How Pharmacists and Community Health Workers Build Trust with Cambodian Genocide Survivors

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(THE CONVERSATION) Wartime trauma associated with a fresh start in a new country makes obtaining health care particularly difficult for immigrant refugees. Talking to a doctor or getting prescriptions filled in an unfamiliar language is hard enough. But for refugees, the physical and psychological scars of escaping war or genocide can complicate and meet their health needs.

I am a clinical pharmacist trained in improving the safety and effectiveness of medications in the outpatient setting. As of 2019, I was with a team of pharmacists serving Cambodian American patients in Connecticut and Rhode Island. I spent 15 months there studying the role of pharmacists and community health workers in helping disadvantaged immigrants get the medications they need and how to take them consistently and safely.

Many of them had fled the Khmer Rouge, a brutal political party and military force operating under the Pol Pot regime in 1970s Cambodia. They have witnessed executions, survived famine, or suffered from famine-related illnesses.

As pharmacists, we learned that the best way to care for these patients was to listen and learn from community members they trusted. It’s a lesson for health care providers that could prove useful as the United States welcomes new refugees from countries like Afghanistan, Sudan, Myanmar and Ukraine.

Dangerous drug

As a traumatized population, Cambodian refugees might be suspicious of outsiders. They can avoid anyone considered to be a member of the government or other official. Therefore, they often rely on their own beliefs and assumptions, even about health.

Our research team learned that some Cambodians expect to receive medicine for every disease. This reassures these genocide survivors that something is being done about everything that is wrong.

If a doctor doesn’t give them a prescription, they might look for one who will prescribe medication. Still, they can take the drug for as long as they feel sick. If side effects occur, they may decide the dose is too high and reduce the amount they take. And drugs are often shared among friends and family.

Limited English proficiency can prevent immigrants from seeking medical treatment. When they do, language barriers prevent healthcare providers from understanding a patient’s symptoms and prescribing the correct medication, especially since interpreters are not always available. Thus, in immigrant communities, translation is often the responsibility of family members, sometimes children.

The presence of family members, especially children, can influence what patients and pharmacists say, especially on sensitive topics such as mental illness or reproductive health. And translation in a medical setting can be a huge burden for children. During our research, we heard of a 7-year-old girl who had been the one to translate her mother’s cancer diagnosis.

Established relationships

Local community health workers tackled these issues. With language interpretation skills and health information, they help residents in their own communities manage their mental and physical health.

Our research team of four pharmacists worked with five community health workers from Khmer Health Advocates, an organization based in West Hartford, Connecticut, for Cambodian American survivors of the Khmer Rouge genocide and their families. After four decades in the region, Khmer Health Advocates knew their community better. That’s why we followed the lead of the organization as it led recruitment for our study.

Health workers introduced us and our research project to churches, temples and events like the Cambodian New Year celebration. They also visited health centers that Cambodians use and posted flyers in Cambodian businesses.

Health workers also reached out to residents individually, connecting with people on a personal level. As genocide survivors themselves trained in trauma-informed care, they met patients in safe and familiar places like their homes. They ate together and discussed not only the study, but also familiar concerns such as the financial difficulties of restarting life in a new country and having to take low-paying service jobs. In total, community health workers helped recruit 63 patients to work with pharmacists.

Cross-cultural problem solving

The health workers educated us in Cambodian culture, which greatly values ​​respect. The “sampeah” greeting, for example, consists of palms joined in a gesture of prayer while bowing the head. The higher the hands and the lower the bow, the greater the degree of respect shown.

We also learned idioms to help us understand patients’ descriptions of their symptoms. For example, “spuck” is what they call neuropathy or nerve damage. It is a common symptom among those who suffered beatings during the conflict. Another expression is “kdov kbal”, which means “hot head”, to describe a feeling of heat in the brain interfering with thinking. And “phleu” refers to the loss of the train of thought, as in the case of cognitive impairment.

Community health workers also helped patients to trust us as pharmacists to help them manage their medications.

By the time of meeting the pharmacists, the health workers had already interviewed the patients to document the medicines, herbal products, traditional Khmer medicines and dietary supplements they were taking. The patient gathered them all together to prepare to speak with the pharmacist while the health worker sat with them.

When I videotaped patients from my office, the health worker held each medication in front of the camera. Then I spoke with the patient about the doses, side effects and questions he had. I explained ways to take medication to avoid side effects, and noted possible drug interactions for my recommendations to their doctors. Through it all, the health worker translated from English to Cambodian, from medical jargon to culturally appropriate terminology and back again.

We helped all 63 patients resolve over 80% of their medication issues, a good resolution rate for any community, English speaking or not. Patients also improved their ability to remember to take their medications, to take the correct doses, and to take them more regularly. Our study found that collaboration between community health workers and pharmacists was essential for these patients to improve their medication management.

I have seen firsthand how a cross-cultural team can effectively resolve medication issues in an immigrant community. As war and genocidal conflicts drive international migration, this model is applicable now that the health of the most vulnerable is increasingly at risk.

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