Many of the Afghans displaced by the Taliban takeover of Kabul in 2021 found refuge in the United States through Operation Allies Welcome (OAW) and the ongoing Operation Enduring Welcome (OEW) Response. OAW was an interagency initiative that coordinated efforts across the federal government, military, state and local governments, NGOs, and private partners to manage the resettlement of nearly 90,000 Afghans. As Afghan newcomers began arriving in the US in 2021–amid the COVID-19 pandemic–resettlement agencies worked alongside federal offices, healthcare systems, public health departments, social service providers, and community-based organizations to provide much-needed assistance.
Resettled Afghans are acclimating to life in the United States, enriching their new communities, securing public benefits, and seeking opportunities for their families. At the same time, they are experiencing ongoing challenges related to the trauma of sudden displacement and navigating complex systems like health care as English-language learners.
The Challenge of Tailoring Healthcare for Afghan Women in the U.S.
Afghan women in the United States face distinct challenges, especially in accessing sexual and reproductive health (SRH) services, which differ from the general population. These women often encounter more significant barriers and have limited access to essential healthcare services compared to other groups. The unique needs of Afghan women, influenced by their cultural background and experiences, necessitate tailored interventions sensitive to their specific needs.
Health Needs Assessments (HNAs) play a pivotal role in understanding and addressing the unique healthcare needs of specific communities. By conducting HNAs, organizations gain insights into individuals' barriers and challenges, allowing for designing and implementing customized interventions that align with the community's needs.
Sexual and Reproductive Health Needs Assessment in Salt Lake City
The IRC office in Salt Lake City, in collaboration with the National Resource Center for Refugees, Immigrants, and Migrants (NRC-RIM), developed and implemented a Sexual and Reproductive Health Needs Assessment (HNA) to better understand the unique SRH needs and barriers this community faces and to inform a comprehensive Afghan Women’s Health Program. The HNA covered various topics such as primary care, family planning, and preventative care.
IRC’s SLC HNA initiative stemmed from IRC staff working across various program areas and anecdotally recognizing Afghan women’s challenges to accessing SRH services and the lack of available health education resources in Dari and Pashto. IRC’s Health and Wellness Program Manager, Jonessa White, highlighted that there was insufficient contraceptive information available to clients, which could be contributing to unintended pregnancies. Close partnerships with Afghan clients and community collaborators informed the HNA's launch. Additionally, IRC community health liaisons, interpreters, and colleagues from Afghanistan involved in different teams and projects supporting Afghans played integral roles in shaping the initiative.
Outreach was conducted to IRC clients actively receiving services and former clients who exited IRC programming. Staff identified and called Afghan women ages 18-55 receiving services within the last 5 years to participate in the assessment. They also invited women through client WhatsApp groups or while attending IRC classes. 41 Afghan women completed the HNA survey. While most participants completing the survey were current or former IRC clients, some participants were from community referrals.
Approach to Administering the Health Needs Assessment
The IRC team in Salt Lake City took a dual approach and conducted client and provider surveys to identify service gaps and understand barriers from both patient and provider perspectives. The client survey lasted 90 minutes to 2 hours and used standard script.
- Community-Centered Surveys: An IRC staff administered the HNA in person at a location of the client’s choice to ensure their privacy and comfort. Staff set up opportunities for the HNA to be taken at the IRC office, a library, a park, or in the clients' homes. A gift card was provided upon completion of the assessment to compensate for the clients' time.
- Engagement with Clinical Partners: Concurrently, IRC collaborated with clinical partners to assess the capacity of health clinics within the University of Utah Health Care System Network to address the community's health needs. Surveys focusing on SRH topics were distributed to providers at health screening clinics, emphasizing clinicians' observations and the clinics' support for these specific health needs.
Validating and Pilot Testing of the HNA: Multiphase Process
IRC Salt Lake City took the following steps to increase the validity and cultural appropriateness of the survey. Survey development lasted 6 months, and implementation took around 2 months.
