Cultural Spotlights

Understanding the cultural backgrounds of the communities arriving in North Dakota is essential for providing respectful, informed and effective support. This page brings together a collection of cultural spotlights designed to help service providers, partners and community members deepen their knowledge of refugee populations resettling in the United States.

You'll find two types of resources here:

  • Switchboard cultural backgrounders, which offer nationally developed, research-based overviews of refugee populations.
  • Cultural spotlights written by North Dakota Health and Human Services Office of Refugee Services team members highlight insights, lived experiences and practical considerations specific to our work in North Dakota.

Together, these resources support stronger cultural awareness, more meaningful engagement and better outcomes for the individuals and families we serve.

Cultural spotlights

Geography and background

Ukraine, the second-largest country in Europe, is in Eastern Europe. It is bordered by Belarus to the north, Hungary, Slovakia and Poland to the west, Romania and Moldova to the southwest and Russia to the northeast and east. To the south, it is bordered by the Black Sea and the Sea of Azov. Ukraine’s landscape includes vast plains, fertile plateaus and mountain ranges like the Carpathians in the west and the Crimean Mountains in the south. Ukraine’s rich history includes periods of rule by various empires and states, such as the Polish Lithuanian Commonwealth, the Austrian Empire, the Ottoman Empire and the Soviet Union. Ukraine declared independence from the Soviet Union on Aug. 24, 1991.

map of Ukraine

 

Culture, family, religious beliefs, traditions, education and values

Ukrainian culture is deeply rooted in its history and traditions. Family is a central aspect of Ukrainian life, with a strong emphasis on respect for elders and close-knit family bonds. Most Ukrainians identify as Christians, with Eastern Orthodox Christianity being the largest denomination. Other Christian denominations, including Roman Catholicism, Greek Catholicism and Protestantism are also present. 

Traditional Ukrainian customs include folk art, embroidery and music. Festivals and celebrations, such as Ivan Kupala Day and Malanka, are integral to Ukrainian culture. Music and dance, particularly the Hopak dance, play a significant role in cultural expression. Embroidery, known as Vyshyvanka, is a cherished tradition seen in traditional clothing and decorative items. Ukrainians are very passionate about their foods and have many food and holiday traditions.

Ukrainians typically refer to each other by their last names. Husbands and wives have different versions of the same name—the wife's name is “feminized.” For example, Ivan Bystrov and Oksana Bystrova.

Ukraine has a well-established education system, with free and compulsory education for children aged six to 15. The primary education system is followed by secondary education, which includes general, vocational and specialized streams. High education institutions, such as Tara Shevchenko National University of Kyiv and Lviv Polytechnic National University, are renowned for their academic excellence. In general, Ukrainians complete five years of university education, which they call a master’s degree. However, this qualification may not always be equivalent to a U.S. master’s degree.

Education is highly valued in Ukrainian society, with a strong emphasis on academic success and intellectual pursuits.

Dates of significance

Ukraine, with its rich history and vibrant culture, observes several significant dates that reflect its national pride and historical milestones.

  1. Independence Day (Aug. 24): Celebrates the Declaration of Independence from the Soviet Union in 1991.
  2. New Year's Day (Jan. 1): The start of the new year, celebrated with various festivities.
  3. International Women's Day (March 8): A Day to honor and celebrate women's achievements.
  4. Labor Day (May 1): A public holiday to celebrate the contributions of workers.
  5. Victory Day (May 9): Commemorates the end of World War II and the victory over Nazi Germany.
  6. Constitution Day (June 28): Marks the adoption of the Ukrainian Constitution in 1996.
  7. Statehood Day (July 15): Celebrates the Christianization of Kievan Rus in 988.
  8. Defenders of Ukraine Day (Oct. 14): Honors the Ukrainian military and those who have defended the country.
  9. Christmas (Dec. 25): Celebrated by Christians to mark the birth of Jesus Christ

These are deeply ingrained in Ukrainian national identity and are observed with various ceremonies and public events, reflecting the nation's resilience and unity.

Economic and employment opportunities

Ukraine’s economy is diverse, with key sectors including agriculture, manufacturing and services. The country is a major producer of agricultural products, particularly winter wheat, maize and sunflower oil. The fertile soil, known as chernozem (black earth), is highly conducive to farming. The industrial sector is concentrated in the Donets Basin (Donbas), which is known for its heavy industry, including coal mining, metallurgy and machinery manufacturing. In recent years, Ukraine has been focusing on developing its technology and IT sectors.

