The Impact of HIV among East Africans Living in the United States Meti Duressa, MSW African...
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Transcript of The Impact of HIV among East Africans Living in the United States Meti Duressa, MSW African...
The Impact of HIV among East Africans Living in the United States
Meti Duressa, MSWAfrican Americans Reach & Teach Health Ministry
Northwest AIDS Education & Training Center
(206) 850-2070 ~ www.aarth.org
Learning Objectives
Explore cultural differences among East African immigrants and refugees
Discuss the impact of HIV and stigma among East African immigrants and refugees
Identify barriers to care for East African immigrants and refugees
Identify strategies to improve access to health care
East African Countries
Sudan is the largest country in Africa
Language & Religion The official languages of Sudan are Arabic and
English
There are 400 languages (dialects) in Sudan, which causes barriers in communication. For example, some members of the Sudanese community in Washington State face challenges in communicating with each other
English, Swahili and Arabic are well spoken within certain tribes, but others speak only their own dialect
The two main religions are Christianity expressed in southern Sudan and Islam in most of regions
DiversityDiversity Ethnicity in Sudan is an important marker of regional
identity and heritage
Around 40% of Sudanese claim lineal Arab heritage or an Arab cultural identity
Ethnicities/People Groups % of Sudan Population
Dinka (or Muonyjieng)
Nilotic people Group
89%
Nuba Approx 6%
Nuer Approx 4%
Etiquette Women hug each other and on occasion men, but this
implies more to the younger generation Older women and men are greeted with full respect and
no eye contact Looking at an elder directly in the eye is a sign of
disrespect Handshakes is a sign of acknowledgement and paying
attention In some tribes and religion, handshakes might not be
appropriate across gender When asked “How are you?” the cultural reply is “Thank
God all is well”
HospitalityHospitality Sudanese love sharing especially when someone
comes to their house Foods: Chai, teas, cookies and desserts Accepting food from a Sudanese is a way of
acknowledging ones’ friendship and courtesy From a young age, most Sudanese (particularly in
the southern region) are taught to live by Biblical principals, including prayer before eating
Reconciliation and Death Reconciliation: is a major practice in the Southern
Sudanese culture and even takes place during funerals
When there is news of death or serious sickness, an elder person is supposed to tell/break the news
Doctors can tell the family about the news but also depends on what kind of news/sickness
If there is no elder of that specific community, a close elderly friend takes that responsibility of eldership
Cont. Reconciliation and Death
Death: In most Sudanese traditions, burial takes place within 1-3 days
In Sudan dead bodies are kept at home and are buried in family graveyards
In the US, dead bodies are kept in the hospital, then in the funeral homes. Sudanese gather in the house of the family of the deceased to mourn and pray
Sudanese cultural prohibits cremation, so it is very disrespectful to suggest burning a dead body for a Sudanese as a mean to saving money
Sudanese Emigration/ImmigrationSudanese Emigration/Immigration
Most Sudanese came to the United States as refugees, some are asylees
Sudanese started migrating to the United States in late and early 1990’s
Many refugees and immigrants who fled Sudan have suffered various traumas
Many of the Southern Sudanese resettled in the United States without family members because of the war
Somalia
Religion More than 99% of Somalis are Sunni Moslem. Allah’s will determines life, death, health and illness Prayer is done 5 times a day, wherever you are,
preceded by ablutions Fasting during Ramadan is a tenet of the faith. This
alteration of eating schedule needs to be factored into assessment and treatment
Many Somali women in Seattle wear hijab and almost all Somali women in Seattle cover their heads. Health care workers need to support Somalis who wish to maintain modesty
Family Islam allows up to four wives, if a man is able to
provide well and justly for four families
Divorce is common in Somalia and the U.S.
The U. S. government only allows one wife to immigrate with one husband
Children who emigrated with their father may be living in a family where the woman is not their mother
Family is defined as extended family
Patient Identification
Somali names have 3 parts: the first name is the given name, the middle is the father’s surname, and the last is the grandfather’s surname
In Somalia it’s rare to use the last name, but common in the U.S. and a potential source of confusion
Women do not change their last names when they marry
Birthdates are not important in Somalia. Many Somalis were assigned January 1st birthdates when they entered the U.S.
Etiquette
The right hand is the correct and polite hand to use in daily life (eating, greeting, etc.)
Greeting is with a handshake and Salam Alechem, but traditionally hand shakes do not occur across gender
Women hug and kiss (on both sides or on the hand) when they meet each other
It is considered impolite to not ask, “how are you and how is your family?”