- Identification of Topics:
The overarching topic areas for the HNA (Primary Care, Fertility, Family Planning, Preventative Care, Healthy Partnerships, Accessing Care, Medications, and Pharmacy) were identified by staff, with input from community members. - Development of the Needs Assessment:
Questions related to Afghan women’s health for inclusion in the HNA were designed collaboratively and reviewed to consider relevance, potential harm, and cultural and contextual appropriateness. This resulted in a comprehensive needs assessment to which all participants contributed ideas. - Cultural Validation Phase:
The next phase involved cultural validation of the HNA by Afghan staff proficient in Dari and Pashto, to ensure that the topics and questions were culturally appropriate and sensitive. - Pilot Testing with Clients:
The HNA was piloted with 10 clients to incorporate their feedback. Questions focused on gathering insights such as feedback on question-wording and opinions on specific topics to ensure the assessment resonated effectively with the target audience. By creating an online version of the HNA in Podio, a flexible and customizable work management platform, the team could streamline tracking methods and response tracking, as well as centralize the data collection for analysis.
Successful Strategies for Administering the Health Needs Assessment
The assessment process began with a thoughtful introduction that emphasized the voluntary nature of participation and assured participants that their responses would not impact their services at IRC. This initial step aimed to create a welcoming and comfortable atmosphere while clarifying the purpose of the survey.
Recognizing the sensitive nature of the questions posed during the assessment, the IRC at Salt Lake City prioritized participant comfort and encouraged responses based on individual comfort levels. Staff received training on trauma-informed approaches, as well as specific protocols for addressing disclosures such as gender-based violence or mental health concerns.
Only female interpreters were used throughout the assessment process to ensure a sense of safety and better align with cultural norms whether in-person or virtual, advanced scheduling ensured the availability of female interpreters to guarantee seamless communication and understanding during client interactions.
The cultural validation step in the assessment process ensured that questions and methodologies were culturally appropriate, enhancing the relevance and accuracy of the data collected. Additionally, participants were incentivized with a $45 per hour compensation to encourage engagement and thorough responses, fostering a collaborative and inclusive approach to the assessment.
Results and Impact of the Health Needs Assessment
The SLC Health Needs Assessment (HNA), which was culturally validated and piloted, focused on Afghan women aged 18–55 who had arrived within the past five years and service providers. Using a mixed-methods approach of quantitative surveys and qualitative interviews, the results revealed significant barriers to accessing SRH services for this population. Key findings included: 56.1% of participants expressed discomfort discussing contraception with male providers, while 78% preferred a female interpreter; 65.9% had not accessed contraceptives in the US, with 78% unaware of their availability at no cost; gender dynamics heavily influenced family planning decisions, with male partners predominantly making choices around contraceptive use (68.3%) and number of children (65.9%); and cultural norms were identified as key obstacles to accessing preventive care. Additionally, clinic-level findings underscored capacity constraints and insufficient discussions on SRH rights and family planning. A summary of the results can be found in a slide presentation available on the NRC-RIM website.
The Health Needs Assessment (HNA) findings led to the development of groups and classes for adults and teens to offer education and clinical services and link clients to the healthcare system. Simultaneously, efforts were made to collaborate with the local healthcare system to enhance accessibility by establishing contraceptive clinics, engaging providers, restructuring health screening appointments, and incorporating insights gathered from the health needs assessment. These findings were also used to generate recommendations based on the findings for each topic area, which informed IRC programming and were shared with other IRC offices to inform their interventions. The results and recommendations were also presented at conferences and community events to inform service providers and those serving Afghan clients.
The barriers encountered during the HNA, such as scheduling challenges, gender-sensitive topics, and survey fatigue, were addressed through efficient appointment scheduling strategies, ensuring privacy and confidentiality, and offering breaks or condensing the survey without compromising data quality. These efforts contributed to successfully implementing targeted interventions that were equitable, culturally sensitive, and responsive to the diverse needs of Afghan women in the United States.