Migration drivers

Several interrelated factors, including economic instability, political unrest and the ongoing conflict with Russia, drive migration from Ukraine. The annexation of Crimea by Russia in 2014 and the conflict in Eastern Ukraine have significantly impacted the lives of millions of Ukrainians, leading many to seek safety and better economic opportunities abroad.

Ukraine has faced economic challenges for many years, including high inflation, unemployment and a struggling economy. The country’s economic instability has been exacerbated by corruption and a lack of structural reforms. As a result, many Ukrainians, particularly young people and skilled workers have sought better job opportunities and high wages abroad. The allure of more stable economies in Western Europe and North America has driven a significant portion of the population to migrate in search of improved living conditions and financial security.

Political instability and governance issues have also contributed to migration from Ukraine. The country has experienced a series of political crises, including the Orange Revolution in 2004 and the Euromaidan protests in 2013-2014, which led to significant changes in government and policy direction. These political upheavals have created an environment of uncertainty and instability, prompting many Ukrainians to seek more stable and predictable environments abroad. However, due to past experiences with corruption in their country, some Ukrainians may exhibit a wariness towards government institutions. This cautious attitude often extends to financial institutions as well.

The ongoing conflict with Russia, which began with the annexation of Crimea in 2014 and escalated with the conflict in Eastern Ukraine, has displaced millions of people. The violence and insecurity in conflict-affected areas have forced many Ukrainians to flee their homes, seeking refuge and safety in other parts of Ukraine and abroad. Internally displaced persons (IDPs) have faced significant challenges in accessing housing, employment and social services, further driving migration.

Younger generations often migrate to Europe and North America in search of higher-paying jobs and better living conditions. Education and professional opportunities in countries such as Poland, Germany, Canada and the United States are particularly attractive to young Ukrainians.

Migration decisions are often influenced by social and familial factors. Many Ukrainians have relatives or friends who have already migrated, creating a network of support and facilitating the migration process. The presence of established migration communities in destination countries provides social and cultural support, making it easier for new migrants to adapt and integrate into their new environments. Ukrainians often form close-knit social groups based on family and religious affiliations. They may prefer to remain within these familiar circles rather than being introduced to other Ukrainians solely based on a shared language.

Health conditions and healthcare

Ukraine faces various health challenges, including high rates of cardiovascular diseases, cancer and respiratory illnesses. Factors such as lifestyle, environmental pollution and limited access to quality healthcare contribute to these issues. The healthcare system is undergoing reforms to improve access and quality of care, including efforts to decentralize the health care system still faces challenges, such as inadequate infrastructure and shortages of medical professionals.

Behavioral health

Mental health is a significant concern in Ukraine, with many individuals experiencing stress, anxiety and depression due to the ongoing conflict and economic hardships. The stigma surrounding mental health issues often prevents people from seeking help, highlighting the need for increased mental health support and services.

Healthcare access challenges for Ukrainians in America

  1. Language Barriers: Limited English proficiency can make it difficult for Ukrainians to navigate the health care system and communicate with providers. This can lead to misunderstandings, misdiagnoses, and inadequate treatment. To mitigate these challenges:
    1. Interpreter Services: Ensure that interpreter services are available and utilized during appointments. This helps to ensure accurate communication and understanding.
    2. Language Access Plans: Develop and implement language access plans within health care facilities to ensure that language services are systematically provided and accessible to all patients in need.
  2. Cultural Differences: Differences in health care practices and expectations can lead to challenges in receiving appropriate care. Cultural misunderstandings can affect the patient-provider relationship and the overall quality of care. To address these challenges:
    1. Cultural Competence Training: Provide ongoing cultural competence training for health care staff to enhance their understanding of Ukrainian cultural norms and health care practices.
    2. Patient-Centered Care: Adopt a patient-centered approach that respects and incorporates the cultural values and preferences of Ukrainian patients into their care plans.
    3. Appointment Practices: In many areas of Ukraine, scheduled appointments are not common practice. For instance, when seeking medical attention, individuals often stand in line and hope to be seen that day. This cultural difference can present challenges when adapting to the appointment-based systems prevalent in the United States. 

