalence of Chronic Non-Communicable Conditions Among Adult Refugees

Implications for Practice and Policy

Katherine Yun; Kelly Hebrank; Lauren K. Graber; Mary-Christine Sullivan; Isabel Chen; Jhumka Gupta

Disclosures

J Community Health. 2012;37(5):1110-1118. 

In This Article

Abstract and Introduction

Abstract

The global rise in non-communicable disease (NCD) suggests that US-based refugees are increasingly affected by chronic conditions. However, health services have focused on the detection of infectious disease, with relatively limited data on chronic NCDs. Using data from a retrospective medical record review of a refugee health program in the urban Northeast (n = 180), we examined the prevalence of chronic NCDs and NCD risk factors among adult refugees who had recently arrived in the US, with attention to region of origin and family composition. Family composition was included because low-income adults without dependent children are at high risk of becoming uninsured. We found that half of the adult refugees in this sample had at least one chronic NCD (51.1%), and 9.5% had three or more NCDs. Behavioral health diagnoses were most common (15.0%), followed by hypertension (13.3%). Half of adults were overweight or obese (54.6%). Chronic NCDs were somewhat more common among adults from Iraq, but this difference was not significant (56.8 vs. 44.6%). Chronic NCDs were common among adults with and without dependent children (61.4 vs. 44.6%, respectively), and these two groups did not significantly differ in their likelihood of having a chronic NCD after adjustment for age and gender (AOR = 0.78, 95% CI = 0.39, 1.55). This study suggests that chronic NCDs are common among adult refugees in the US, including refugees at high risk for uninsurance. We propose that refugee health services accommodate screening and treatment for chronic NCDs and NCD risk factors, and that insurance outreach and enrollment programs target recently arrived refugees.

Introduction

In the past decade, over 527,000 refugees have immigrated to the United States, seeking protection from persecution and violence.[1] Refugees are individuals who are unable to return to their home countries due to "persecution or a well-founded fear of persecution on account of race, religion, nationality, membership in a particular social group, or political opinion".[2] The US accounts for nearly three-quarters of all permanent refugee resettlement worldwide.[3] Most recently, the majority of refugees receiving shelter the US have been individuals escaping war or persecution in Iraq (24.6%), Burma (22.8%), and Bhutan (16.9%).[4] However, after arrival in the US, these individuals, like other vulnerable immigrant groups, may face disproportionately poor health outcomes.[5–10]

The rising prevalence of chronic non-communicable diseases (NCDs) in refugees' regions of origin suggests that chronic conditions may be increasingly common among recent refugees and underscores the need for a greater understanding of NCDs in this population. Chronic NCDs now account for 61% of all deaths and 46% of the burden of disease among low- and middle-income countries.[11,12] The global rise in chronic NCDs has dramatically increased the likelihood that adults from low- and middle-income nations will arrive in the US with pre-existing chronic conditions. However, the extent to which refugees in the US may be impacted by NCDs remains under-investigated.

To date, research with refugee populations in the US has overwhelmingly and justifiably focused on communicable diseases[13] or mental health,[14] with relatively little research attention to other conditions.[15] Extant studies of chronic illness among this population are likely to underestimate the extent of chronic NCDs among US-based refugees. They generally rely upon screening protocols that assess only a small number of chronic NCDs, such as diabetes and hypertension, and are limited to the initial US health encounter, without allowing time for additional diagnostic evaluation.[16–19] The latter is of particular importance for refugees who have had little prior access to health care. In sum, data are not available on the full spectrum of chronic health problems that may impact US-based refugees.[20] More comprehensive data on the burden of chronic NCDs among US-based refugees would help prepare both clinicians and community-based organizations to better address the full range of health concerns impacting this population.

Studies are also needed to better document refugees' health care needs as they transition out of the early resettlement period. Current federal policy provides supplementary funding for refugee health services (Refugee Medical Assistance, RMA) for refugees' first eight months in the US. After this time, adults without dependent children, who are generally ineligible for federal Medicaid or the Children's Health Insurance Program (CHIP), are at high risk of becoming uninsured.[21–23] As seen in other populations without medical coverage, being uninsured places refugees at risk for poor health outcomes, often due to delays in seeking care and to forgoing necessary services, including chronic disease treatment and indicated preventive services.[24–27] Those with chronic NCDs face even greater barriers navigating a poorly organized and fragmented health system, placing them at even higher risk for poor health outcomes.[28–31]

To address these gaps in the existing literature, the current study uses data from a refugee health clinic at a large academic medical center to describe the prevalence of chronic NCDs among adult refugees eight months after arrival in the US. Additionally, we documented the prevalence of chronic NCDs among two key subgroups: individuals from Iraq, who accounted for 20.4% of US refugee resettlement from 2007 to 2010, and individuals without dependent children, who are at heightened risk for becoming uninsured.

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