Dying
It is considered uncaring for a physician to tell a patient or their family that they are dying
It is acceptable to describe the extreme seriousness of an illness
A special portion of the Qur’an, Yasin, is read at bedside when a patient is dying
Relationship Building and Communications
Time spent establishing a relationship will pay off for the patient and the provider
Somalis are traditionally oral historians and are not prone to brevity
The evil eye and “Mashallah” A loud and serious tone of voice is not unusual for a
Somali speaker and doesn’t necessarily imply anger
ETHIOPIA
Language & Religion
There are 80 languages and 200 dialects among Ethiopians
The predominant language among Ethiopians in Seattle is predominantly Amharic, Tigrigna, Oromiffa
The predominant religions are Ethiopian Orthodox, Moslem, Pentecostalism, and Catholicism
Etiquette
Women, and women & men who know each other, hug and kiss on the cheeks three or four times
Handshakes are exchanged between people who do not know each other
Those of the Moslems faith do not touch across genders
Modesty is highly valued
Death and Dying
Death is a community responsibility: In Ethiopia burial societies support when there is a death
in a neighborhood The society is responsible for making the announcement
and for taking care of all the organizational details of the funeral including preparing the food
Members of a burial society pitch in money every month for membership
In Ethiopia the family will wash the body. In the U.S., the funeral home prepares the body and the family brings the clothing
Delivery of news about death:
In Ethiopia the immediate family usually isn't told right away
An elder is called upon to deliver the news
In the United States, a close friend or family relation, other than an immediate family member, is still told first. Often, this person is an elder
For three days after a death, a family doesn't have to do anything except mourn
Cont. Death and Dying
Relationship Building and Communications
Relationships will be established by accepting the offer to drink tea or coffee
Time spent establishing a relationship will pay off
The answer to “ How are you?” will likely be “Thank God, I am fine.” This may not be an accurate statement
concerning the patients state of being
A numeric assessment of pain is not usually helpful
Healthcare Services Preference
Most East Africans prefer to be seen by female healthcare providers especially if it involves examination of private parts
In some cases it is okay for health providers of different gender to examine Sudanese patients; however, some might not be open to express themselves fully.
Common Cultural Practice
Self-Care
Men and women do not often complain about experiencing pain
Pain is not supposed to be expressed unless in death, where people tend to cry out loud, scream or throw themselves on the floor
Sickness is not taken seriously until one is very seriously ill
Over the counter medications such as Pain medications are used for serious illness
Children are not supposed to know what parents are suffering from unless the parents decide to tell them
HIV/AIDS Stigma as a Barrier to Care and Services
Part 1: Recall a time when you felt rejected for seeming
different from others
Time = 2 minutes
Part 2: Recall a time when YOU rejected another person
because they were different
Time = 2 minutes
Activity 1: What Does Stigma Feel Like?
Stigma perpetuates denial and silence
Stigma prevents acknowledgment of problem and care-seeking
Stigma is associated with shame
Stigma prevents dissemination of accurate information
Stigma
What is it?
The shame that PLWH/A experience when they internalize negative reactions of others
What impact does/can it have?
It may lead to: Mental health issues, depression, withdrawal, and feelings of
worthlessness, suicidal tendencies
Isolation of the person
Negatively impact his/her ability to access critical services
Self-Stigmatization
1. Testing and counseling seeking behavior
2. Disclosure of seropositive status
3. Access to care
HIV/AIDS related stigma impacts:
1. Impact on Testing & Counseling
The decision to test is impacted by:
Stigma (concerns that others may think less of us)
The manner in which HIV/AIDS testing and
counseling is perceived by others
2. Impact on Disclosure of
Serostatus Disclosure of HIV positive status is associated with
level of comfort within one’s environment
Disclosure tied to perceptions of the risks associated with the disclosure
The more accepting, caring, and nonjudgmental a social network is towards HIV, the more likely it is for individuals to disclose their status
Fear of rejection
Fear of being ostracized by family/friends
Fear of loss of employment
Fear of physical violence
Fear of deportation
Common Reasons for Not Disclosing HIV-Positive Status
3. Impact on Access to Care
Once diagnosed, individuals who are concerned about being stigmatized are more likely to delay care and/or not to adhere to care
As the disease progresses, individuals tend to retreat and isolate themselves
Denial of serostatus can also cause delayed care
Health care providers may exacerbate avoidance of care
Lack of HIV/AIDS Information
Prevention vs. treatment Ignorance Some cannot read Lack of trust It cannot happen to me
Women are a strong supportSystem for those exposedto HIV/AIDS
Responsibility of raising grandchildren for those lost their parents to AIDS
Activity 2: What are the Outcomes of HIV/AIDS Stigma?
Individual Response: Consider the three areas that HIV/AIDS stigma
impacts: Testing and counseling seeking behavior
Disclosure of seropositive status
Access to care Discussion the results of each of the above
situations?”