Key cultural considerations for providing care to Ukrainians in America

  1. Language and Communication: Many Ukrainians may speak Ukrainian or Russian as their primary language. This can pose significant challenges in healthcare settings where English is the primary language. Ensuring effective communication is crucial for the delivery of quality care. To address this, healthcare providers should:
    1. Provide Interpreters: Employing professional interpreters or using interpretation services can help bridge the language gap. This ensures that patients fully understand their diagnoses, treatment plans and medication instructions.
    2. Bilingual Staff: Having bilingual healthcare staff who can communicate directly with Ukrainian-speaking patients can improve the patient experience and reduce misunderstandings.
    3. Translated Materials: Offering translated information materials, such as brochures, consent forms and instructions, in Ukrainian or Russian can help patients better understand their healthcare options and procedures.
  2. Cultural Sensitivity: Understanding and respecting Ukrainian cultural practices is crucial for building trust and providing effective care. Ukrainian culture strongly emphasizes family and family members often play a significant role in healthcare decisions. Healthcare providers should:
    1. Involve Family Members: Recognize the importance of family involvement in the patient’s care. Encourage family participation in discussions about treatment options and respect their input and decisions.
    2. Respect for Traditions: Be aware of and accommodate traditional practices and preferences whenever possible, such as dietary restrictions or specific health practices rooted in cultural beliefs.
  3. Religious Beliefs: Religion plays a significant role in the lives of many Ukrainians, influencing their values and health care decisions. Most Ukrainians are Christians, primarily Eastern Orthodox and their religious beliefs can impact their approach to medical care. Healthcare providers should:
    1. Acknowledge Religious Practices: Know important religious practices, holidays and dietary restrictions that may affect a patient’s healthcare needs. For example, some patients may observe fasting periods that could impact their nutrition or treatment schedules.

Provide Spiritual Support: Offer access to chaplaincy services or spiritual care providers who can provide comfort and support to patients and their families.

References

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Geography and Background

The Democratic Republic of the Congo (DRC), formerly known as Zaire, occupies most of the Congo River Basin. The Democratic Republic of the Congo has a short 25-mile coastline along the Atlantic Ocean, making it one of the few Central African countries with direct access to the sea. As the second-largest country in Africa, after Algeria, the DRC is located directly on the equator, which influences the climate in significant ways. The central region experiences a hot and humid tropical climate with abundant rainfall year-round. In contrast, the southern highlands, located further from the equator, enjoy a cooler, drier climate due to higher elevation.

Map of the Democratic Republic of the Congo

The country gained independence from Belgium in 1960 as the Republic of the Congo. In 1964, it became the Democratic Republic of the Congo, was renamed Zaire in 1971 under President Mobutu Sese Seko and returned to the Democratic Republic of the Congo in 1997.

The DRC has experienced two major wars: the First Congo War from 1996 to 1997 and the Second Congo War, also known as the “Great African War,” from 1998 to 2003.3 Despite peace agreements, armed groups continue to terrorize civilians. Ethnic conflicts, sexual violence, human rights violations, poverty and economic collapse continue to displace people and force them to seek refuge elsewhere.

Culture, family, religious beliefs, traditions and values and education

The DRC is one of the most ethnically diverse countries in the world, with more than 200 ethnic groups. It is estimated that 215 languages are spoken, with French as the official language. Other prevalent languages include Kikongo (or Kituba), Tshiluba, Lingala and Swahili, a Bantu language spoken mainly in eastern Equatorial Africa, among many others. Given the country’s linguistic diversity, many individuals are fluent in four or more languages.

With the country’s rich cultural diversity, manifested through various ethnic groups, traditions and beliefs play a significant role in Congolese identity. Music and dance go hand in hand, with Ndombolo among the most popular traditional dances in the DRC. 

Family is the central focus of life in Congolese culture, with respect being one of the most deeply held values. Large extended families are common, often living under the same roof or in closely clustered homes. In some matrilineal communities, particularly among certain ethnic groups in western DRC, a maternal uncle may play an important leadership role within the family.

Women typically handle the majority of household chores and childcare, while men are expected to protect and provide for the family. Raising children is seen as a shared responsibility, with extended family members, especially during puberty, playing a significant role in guiding and supporting the younger generation. Physical forms of discipline may be more commonly accepted in some Congolese communities than in the United States. When resettling in the United States, Congolese parents should be aware of U.S. laws regarding child abuse. 

In rural areas, which make up more than half the country, women are largely dependent on men; however, urban women, especially those with higher levels of education, tend to be more independent. Additionally, events since the mid-1990s have altered traditional roles, with women becoming wage earners and, in some cases, the primary income providers. 

Marriage in Congolese society is highly valued and is often seen as a union of two families, not just two people. Arranged or semi-arranged marriages are especially common in rural areas. Congolese women tend to marry at a much younger age than is common (or lawful) in the United States.

Many communities practice bridewealth, in which the groom's family provides money or gifts to the bride’s family as part of the marriage process. The practice has been criticized for its potential to trap women in marriage, often requiring repayment of the bride price before they are allowed to leave. This is particularly concerning given that approximately half of women report experiencing physical violence, and nearly one-third report experiencing sexual violence, most often at the hands of an intimate partner. 

