NEEDS ASSESSMENT 1

Needs Assessment

Angel Alvarez, Ajaybir Kalket, Navi Lehal, & Lou Luis

PNWU School of Occupational Therapy

OTH 555: Occupation-based Health Promotion

Brandon Imamshah, PhD, OTR/L & Heather Fritz, PhD, OTR/L

June 7th, 2024

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Needs Assessment

Stakeholder Interview

In Washington the largest refugee population is Afghans. They need immigration

assistance, basic needs, employment, mental health, and family services (Economic Services

Administration, 2023). Afghans have fled persecution in their country and made the journey to

the United States (U.S.) in search of a better life. They need healthcare services because their

journey has left them tired and in poorer health. The war-torn country makes them fear for their

lives.

The Afghan Health Initiative is an organization that current and former refugees founded

to aid in the resettlement process and address the social determinants of health of Afghans. They

hope to advocate for their community and make sure their needs are met. Additionally, they

advocate for access to education, healthcare, and financial opportunities. They have health and

wellness programs for lead and toxics prevention and prior workshops focusing on nutrition,

mental health, hypertension, and diabetes management. Additionally, they provide a case

management program to provide referral for food, financial, and emergency assistance. The

displaced Afghan refugee population experience higher rates of housing instability, food

insecurity, unemployment, and rates of chronic health conditions (Synovec & Aceituno, 2020).

These factors influence their health and welfare, they need services to aid them in their struggles.

The stakeholder needs proper funding as well as enough employees to carry out their mission.

We envision that the Afghan Health Initiative would benefit from a health literacy program as a

preventive measure to support accessing specialty health needs, navigating Medicaid, managing

chronic conditions, and strategies for self-advocacy (Synovec & Aceituno, 2020).

Program Participant Interview

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The participant, an Afghan refugee, faced immense challenges in transitioning to life in

the U.S. He and his family fled Afghanistan due to persecution by militant groups. The journey

was difficult, with family separations and bureaucratic hurdles. Despite having a degree in

finance and completing English courses, he works as a security guard in Tacoma, struggling to

find a job in his field. Economic instability and the need to support family members in both the

U.S. and Afghanistan add to his stress.

His health and well-being are major concerns. Although they receive some government

aid like food stamps and Medicaid, language barriers and the tough transition into American

society hinder their access to healthcare. He suffers from persistent back pain due to previous

jobs involving heavy lifting, which limits his ability to work in desired roles. Despite these

difficulties, he values his role as the sole breadwinner and stays committed to his family and

religious practices. However, his quality of life is compromised, and he constantly worries about

meeting his responsibilities as a father, husband, and son.

Interview Questions for participant.

1. Can you describe the daily routines and responsibilities that the participant manages at
home?
2. What are some of the biggest challenges in accessing healthcare and other essential
services?
3. How does the participant's back pain impact his ability to perform daily activities and
work?
4. What support systems (family, community, religious) do you rely on for emotional and
practical support?
5. What are your family’s most pressing needs right now, and how do you think these needs
could be better addressed?
SWOT Analysis
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Opportunities
1. Funding opportunities
for refugee health
programs.
2. Growing public
awareness and concern for
refugee health.
3. Potential to collaborate
with local health agencies
in Washington that work
with Afghan refugees.
Threats
1. Cultural stigma or
discrimination against
refugees.
2. Health beliefs or
traditional views that are
specific to Afghan refugees.
Background Review
Impact on Occupational Participation and Performance
The forced displacement of Afghan refugees has various impacts on their lives. Many
Afghans reported that it was very difficult to find employment that connected to their skills
Strength
1. Strong team collaboration
and diverse skill sets within our
group.
2. Strong cultural competence
due to the exposure to a
multitude of cultures.
3. Possess strong skills in
adaptability and flexibility.
Opportunity-Strength
Strategies
1. Our teamwork, skills, and
cultural understanding will
increase our collaborations
with agencies that serve
Afghan refugees.
2. Our strong adaptability and
flexibility will work within the
procedures of the agencies we
work with.
Threat-Strength Strategies
1. Our team's strong
collaboration and diverse skills
can be used to develop and
implement strategies that will
aid Afghan refugees.
2. Our team’s diverse skill set
can be beneficial in
understanding and respecting
the health beliefs and
traditional views of Afghan
refugees.
4
Weaknesses
1. Potential language barriers
in communication (group).
2. Lack of direct experience
working with Afghan refugees
(group).
3. Limited Experience when
implementing health
promotion programs (group).
Opportunity-Weakness
Strategies
1. Use the growing public
concern for refugees to help
provide translation services.
2. Work closely with local
health agencies that work with
Afghan refugees to learn how
to implement similar
programs.
Threat-Weakness Strategies
1. Lack of experience working
with this population can lead
to unintentional cultural
insensitivity.
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(Rezaei et al., 2021). They have concerns about psychological issues, concerns about safety, and

