Easing Anxiety: Helping Afghan Refugees Access Oral Health Care

In early 2022, 700 Afghan refugees arrived in central Iowa, trying to settle into a community unlike any they’d ever seen. A strange landscape. A sea of unfamiliar faces. A new life.

And they had 90 days to get settled.

“The resettlement agencies had care coordination for 90 days — and that’s a federal guideline — when they’re funded to help them find housing and help them get into the community,” says Mary Kelly, RDH, a former care coordinator at Broadlawns Medical Center, a safety net clinic in central Iowa. “And in that time, they [the refugees] have to get medical and housing, know how to get transportation, and essentially get used to whatever environment they’re living in — and know how to access the community after that.”

In addition to that long list, there’s another task that many refugees need to complete in those 90 days: setting up a dental appointment. Many Afghan refugees are in desperate need of oral health care. Making the situation even more challenging, many of them don’t know English and have never set foot inside a dental office.

“It was either that they didn’t have access to [oral health] care ever, or they just hadn’t had it,” says Kelly. “Unlike other refugees — a lot of refugees camped for 10 years. Afghans didn’t because they had an immediate evacuation. So, it’s not like they had time to get dental work done in a camp.”

Kelly says she wishes she had known about — and implemented — the strategies on how to ease Afghan refugees’ anxiety that she gained from a CareQuest Institute webinar, “Understanding and Providing Trauma-Informed Oral Health Care.” (The webinar is now available as a self-paced course that includes strategies to help providers sensitively interact with trauma survivors.)

“I probably would have prepared something that says what to expect from your first dental visit,” says Kelly. “And maybe even taken them into the clinic and shown them what the chair was.”

Ongoing education and support from community-centered grants can help improve the situation for future refugees. CareQuest Institute offers both education and grants, and partners with dozens of organizations across the country to expand access for underserved populations. Improving access to the oral health system is a complex and multifaceted problem, Kelly adds, that will take new ways of thinking and new solutions.

“It’s not just Afghans, it’s all refugees,” Kelly says. “The solution — there really isn’t one, because the solution is bigger than just the refugees, unfortunately. It’s the dental provider network and access to care generally.”

When Oral Health Isn’t a Top Priority

Since the US withdrew its military from Afghanistan in August 2021, tens of thousands of Afghans have evacuated to the US to escape the Taliban. Refugees often experience nutritional deprivation, inadequate living conditions, and a lack of access to basic dental care before they arrive in the US. Those refugees are now working to resettle — with help from state and federal governments — in a country where they must quickly find housing, transportation, and employment to try to support their families.

Resettlement may bring additional health challenges related to a lack of familiar foods and challenges navigating the US health care system.

Fortunately, there are organizations that help ease the transition.

Broadlawns Medical Center, Kelly’s employer at the time, received a six-month grant from Delta Dental of Iowa to help some of those Afghan refugees access oral health. Another health center in the area, Dental Connections, a private, nonprofit community organization that strives to be a dental home for people who experience barriers to accessing dental care, also received a grant to help all refugees, not just Afghans.

“These refugees have fled their home country because of violence or persecution and often spend years stuck in refugee camps overseas,” says Carly Ross, the executive director of Dental Connections in Iowa. “In these environments, most refugees do not receive oral health care.”

The need for care, Ross adds, is clear.

“Once in the US, the dental needs of new refugees are often extensive,” she says. “New refugees also need oral hygiene instruction and education on healthy behaviors.”

Challenges and Complications of Providing Care

“Dental Connections and Broadlawns Medical Center made a concerted effort to streamline refugees in general and give them a higher priority and more care coordination,” Kelly says.

After the 90 days of care coordination with resettlement agencies expired, the grants allowed both organizations to continue to help Afghan refugees access oral health care.

“They would come in, and I’d reaffirm all the paperwork that they needed, all the registration,” Kelly says. “After registration, each refugee patient would be seen by the dentist for a complete oral exam, including all the x-rays . . . and explain the treatment plan.”

Often, the need for care was urgent.

“We worked with the University of Iowa. They have a lot of dental students, and they would rotate through Broadlawns to provide dental treatment,” Kelly says. “So if there was ever an urgent need, pain or swelling diagnosed at the comprehensive exam visit, the Broadlawns dentist would try to have a dentist or dental student get that urgent need taken care of at the same visit. Sometimes it worked, and sometimes it didn’t. They [the refugee patients] were usually seen within a day if they had anything that couldn’t be done at the comprehensive exam that was really needing care.”

Just scheduling the appointment can be a complicated process.

“All these refugees have Medicaid for at least a year in Iowa,” Kelly explains. “Iowa has extensive Medicaid benefits for adults. So, they all had Medicaid, but when I would look them up in the computer, sometimes they were already at another dental clinic. Sometimes their names and birthdays didn’t match up. I’d find them, but their birthday was different than their refugee identification. Their names were merged sometimes instead of separated. It was nearly impossible. Each person took a minimum of 45 minutes to make one appointment.”

And after those first 90 days are up, many refugees still struggle to find transportation or childcare to go to the scheduled appointment. The language barrier was yet another hurdle.

“They need a lot of extractions,” Kelly explains. “And they want to keep their teeth, so it was really difficult to explain. They didn’t know what a cavity was, but they knew what an implant was. They’d rather keep that infected tooth. Their bone was diseased enough they couldn’t get implants.”

Oral Health Grants Expanding Access to Care

CareQuest Institute’s philanthropic strategy is focused on addressing complex and upstream drivers of oral health disparities like the ones facing many refugees. The Institute recently issued a grant for $50,000 to Dental Connections to continue its program to improve oral health care coordination and public health partnerships for refugee communities. The Institute also issued a grant for $128,000 to New Mainers Public Health Initiative (NMPHI) to serve the needs of the immigrant and refugee communities in Maine and help create a community outreach program.

John Gabelus, grants and programs associate at CareQuest Institute, highlights the need for this attention and support.

“With these grants, resources, and new partnerships, we are working to make sure that everyone, no matter how long they’ve been in the United States or their reason for coming, has an opportunity to access oral health care and learn about its impact on overall quality of life,” he says. “More importantly, these grants create a pathway and opportunities for immigrant and refugee communities to participate actively in our collective effort to transform the oral health system in ways that respond to their needs and the needs of immigrant and refugee communities in the future.”

Although grants can support clinics in helping refugees make dental appointments and get access to the oral health care they need, Kelly says the system is far from perfect. Because the process was new to the refugees, many would show up at the wrong clinic, not realizing there was a difference between Broadlawns Medical Center and Dental Connections. Some would get a referral to one clinic but then move on to different clinics and book additional appointments. They were trying to get seen earlier but not understanding that they needed to go to the appointment they were referred to, she says.

“Everyone is in desperate need of care,” she says.

Although a lot is out of Kelly’s control, she says it is important to make those refugees feel as comfortable as possible before they get in the dental chair.

“Here, they say laying down and having someone in a more dominant role can be traumatic,” Kelly says. “I think I would’ve been more aware of that type of orientation of the dental clinic beforehand.”

She plans to share the information she learned from the webinar with others to help refugees in any way they can.

“I am definitely going to incorporate it into the report that I’m doing for all Afghans,” Kelly says. “And I’ve already referred that webinar to several people, including all the people in my clinic.”