Today, more than 90% of the population identifies as Christian, primarily Catholic or Protestant.9 Islam accounts for roughly 10%, while the rest follow other religions or indigenous beliefs. Many Congolese Christians and Muslims also incorporate elements of traditional African religions, such as ancestor veneration, traditional medicine and spirit worship, especially during illness, funerals and major life events. Religion remains a central part of life in the DRC, offering comfort, guidance and a sense of peace.

The education system includes one year of pre-primary education, six years of primary school and six years of secondary school. Primary education is free, but secondary schools charge tuition, which many families cannot afford.

Education faces numerous challenges, including inadequate funding, poor infrastructure, limited access and a lack of educational materials. Ongoing conflict further disrupts schooling, as many children are forced to flee their homes or are recruited as soldiers. Even when access to education is available, many parents choose to keep their children at home due to safety concerns.

Dates of significance

The country observes many globally recognized holidays, including Labor Day, New Year’s, Christmas and Easter. However, Christmas is observed as a more religious than commercial holiday and gift-giving is uncommon. Martyrs’ Day, celebrated on January 4, is a country-specific festival that commemorates those who died in the struggle for justice, as well as those who lost their lives due to human rights violations, including the millions of Congolese killed under the reign of King Leopold II. Other dates celebrated include National Liberation Day (May 17), Parents’ Day (August 1), Army Day (November 17) and National Heroes’ Day (January 17).

Economic and employment opportunities

The DRC is rich in natural resources, including minerals like cobalt, diamonds, silver, gold and copper, powerful rivers that support hydroelectric energy, fertile farmland, diverse wildlife and the world's second-largest rainforest. Despite this abundance, most Congolese people have not benefited from this wealth. The DRC remains among the five poorest countries in the world and in 2024, an estimated 73.5% of the population lived on less than $2.15 a day.

In the DRC, the economy is largely shaped by the informal sector, which provides the majority of employment and serves as a primary survival strategy for many households. A Congolese community leader described the informal economy using the commonly cited expression “Article 15,” meaning “survival mode,” and explained, “You wake every day; you don't know what your family will eat.” Most people work in small-scale, unregulated activities such as street vending, market trading, informal transport, fishing, subsistence farming and artisanal services, often without job security, legal protections or access to formal financial systems. Congolese women face additional barriers to economic opportunity and empowerment, including high rates of gender-based violence and discrimination.

Migration drivers

Since 2021, the DRC has been experiencing one of the longest crises in its history, with an alarming upsurge in violence carried out by armed groups, causing the deaths of civilians and triggering massive and repeated forced displacement of hundreds of thousands of people. Safety has substantially decreased, causing many humanitarian activities in these provinces to be suspended, endangering the Congolese population and increasing food insecurity.

Health conditions and healthcare

The DRC continues to face one of the most complex and ongoing humanitarian and health crises in the world. This situation is driven by a combination of connected factors, including armed conflict, mass displacement, food insecurity, disease outbreaks and natural disasters.

The humanitarian crisis has caused serious food shortages. In 2024, about 23.4 million people faced high levels of food insecurity. Conflict and displacement make the problem worse by limiting access to farmland and markets.

Public health in the DRC remains in a critical state, with frequent disease outbreaks such as cholera, measles, malaria, yellow fever and more recently, monkeypox. The health system is strained, making it difficult to control these outbreaks and provide basic care. Despite these challenges, steady progress has been made in reducing mortality from Human Immunodeficiency Virus and Tuberculosis, with rates declining each year since 2015.  

The DRC continues to face the burden of several neglected tropical diseases that require large-scale treatment efforts. These include lymphatic filariasis, soil-transmitted helminths, schistosomiasis, trachoma and onchocerciasis. 

Childhood vaccination coverage has been historically lower than national standards. In 2024, 82% of children received the first dose of the Diphtheria, Tetanus and Pertussis vaccine, but only 65% completed the full series. For measles, 55% received the first dose, with coverage dropping to 51% for the second dose (MCV2). The DRC accounted for 19.1%or 772,000 of the zero-dose children in West and Central Africa in 2024.

Behavioral health

The DRC faces severe mental health challenges due to decades of chronic crisis marked by conflict, widespread violence, displacement and deep poverty. This long-term instability exposes communities to ongoing trauma and contributes to high rates of anxiety, depression and Post-Traumatic Stress Disorder. Despite the significant need, most people receive no mental healthcare because of limited services, weak health infrastructure, low political prioritization and persistent stigma and human rights concerns. The COVID-19 pandemic has further strained an already fragile system. As a result, mental health remains one of the most neglected areas of public health in the DRC.

