Letters to the Editor  |   August 2014
Bosnian Refugees: Screening and Treatment in an Immigrant Population
Article Information
Addiction Medicine / Imaging / Medical Education / Obstetrics and Gynecology / Psychiatry / Graduate Medical Education
Letters to the Editor   |   August 2014
Bosnian Refugees: Screening and Treatment in an Immigrant Population
The Journal of the American Osteopathic Association, August 2014, Vol. 114, 617-618. doi:
The Journal of the American Osteopathic Association, August 2014, Vol. 114, 617-618. doi:
To the Editor: 
A large number of Bosnian refugees immigrated to the United States during the Bosnian War (1992-1995), with little money and little time to assimilate into a new culture and become fluent in English. It important for primary care physicians to understand the medical, emotional, and financial hardships confronted by the Bosnian community and to increase health literacy in this population. 
Bosnian refugees are 3 times more likely to smoke tobacco than US-born residents, and the prevalence of Bosnian refugee smokers in the United States far surpasses the population of smokers per capita in Bosnia.1 It may be that the hardship of moving to a new country with little financial or emotional support increases the rate of habitual use of tobacco. Many Bosnian immigrants also have psychiatric disorders, such as post-traumatic stress disorder and depression, even if they did not fight in the war.2 Mental illness has a primary correlation with increased rates of tobacco use and therefore must be considered paramount when assessing these patients.1 
A study of 499 Bosnian refugees living in St Louis, Missouri, found that 66.4% were smokers, 20.2% were nonsmokers, and 13% were former smokers.1 Of the two-thirds of refugees who smoke, over three-fourths smoked more than 1 pack of cigarettes per day, which is a statistically significant higher pack use than that of the average smoker in the United States.1 Bosnian American refugees understand that smoking is attributed to health problems and a shorter life expectancy; yet, they believe that their risk for tobacco-related illness is lower than that of other populations.1 Further research must be done to understand the rationale behind this belief so that physicians can educate patients effectively. 
Another factor associated with the rate of smoking in this population is cultural peer pressure. While 69% of US-born smokers want to quit smoking,3 only 57.2% of Bosnian Americans stated they “really want to stop smoking.”1 The rest were ambivalent or did not want to quit because of cultural norms and the addictive nature of nicotine. Many refugees also associated smoking with camaraderie, and they believed that by quitting smoking they would lose valuable friendships.4 Taking into account the perceived barriers Bosnian refugees face when attempting to quit smoking may guide physicians in educating this population. 
Mammography screening is another aspect of Bosnian American health care that requires attention because many Bosnian women do not understand its importance.5 Whereas breast cancer is the second leading cause of death in women in the United States,6 it is the most common malignant disease in Bosnian women.7 In a study of 91 Serbo-Croatian–speaking women between the ages of 40 and 79 years, only 44% had received a mammogram, whereas 65% of US-born women had undergone screening during the same period.5 With the help of a female Serbo-Croatian patient navigator who conducted telephone calls, home visits, and educational group meetings, screening increased from 44% to 67% within 1 year.5 That outcome reiterates the importance of understanding the language and customs of the population and indicates the possible benefits of using a patient navigator who is familiar with the Bosnian and US health care systems. 
As previously stated, Bosnians also face mental health problems, in part brought on by wartime and being forced to leave their homes and adjust to a new language and culture. A small study was conducted to assess the mental health of female Bosnian refugees who had not adjusted to the United States as being their “home.”8 The women were asked to describe their experiences of living in the United States, a question that elicited an abundance of past memories and present struggles. These women led relatively normal lives until they and their families were forced to leave Bosnia out of fear for their safety during the war. Once in the United States, many struggled, which further engrained feelings of inadequacy. The jobs that were available were in manual labor or factory work, with long hours and little pay to support their families. Some coped with their feelings by working excessive hours, while others took to dreaming and clinging to memories of the lives they left behind. When approaching a Bosnian patient, one must take all of these psychological issues into consideration and work to recognize how these experiences have shaped their perception of health care. 
Although many Bosnian Americans speak some English, it is vital to ensure that patients comprehend health care information to make decisions and follow instructions for treatment. Guidelines should be established to assist providers in effective communication methods with this population. Children in the family often serve as interpreters; however, this communication is not effective because a child may not grasp the complexity of medical information given to them. Instead, providers should use patient navigators, experienced interpreters, and translated pamphlets to effectively deliver information. Language Line, which allows health care providers to speak to interpreters throughout the world, is an option if other means are inaccessible. 
Physicians might encourage patients, especially those who feel isolated from the community, to engage in social activities or groups. Bosnian community events that appeal to all ages are an effective way to educate the population. In the past, programs such as Coffee and Family Education and Support for Bosnian Families (CAFES) were established to bring families together for discussions.9 These organizations focus on creating a supportive social environment where families can interact, teach, and learn from one another.9 A similar approach may be beneficial when addressing smoking cessation, mammography screening, and mental health. 
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