post-traumatic stress disorder. Afghans in Australia reported that relationships outside their

community and in their communities were weak. One of those barriers with outside community

members was not being able to speak English. The Afghans who declared having no religion had

weak relationships within the community. In Quetta, Pakistan, Afghan refugees reported that

10.3% had some trouble walking around, 7.8% had some problem washing and dressing

themselves, 16.9% had some problems performing usual activities, 26.7% felt some pain and

discomfort, and 36.6% were moderately anxious or depressed (Kaleem et al., 2024). It was found

that challenges of integration can negatively affect refugees’ health and well-being (Rezaei et al.,

2021).

Refugees don’t use behavioral health care regularly (Siddiq et al., 2023). Afghan women

have higher instances of chronic diseases the longer they stay in the U.S. This may be due to not

knowing that they should engage in healthy practices such as getting screened for chronic

diseases. They also found that Afghan women were left out of public health promotion and

research. Older-aged women found that family was a strong reason to stay healthy. Some women

also reported that not having optimal results with the doctor can lead to doubts that they are

providing the best care. Afghans spend high amounts of money on medications or services

(Summit County Public Health Department, n.d.). Many Afghans are given Medicaid to spend

on treatment and vital health costs. There is little literature on Afghan refugee healthcare

spending.

Prevalence

In 2022, the population of Afghans in the U.S. reached 195,000 (Batalova & Montalvo,

2024). More than 15,000 Afghan and Ukrainian refugees have come to Washington from 2022-
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2023 (Washington State Department of Health, n.d.). They were more likely to be between 18 to

64 years old, which is the working age. Afghans have lower educational experiences compared

to other immigrants. 29% of Afghans had less than a high school diploma. Afghans have lower

incomes when compared to native-born and immigrants in the U.S. and are more likely to be in

poverty. Afghan refugees in the U.S. face numerous contextual factors contributing to their

increased risk for health problems.

Socio-Economic Status

According to Pakravan-Charvadeh et al. (2021) and Synovec & Aceituno (2020), Afghan

refugees frequently face considerable socioeconomic hardships. These include challenges in

obtaining stable employment due to language barriers and the non-recognition of their

professional qualifications. This economic instability restricts their access to nutritious food,

secure housing, and healthcare services, leading to financial stress and anxiety.

Discrimination

According to studies by Alemi & Stempel (2018) Discrimination based on ethnicity,

religion, or refugee status is a substantial barrier, manifesting in the workplace, healthcare

settings, and daily interactions, leading to chronic stress and mental health issues. The participant

reported feelings of alienation and difficulty integrating into American society, highlighting the

impact of discrimination on well-being.

Healthcare Access and Quality

Access to quality healthcare is a significant issue for Afghan refugees due to a lack of

health insurance, language barriers, and unfamiliarity with the U.S. healthcare system. These

barriers result in delayed care and untreated health conditions (Pakravan-Charvadeh et al., 2021;

The Centers for Disease Control and Prevention (CDC, 2021).

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Health Literacy

According to articles by Pakravan-Charvadeh et al. (2021) and Synovec & Aceituno

(2020), Health literacy is often low among Afghan refugees because of language barriers and

different educational backgrounds. This hinders their understanding of medical information,

managing chronic conditions, and navigating the healthcare system. The participant’s limited

English proficiency affects his ability to access healthcare and understand health information for

himself and his family.

Physical Environment

Many Afghan refugees live in substandard housing, increasing the risk of infectious

diseases and other health issues Lipson & Omidian (1997). Overcrowded and poorly maintained

living conditions negatively impact health (Pakravan-Charvadeh et al., 2021).

Systems, Policies, and Support

Inadequate systems and policies can increase the health risks faced by Afghan refugees.

