ARAP AMERİKALILARIN ZİHİNSEL SAĞLIK HİZMETLERİNE ERİŞİMDE KARŞILAŞTIKLARI SORUNLAR

Özet: Amerika’da yaşayan Araplar ortak bir kültürel arka plana sahiptir. Yeniden kültürlenmeden göç gerekçelerine varan

geniş bir çerçevede, Amerikalı Arapların zihinsel sağlık hizmetlerine erişimini etkileyen değişik düzeylerde katılım ve ilişki tecrübesi paylaştıkları düşünülebilir. Onların alt sosyal grupları arasındaki farklılıklar, bu gruplara hizmet veren- lerin kültürel olarak yeterli bir hizmet üretebilmelerini sağlayacak bilince erişebilmeleri ile mümkün olacaktır. Zihinsel sağlık hizmet sunumu ve bu hizmetlere ulaşım bu araştırmanın üzerinde durduğu temel konudur. Bu araştırma Amerikalı Arapların uygun zihinsel hizmet alımlarını etkileyen farklı etkenleri araştıran ve çok disiplinli bir anlayışı benimsemiş bir çalışmadır.

Anahtar kelimeler: Amerikalı Arap, Zihinsel Hastalık, Tedaviye Erişim, Engel INTRODUCTION

From diagnosis to treatment, culture has been identified as a critical factor when it comes to utilizing mental health care services (de Anstiss, Ziaian, Procter, Warland, & Baghurst, 2009). To best serve Arab Americans, providers must understand their culture. Arab Americans are an extremely diverse and heterogeneous population. They are residents of the United States who trace their heritage and ethnic origins to one of 22 Arab counties, with the Arabic language often seen as

the main unifier (Amer & Hovey, 2007). Im- migration to the United States occurred in three waves, beginning with many Syrian and Leba- nese Christians working non-professional jobs in 1875. World War I suspended immigration from the Arab world until after World War II, when Palestinian refugees constituted a large majority of the immigrants, as did Egyptians, Syrians and Iraqis. The third wave began in the 1960s and came about after immigration policies

became friendlier towards Arabs. This wave included the most-educated level of Arab im- migrants at that time (Amer & Hovey, 2007). As a testament to their diverse backgrounds, Arab Americans fall into a myriad of categories, including immigrants, refugees, native-born, Muslim, Christian, professionals, entrepreneurs and more. They are disproportionately recent immigrants to the United States and have been historically marginalized, and even more so in recent years. More than 90 percent of Arab Americans live in metropolitan areas, with the largest urban concentration in Detroit, MI. More than 80 percent are U.S. citizens (El-Sayed & Galea, 2009).

Unlike Arab Americans’ access and utilization of general health care services, the issues surround- ing mental health care are far more convoluted. It’s important to understand the cultural practices and customs that Arab Americans or their parents or grandparents brought with them when they immigrated to the United States. For example, many families do not ascribe odd or disturbing behavior to mental health factors, but instead fault personal weakness, moral lapses, physical ailments or even blame evil spirits (de Anstiss, Ziaian, Procter, Warland, & Baghurst, 2009). Admitting to psychological distress is not always easy for Arab Americas because visiting a mental health provider can be viewed as disloyal or a sign of shame and weakness (Amer & Hovey, 2007).

Moreover, in a study of Arabs in the West, mental health rehabilitation was associated with stigma and families were not supportive of attendance

(Tobin, 2000). As such, in researching this population, online surveys may be preferred because they allow for greater anonymity and confidentiality (Amer & Hovey, 2007).

In general, Arabs rely on extended family during an illness. Intergenerational contact is common, and many children live with their parents until they get married. Children are then in turn expected to care for their parents once they are unable to care for themselves (Aboul-Enein & Aboul-Enein, 2010). Because punctuality is not as emphasized in the Arab culture the same way it is in the American culture, it’s not uncommon for patients to be late to an appointment or not show up at all (Aboul-Enein & Aboul-Enein, 2010).

The approach to care differs in the Middle East. Preventive care is not commonly practiced. For Arab Muslims, there is an understanding that God determines illness, recovery and death, whether or not care is provided. Some Arab Americans may take that to mean that treatment entails prayer, natural herbs or over-the-counter drugs, and may rely on those remedies before speak- ing to a medical professional (Salman, 2012). As a whole, ethnic minorities are more likely to believe that antidepressants are addictive, and as such, will choose prayer and counseling for the treatment of depression (Chen & Vargas- Bustamante, 2011).

In addition, Arab patients tend to present their emotional symptoms, especially depression, as somatic complaints (Nakash, Nagar, Mandel, Alon, Gottfried, & Levav, 2012).

Particularly with the older generation, there is a preference for injectable medication over pills. Fixing an ailment through surgical or medical and pharmacological means represents a cure. This is problematic when addressing mental illnesses, when the treatment of choice may be therapy (Sayed, 2003). Therefore, if patients did not receive any medication at all, they may feel as if the visit was not helpful (Aboul-Enein & Aboul-Enein, 2010). In addition, Aboul-Enien et al. found that it is common to reveal bad news or a negative prognosis in the Middle East in stages. Information that can upset the patient should be given gradually and peppered with cautious optimism.