Time = 2 minutes
Psychosocial Factors
Psychosocial factors play a major role in delay in care
Denial/secrecy of status and significance of one’s infection Fear and anxiety about the illness HIV as a “death sentence…”
o Who view HIV as a death sentence experience feelings of hopelessness, despair, and fears of dying
Harmful traditions
Female genital circumcision
Abduction
Forced marriage
Underage marriage
Exposes to HIV/AIDS
HIV/AIDS and Women’s rights
Fear of domestic violence/ Divorce She is not faithful Cultural practice that expose woman to infection Women’s Rights Issues
Rapes occur without legal attentionWitches/ traditional doctors plays role on hurting
young girls and children
Respecting women’s rights wouldprevent HIV/AIDS
Immigration Issues
Concern that as part of the application they would be required to take an HIV test
FALSE for citizenship status True for asylum and refugee process Fear of deportation Especially for those who are in the asylum process
Sample case 50 y/o African born heterosexual male tested HIV+ as a part of INS screening for asylum purpose. Patient (Pt). referred to clinic to establish HIV care. Pt. came to clinic with his girlfriend. Repeat blood rest done in the clinic for him and checked his girlfriend. Lab result shows that he has low CD4 count. His girlfriend tested HIV negative. Medical provider suggested pt. to start on HIV meds. Pt. resisted starting on HIV meds; he does not believe he is HIV+.
1. Explore possible barriers for this Pt?
Traditions & Beliefs I am under a spell-witchcraft Voodoo Sun-Power
My girlfriend/boyfriend, wife/husband is negative so that means it is a bad spirit or witchcraft- People wanting to make money and they put spell/witchcraft on me
Looking for “traditional” medicine; meaning traditional religious cure to exercise or cure the bad spirit
Western vs. Traditional Medicine It differs from culture to culture It has to be visible to the patient:
• Must have symptoms• Weakness• Losing weight• Unable to work or move• To be bed ridden
To Take Meds or Not
Once past the original denial they are now ready and eager to take medications as soon as possible
Confusion If I have it then give me the medications-do not want to wait,
cannot understand the “wait” until the CD4 drops and the Viral Load increases…
Undetectable Viral Load vs. Detectable-what does this mean? Either I have it or I do not have it…
Important to stress that Undetectable does not mean Cured!
Financial Constraints Financial constraints have been found to be
a barrier to care for African born trying to access care: Costs associated with treatment, not
reimbursable by medical insurance Lack of private medical insurance Cost associated with child care services Access to reliable means of transportation
Cont. Financial Constraints
Burden of helping family back home
Sending money back home is a priority and will cause refugees and immigrants to neglect their own health needs.
Confidentiality Given the size of the community people are VERY
concerned regarding confidentiality
Avoid as much as possible to be seen at the clinic, especially if they see someone from the same country or their same origin
They suffer due to lack of cultural and or emotional support
Four Types of Stigma Reduction Intervention Methods
1. Information-based Approaches
2. Coping Skills Approaches
3. Counseling Approaches
4. Contact with Affected People
Source: Brown, L., Trujillo, L., & Macintyre, K. (August 2001) Interventions to Reduce HIV/AIDS Stigma: What Have We Learned?
1. Information-Based Approaches Information-based approaches focus on disseminating
information: At multiple levels Using various mediums of communication To reach a variety of audiences Appropriate languages Ethnic, gender, age appropriate
Examples:flyers, ads, information packets, and/or
presentations to community based organizations (e.g., schools)
2. Coping Skill Acquisition Designed to reduce negative attitudes directed at
PLWH/A
Provide techniques and tools for coping
Exercises such as role-playing to act out various confrontational situations, group discussions have been found to reduce negative perceptions directed at PLWH/A
Coping with Illness & Living Well Denial
For some people this may take for a year or more before they accept the diagnosis.
Once they get past the denial process and established HIV care they engage in medical care.
Patients gain hope (and weight) and think of family and of having children once they start feeling well
Strengths Perspective
Family Children Future plan Hope Coping skills Religious belief
3. Counseling Approaches
Counseling approaches have been utilized with: The target of HIV/AIDS stigma (PLWH/A ) The perpetrators of stigma
In counseling PLWH/A, the focus is on building coping
and conflict resolution skills In counseling perpetrators of stigma the focus is to:
Provide information Defuse potential volatile situations
4. Contact with Affected People
Infected individuals disclose their seropositive status to members of a community and interact in a way that provides information and allows the audience to interact with the individual
By giving a “face and voice” to PLWH/A, contact interventions often are an effective tool for reducing stigma
Summary
HIV in African Immigrants differs from other groups in the United States.
Cultural considerations are important for building rapport.
There are several barriers that prevent African Immigrants from receiving the care that they need.
The impact of HIV/AIDS stigma on accessing care.
Resources AARTH Ministry Seattle, WA; www.aarth.org
Ethnomed www.ethomed.org
Hearts of Angels for Health-Sudan Initiative (HAH-S), Seattle WA; www.hah-s.org
lliuliuk Family Health Services, Dutch Harbor Unalaska 907-581-1201
Northwest AIDS Education and Training Center, University of Washington Seattle, WA; http://depts.washington.edu/nwaetc/
National Minority AIDS Council: HIV/AIDS Stigma Program; www.nmac.gov
Harborview Medical Center: Community House calls program Bria Chakofsky-Lewy 206-744-9256; [email protected]