Limited job opportunities, insufficient support for higher education, and inadequate integration

programs increase vulnerability. (Hosseini Divkolaye & Burkle 2017). The participant noted the

initial 90-day support from government agencies but mentioned the lack of long-term assistance,

leaving many refugees struggling to secure stable livelihoods.

How the Needs of Afghan Refugees are currently being Addressed

Addressing the health needs of Afghan refugees requires a deeper understanding of their

unique experiences and challenges. Given the high levels of mental distress and the challenges

that Afghan refugees face, humanitarian aid groups have played a crucial role for Afghan

refugees. These groups not only address the immediate needs that Afghan arrivals require by

providing essential items like baby formula and parent education (Butler & Seriff, 2021) but also
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facilitate access to government assisted programs. Such programs offer a comprehensive range

of health services for refugees, including vaccinations, malnutrition management, treatments for

various infections and diseases, and screenings. Moreover, these efforts are also met with shelter,

food, culturally appropriate clothing, financial support, hygiene essentials, and other vital

resources (Higgins-Steele et al., 2017).

An essential part of occupational therapy is developing interventions that not only

promote health but also advocate for occupational participation and address the multiple

determinants of health (Braveman, 2015). Indeed, evidence suggests that it is beneficial for OTs

to work with refugees who face occupational deprivation. For instance, community-based

rehabilitation techniques that have similar aspects of the refugee's home environment, along with

strategies that promote positive emotions and the ability to learn practical skills to navigate the

necessary changes, can be particularly effective. Furthermore, activities designed to aid different

skills, inclusion, and involvement of OTs are crucial in assisting refugees facing occupational

difficulties (Siddiqui et al., 2018). However, addressing the health needs of Afghan refugees is

not limited to just medical care but also involves addressing systemic barriers that slow down

access to health services. These barriers include social determinants of health such as housing

scarcity and vulnerable communities, along with refugee health-seeking behavior and poor health

literacy (Sherif et al., 2022).

Domains, Outcomes, & Interventions

When evaluating the needs of Afghan refugees, it is crucial to delve into their context,

occupation, and performance patterns. The context can be addressed by connecting them to local

or online religious communities. Addressing occupation is instrumental in fostering community

involvement and navigating the complex healthcare system in the U.S. (Krishnakumaran et al.,
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2022). Lastly, the resettlement process disrupts individuals' habits, roles, and routines, impacting

their ability to establish normalcy in day-to-day occupations and community engagement

(Synovec & Aceituno, 2020).

The most relevant outcomes when addressing the needs of Afghan refugees include

quality of life, health, wellness, and well-being, as well as participation in meaningful

occupations. Afghan refugees have an increased risk of lower levels of health-related quality of

life, specifically mental health, and also have a high risk of experiencing food insecurity, housing

instability, and lack of healthcare access, which have a downward rippling impact on every

aspect of the individual (Saif-Nijat et al., 2023; Solberg et al., 2020; Synovec & Aceituno, 2020).

Two primary approaches to interventions aimed at improving health outcomes include

prevention, which involves identifying and addressing risk factors before they result in health

issues, and health promotion, which focuses on empowering individuals to take control of their

health through education, routine change, and access to resources. Three types of interventions

that are more prevalent are education, self-advocacy, and advocacy. Many refugees covered by

Medicaid face challenges in accessing healthcare, including transportation issues, longer wait

times, and difficulty making appointments (Synovec & Aceituno, 2020). An occupational

therapist can educate clients on how to get time off from work, make appointments, and find

transportation resources (Solberg et al., 2020; Synovec & Aceituno, 2020). Efforts should focus

on educating about available resources and advocating for improved access to primary medical

care for this population.

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References

Alemi, Q., & Stempel, C. (2018). Discrimination and distress among Afghan refugees in

northern California: The moderating role of pre- and post- migration factors. Public

Library of Science one, 13(5): e0198622. https://doi.org/10.1371/journal.pone.0196822

Batalova, J., & Montalvo, J. (2024, February 15). Afghan immigrants in the United States.