For Arab Americans who are dealing with a whole host of factors with regard to mental health care, they are like any other patients who have a comorbid medical condition. It is even more difficult to identify mental health disorders among people with cancer when the patient and doctor had differing ethnicities (Nakash, Nagar, Mandel, Alon, Gottfried, & Levav, 2012).

METHODS

This review explores the issues related to Arabs in America and their access to mental health care. This author reviewed the current knowledge about this population as evidenced in peer-reviewed literature published between 2000 and 2012. This author limited the review to these years in order to reflect current thinking about the relation between culture and access or barriers to care. The literature reviewed was identified through the PubMed and EbscoHost databases and limited to

studies published in English. It covered empirical studies about any aspect of immigration, health care, treatment, and mental health, mental illness in America and among Arabs.

Studies were limited to those that empirically and specifically related to Arab patients accessing ser- vices through the health care system. This author focused on Arabs living in America, however also reviewed some of the shared concerns of subgroups such as Arabs, Muslims, immigrants and refugees. The results of the search criteria are summarized in Table 1.

Table 1

«Issues Facing Arab Americans and Their Access to Care»

All search terms were queried into the PubMed and EbscoHost databases:

1 (Arab AND America*) AND («Immigrant*»)

EbscoHost 431

PubMed 65

2 (Arab AND America*) AND (Treat*)

EbscoHost 653

PubMed 112

3 (Arab AND America*) AND (access to healthcare)

EbscoHost 2

PubMed 19

4 (Arab AND America*) AND (Barrier*)

EbscoHost 75

PubMed 30

5 (Arab AND America*) AND (Mental*)

EbscoHost 229

PubMed 50

6 (Arab) AND Mental*

EbscoHost 1666

PubMed 432

This search process yielded a total of 2098 studies, of which 97 were kept. From these studies, 72 were removed because they did not meet the standards outlined for this literature review.

RESULTS

In the review of available literature addressing Arab-American mental health issues, it was difficult to pinpoint only a few factors that encompassed attitudes toward mental health services and obstacles in their utilization. Like any other ethnic group, the diversity within the Arab-American population translated to an array of beliefs regarding the acceptability of seeking mental health treatment and the probability of doing so. As such, identifying the subgroups within the Arab-American culture provides a more precise explanation while attempting to avoid the sweeping generalizations that can manifest themselves when a population is not heavily researched.

IMMIGRANTS

As mentioned, Arab Americans are exceedingly recent immigrants. In a study that looked at the effects of immigration status on mental health care utilization in the United States, results showed that immigrants often had inferior access to health care services as well as poor health insurance coverage. Those were identified as critical factors related to disparity of mental health services utilization. If non-US citizens had the same access to the health care often afforded to US-born citizens, disparities could be reduced by 20 to 30 percent (Chen & Vargas-Bustamante, 2011).

Arabs who immigrated to the US since 1990 are more likely to keep ties, both social and cultural, with their homeland (Norris & Aroian, 2008). In addition, those who made frequent trips back to the Middle East were more likely to participate in ethnic practices as well as exhibit a stronger

likelihood for being separated from the main- stream American culture (Amer & Hovey, 2007). Moreover, immigrants who experience trauma in their country of origin prior to immigration are at risk for post-traumatic stress disorder and major depressive disorder (Norris, Aroian & Nickerson, 2011).

A number of studies identified Arab immigrant women in particular as being at risk of psychologi- cal distress. Arab American Muslim immigrant mothers face conflicts when trying to adjust to life in a new country. They struggle to instill their culture and religious values and norms while trying to meet societal pressures. They have their own stressors that they are trying to overcome after having being uprooted from their homes and resettling in a new country that can be hostile (Aroian, Hough, Templin, Kuwicki, Ramaswamy, & Katz, 2009). Their higher risk for mental illness is also tied to the fact that it may take longer for the adjustment and acculturation process to occur. That is compounded by the social and economic demands placed on them that may lead to them neglecting their health and failing to recognize a need for service (Salman, 2012).

Very little research has been conducted on Arab immigrant children or immigrant children in general. However, it was noted that children from immigrant families seem to do somewhat better is mental health areas than children from native families (Mendoza, 2009).

REFUGEES

More than any other group, refugees tend to suf- fer from mental health and medical symptoms at a greater rate than other minorities. A study of

Iraqi refugees showed that they were more likely to report PTSD than other Arab Americans. A possible explanation is that they did not receive sufficient care during the Gulf War. From pos- sible exposure to chemical warfare agents to psychological stress, the war directly impacted their health (Jamil, Hakim-Larson, Farrag, Kafaji, & Hammad, 2005).

Immigrants face a number of barriers when accessing care, including what can be an un- welcoming and hostile host country, as well as unfavorable refugee practices (de Anstiss, Ziaian, Procter, Warland, & Baghurst, 2009). For young refugees in need of mental health services, bar- riers occurred at three levels: ethnic community, service system and society. Parents struggled with language issues and lack of knowledge of what mental health services are available, as well as a lack of information to recognize the signs of a mental illness. Service-system barriers include limited access to mental health professionals who were of the same culture. High cost of services was also noted as a barrier. Lastly, many of the refugee families found difficulty in relying on the primary health care sector for mental health treatment (de Anstiss, Ziaian, Procter, Warland, & Baghurst, 2009).