Building Culturally Competent Environments

Uninformed urban planning in resettlement cities creates environments that are unsustainable for refugees.⁵ As rental prices increase, low-income families, many suffering property owner exploitation, live in poor living environments, often exposed to problems like lead poisoning. However, businesses and municipalities are responding. In 2018, Buffalo created a lead action plan⁷ to end lead poisoning among its most vulnerable populations. One exemplary organization, PUSH (People United for Sustainable Housing)⁶, empowers refugees to understand their rights by helping home renters and owners with housing issues.

Although immigrants and refugees run food-related businesses in Buffalo to provide fresh, healthy foods in urban neighborhoods,⁸ some communities still lack access to culturally preferred, healthy, and affordable food. Additionally, dietary shifts, a result of their displacement, may create unanticipated health consequences for refugees. Dr. Samina Raja,⁹ professor of urban and regional planning at the University at Buffalo, led a pilot study assessing how refugees in Buffalo adapt to a new food environment. “Dealing with Disparities in Food Access Among Refugees (DDFAR)”,^10,11,12,13 used a community-engaged qualitative approach, interviewing refugee households from Burma living in Buffalo. Their responses noted that limitations to accessing healthy, nutritious food included transportation (stores are quite far from where they lived, especially for those without a vehicle), a burdensome land use pattern not conducive to walking, limited English proficiency for some refugees, a lack of available land to grow food, and social isolation.

Several local projects seek to improve the food environments in Buffalo:

• Refugee households desire to grow their own produce. Grassroots Gardens of WNY acts as a liaison between the city government and gardeners – securing land access, providing access to liability insurance, and supporting gardeners. Already, 15,000 parcels and more than 100 community gardens¹⁴ exist, several run by refugees. However, the current needs far outweigh what is available, and many gardens located in the suburbs are only accessible by personal vehicle.
• Health care providers now write prescriptions for fresh fruits and vegetables, which patients can obtain through a mobile market called VeggieRx.¹⁵ To be culturally acceptable, the foods available through such a program should reflect the foodways of refugees who may cook with ingredients different than what is commonly consumed in WNY.
• A new effort funded by a grant from the General Mills Foundation provides financial support for establishing or strengthening food projects in Buffalo,¹⁶ including at least two that support refugee households. Specifically, the project supports a farm for the Somali Bantu refugee community. 

In Western New York, African refugees from Somalia, Congo, South Sudan, Burundi, and Rwanda, account for 23% of total refugees resettled over the last ten years.² Of these, the Somali Bantu are the most populous.²

Reproductive health care is integral to eliminating health disparities and improving overall health, while increasing educational attainment, career opportunities, and financial stability.² Scant research exists that assesses, for example, the reproductive health needs of diverse populations, as well as potential interventions and health outcomes that improve their health and wellbeing. Dr. Kafuli Agbemenu,¹⁷ assistant professor of nursing at the University at Buffalo led a study¹⁸ to explore reproductive health experiences of Somali Bantu women living in Buffalo and their knowledge of reproductive health services, family planning, and care during pregnancy and childbirth. Dr. Agbemenu interviewed thirty women aged 18-65 years. Her study suggests providers should pay particular attention to the language they use in health care communication. Somali Bantu women in her study believe children are a blessing; large families are the norm. For a culture that believes reproduction is determined by biology and not choice, phrases like “delay your pregnancy” can be off-putting. More culturally appropriate language, such as “space out pregnancies,” ensures patient-centered care.

Good care takes time. When providers adhere to scripted ways of providing physical and mental health care, they can miss important culturally nuanced information. When working with populations from different cultures, Alexandra Burger, director for the Western New York Center for Survivors of Torture takes extra time to listen to patient concerns with an open mind. Patients from diverse cultural backgrounds may describe their physical and mental health issues in an unfamiliar and unique way.³ Dr. Sara Safarzadeh-Amiri, Medical provider at Jericho Road, practices culturally sensitive care while also identifying and addressing other existing barriers to health and wellbeing such as language, cultural identity, socioeconomic status, and diet.³ To ensure her clients receive the most appropriate care, Merlyn Vilma, director of public health at Neighborhood Health Center recruits, hires, and trains people from the community.³ A number of health centers in Buffalo provide culturally appropriate, trauma-informed care to their patients. These include Federally Qualified Health Centers Jericho Road Community Health Center¹⁹ (JRCHC) and Neighborhood Health Center,²⁰ as well as the Western New York Center for Survivors of Torture,²¹ which supports individuals and their families who have experienced trauma, and political and state-sponsored torture.

Good dental health affects whole health. However, a lot of care seeking is episodic (patients seek care when something is wrong) which can lead to complications and further health problems. Joe Gambacorta,²² assistant dean for clinical affairs with the University at Buffalo’s School of Dental Medicine²³ notes that preventive oral health services²⁴ exist via the Medicaid program. Patients with Medicaid can be seen at UB Dental locations,²⁵ where all services are available to patients with limited English proficiency, subject to their insurance plan limitations, and/or budgets. 

Refugees bring a wealth of diversity, skills, culture, and knowledge to our communities, yet there are still barriers hindering their ability to lead healthy and successful lives in Buffalo. It is crucial, for the health and wellbeing of all Americans that together we purposely work toward the creation or maintenance of culturally competent environments.

• Cross-sectoral collaborations among resettlement agencies and local government agencies, especially urban planners are important. We need to engage diverse voices – including refugees – in local government policy and planning. Organizations that work with refugees can communicate with the city’s department of planning to ensure relevant neighborhood information is communicated and policy changes occur that reflect real community needs.
• To file lead poisoning complaints and requests for services, call the Erie County Department of Health Environmental Health Division²⁶ at 716-961-6800. For individuals interested in participating in a recently released lead task force and lead action plan²⁷ through the Community Foundation for Greater Buffalo, contact the City’s Office of New Americans²⁸ at 716-851-4315.
• In dealing with inequitable food environments, we can amplify culturally inclusive VeggieRx programs,¹⁰ provide secure, safe, and affordable access to public land for gardening and farming, and support ethnic mobile markets and ethnic grocery stores.

• Health care providers have limited time with their patients. They often deliver care without understanding important culturally relevant practices or providing the legally required language resources²⁹ like interpreters. But misunderstandings can lead to improper diagnosis and care. For example, a patient may express he has “a dirty heart,” something a provider may not understand translates to “I feel depressed”. Providers and clinics must allocate extra time and resources to meet diverse patient needs.
• Health care visits should include important discussions around food access and family planning – subjects affected by culture and a major factor in a patient’s health and wellbeing. To understand what food is available and to provide realistic advice and care for their patients, health care providers can visit the stores frequented by their refugee patients.
• Providers should recognize the dominant culture’s assumptions about reproductive health. To ensure they meet their patients’ needs, providers can ask the patient and her family members questions about birth control as well as their desire for “child spacing”, religious and cultural beliefs, and other factors that influence these decisions
• Researchers seeking to understand diverse population needs should organize intimate discussions, like family planning, in same-sex community groups. It is best to hire community health workers from the community to organize and run these groups. 

• Many populations do not prioritize preventive care. With preventive care, individuals can minimize the potential of future disease risk. Health care providers, community health workers, resettlement agencies, and refugee leaders must work together to provide preventive care education that is culturally appropriate and shared in multiple languages.