Migration Policy Institute. https://www.migrationpolicy.org/article/afghan-immigrants-

united-states-2022

Braveman, B. (2015). Population health and occupational therapy. American Occupational

Therapy Association, 70(1), 7001090010p1-7001090010pg6.

https://doi.org/10.5014/ajot.2016.701002

Butler, M, B., & Sheriff, N. (2021, October 14). The challenge of addressing the health care

needs of Afghan evacuees. https://www.brookings.edu/articles/the-challenge-of-

addressing-the-healthcare-needs-of-afghan-evacuees/

Centers for Disease Control and Prevention. (2021). Refugee health guidelines.

https://www.cdc.gov/immigrantrefugeehealth/guidelines/refugee-guidelines.html

Economic Services Administration. (2023, December). Office of refugee and immigrant

assistance. Washington State Department of Social Health Services.

http://www.dshs.wa.gov/esa/office-refugee-and-immigrant-assistance

Higgins-Steele, A., Lai, D., Chikvaidze, P., Yousufi, K., Anwari, Zelaikha., Peeperkorn, R., &

Edmond, K. (2017). Humanitarian and primary healthcare needs of refugee women and

children in Afghanistan. BioMed Central, 15(196), Article 196.

https://doi.org/10.1186/s12916-017-0961-y
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Hosseini Divkolaye, N. S., & Burkle, F. M., Jr (2017). The Enduring Health Challenges of

Afghan Immigrants and Refugees in Iran: A Systematic Review. Public Library of

Science one currents, 9, ecurrents.dis.449b4c549951e359363a90a7f4cf8fc4.

https://doi.org/10.1371/currents.dis.449b4c549951e359363a90a7f4cf8fc4

Kaleem, S., Ahmad, T., Wahid, A., Khan, H. H., Mallhi, T. H., Al-Worafi, Y. M., Alam, A.,

Khan, A., Khan, Y. H., & Khan, F. U. (2024). Assessment of health-related quality of life

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Krishnakumaran, T., Bhatt, M., Kiriazis, K., & Giddings, C. E. (2022). Exploring the role of

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https://doi.org/10.1177/00084174221084463

Lipson, J. G., & Omidian, P. A. (1997). Afghan refugee issues in the U.S. social

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https://doi.org/10.1177/019394599701900108

Pakravan-Charvadeh, M. R., Vatanparast, H., Frongillo, E. A., Khakpour, M., & Flora, C.

(2021). The assessment of an extended set of socioeconomic determinants to explain

anxiety and uncertainty, insufficient quality and food intake of Afghan refugees. Public

Health Nutrition, 25(3), 554–564. https://doi.org/10.1017/S1368980021004043

Rezaei, O., Adibi, H., & Banham, V. (2021). Integration Experiences of Former Afghan

Refugees in Australia: What Challenges Still Remain after Becoming Citizens?.

International Journal of Environmental Research and Public Health, 18(19), 10559.

https://doi.org/10.3390/ijerph181910559
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Saif-Nijat, J., Pakravan-Charvadeh, M., Gholamrezai, S., Rahimain, M., Lane, G., Béland, D.,

Koc, M., Clark, N., Omidvar, N., Sadeghi, R., & Vatanparast, H. (2023). The association

of the quality of life with Afghan households’ food insecurity before and after the recent

political change in Afghanistan: a comparative analysis. BMC Public Health, 23, Article

2066. https://doi.org/10.1186/s12889-023-16967-z

Sherif, B., Awaisu, A., & Kheir, N. (2022). Refugee healthcare needs and barriers to accessing

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Central, 22, Article 1310. https://doi.org/10.1186/s12913-022-08560-8

Siddiq, H., Alemi, Q., & Lee, E. (2023). A Qualitative Inquiry of Older Afghan Refugee

Women's Individual and Sociocultural Factors of Health and Health Care Experiences in

the United States. Journal of Transcultural Nursing: Official Journal of the

Transcultural Nursing Society, 34(2), 143–150.

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Solberg, Ø., Sengoelge, M., Johnson-Singh, C. M., Vaez, M., Eriksson, A., & Saboonchi, F.

(2020). Health‐related quality of life in refugee minors from Syria, Iraq and Afghanistan

resettled in Sweden: a nation‐wide, cross‐sectional study. Social Psychiatry and

Psychiatric Epidemiology, 57, 255–266. https://doi.org/10.1007/s00127-021-02050-8

Summit County Public Health Department. (n.d.). Health needs assessment report for Afghan

refugees of Summit County. 0-32.

https://www.scph.org/sites/default/files/editor/Needs_Assessment_AFG.pdf

Synovec, C. E., & Aceituno, L. (2020). Social justice considerations for occupational therapy:

The role of addressing social determinants of health in unstably housed populations

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[none]. Work: Journal of Prevention, Assessment & Rehabilitation, 65(2), 235–246.

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