Immigrant women's health: initial clinical assessment

This article is the first in a series of 5 articles exploring immigrant women's health. These articles are adapted from the book Immigrant Women's Health, published by Jossey-Bass, San Francisco, 1999. The medical care of recent immigrant women must reach beyond the western focus on identifying pathologic processes that cause a symptom or might lead to disease. Physicians are confronted with a variety of backgrounds and experiences, all of which may have health consequences and effects on communication, modesty, and the use of health services. In the initial meeting with a new immigrant, the primary care physician aims to achieve the following goals: To understand the effects of migration on health To incorporate the patient's health belief system into the therapeutic relationship To use screening tests only when indicated To render necessary care and comprehensive services in a culturally competent manner. Whether the newcomer is an immigrant or a refugee, how long she has been in this country and whether she has had prior screening should be ascertained at the first visit. Although immigrants generally have time to plan their move, refugees often have to flee their country of origin with little time to plan or to choose their destination. The flight itself can have health consequences, and refugees may have interim stays in camps under less-than-optimal conditions.1 Immigrants and refugees have sustained the stresses of both a move and of being newcomers to our society, with similar barriers in language and understanding of a new culture and health system. Some legal immigrants from Central America or the Middle East, for example, may not technically be refugees but have nevertheless undergone the same trauma of war and survivorship. In general, refugee patients are at higher risk for physical and emotional crises after arrival than at other times.2 Details of their migration experience may elicit emotional pain, so such questioning should be deferred until a later visit if they are not directly related to making a diagnosis. The clinician must also establish trust with the patient by ensuring, as much as possible, that her immigration status will not affect the care delivered. Sluzki has identified 5 stages of migration (see box).3 Many refugees will have the assistance of a social service agency or sponsor. Immigrants may have less social service support, particularly if they are undocumented persons. During the decompensation stage, refugees who have obtained only initial screening services may now return because of symptoms that may be either somatic manifestations of stress or exacerbations of chronic conditions for which they have delayed seeking care because other concerns (such as basic survival) were more pressing.