Mental health problems, particularly the psychological impacts of sexual violence, are highly stigmatized in the DRC. Survivors, especially women who have experienced rape, often face shame, family or spousal rejection and loss of social support. Additionally, many communities attribute mental illness to curses, witchcraft or spiritual causes, which leads families to seek help from traditional or religious healers rather than mental health professionals, limiting access to appropriate care.

Healthcare access challenges for Congolese in America

  1. Relaxed concept of time. Schedules in the DRC are relaxed and flexible. It’s common for people to arrive after the designated time or for services to be delayed. Make sure to confirm the appointment several times and give reminders for the appointment. It’s also crucial to explain that appointments are at the exact time.
  2. Health literacy and system navigation. Limited familiarity with the U.S. healthcare system (insurance, preventive care, primary care structure) can create confusion and missed care.

Key cultural considerations for providing care to the Congolese in America

  1. Take time to build rapport before jumping into questions or interventions. Ask about family or personal well-being as an entry point.
  2. Listen carefully to nonverbal cues or hesitations. Ask open-ended questions rather than yes/no questions to get accurate information.
  3. Cultural norms about modesty and gender roles may affect willingness to see certain providers. Make sure to ask if the client has a preference for seeing a male or female provider. 
  4. Mental health problems may be linked to curses, witchcraft or shame; survivors of sexual violence may be rejected socially. Normalize mental health discussions, use trauma-informed approaches and anticipate reluctance to disclose symptoms. It’s important to find culturally appropriate ways to discuss stress and trauma.

References

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Geography and background

Haiti, home to approximately 11.8 million people, occupies one-third of the island of Hispaniola. To the east lies the Dominican Republic, while the Atlantic Ocean and the Caribbean Sea are to the north and south. Jamaica is located to the west and Cuba is situated to the northwest. Hayti means "land of the mountains” in the native Taíno language. The country is divided up into three regions including mountainous areas, coastal plains and numerous small islands.

In 1804, following a successful revolt against the French, Haiti emerged as the first independent nation in Latin America and the Caribbean and as the first Black-led republic globally.

map of Haiti

Culture, family, religious beliefs, traditions and values and education

Family holds a central place in Haitian culture, and it’s common for extended families, often spanning multiple generations, to live together under one roof. In Haitian society, respecting elders is a key value, with younger family members expected to defer to their elders in decision-making and other important matters. Women in Haiti also play a crucial role in society. In addition to managing the household, they are also indispensable in economic actives such as street vending and supporting agricultural supply chains. Despite their important roles, women and girls endure many harsh inequalities and are impacted greatly by gender-based violence. According to a study by the Universal Periodic Review of Haiti, about 70% of Haitian women and girls survived a form of gender-based violence. 

Traditional Haitian cuisine includes locally grown vegetables and fruits such as cabbage, plantains, mango, guava and pineapple and starches such as beans, corn and rice. Many dishes include flavorful meats such as pork, chicken, fish or beef. Popular dishes are “Griot” (fried pork), “Diri ak djon djon” (rice with black mushrooms) and “Accra” (malanga fritters). However, foods such as meat and cheese are expensive and most people in Haiti cannot afford them.

Religiously, 54.7% of Haiti's population identifies as Roman Catholic, 28.5% as Protestant and 10.2% as non-religious. However, many Haitians also incorporate Vodou into their religious practices and traditions. Haitian Vodou is a spiritual tradition involving the use of herbs, supernatural beings and magical ceremonies to heal people and cure diseases.

Haitians are known for being expressive and openly displaying their emotions10. Greetings are extensive and skipping them is considered impolite. Additionally, Haitians are recognized for their hospitality and willingness to help strangers visiting their country.

In Haiti, more than 80% of schools are privately operated by communities, religious groups and non-governmental organizations. These private schools often charge tuition that most families cannot afford. Public schools often lack proper education tools, instructors and are very crowded. The language of instruction in most schools is French, even though the majority of Haitians speak Haitian Creole. The language barrier can make learning difficult for students, particularly in rural areas. In primary schools (ages 6-11), the enrollment rate stands at 57%, while only 20% of students of eligible age are enrolled in secondary schools (ages 12-18). Attendance is also inconsistent due to factors such as poverty, distance to schools and the need for children to contribute to household income. As of 2016, 83% of Haitian students aged 15-24 are literate; however, approximately 50% of adults remain illiterate.

Dates of significance

Haitians love to celebrate, and their festivals express their culture and history with colorful costumes, music and dance. A Haitian newcomer said, “November 1st is known as Fèt Gede (Festival of the Ancestors) or the Haitian Day of the Dead which is celebrated widely throughout Haiti. On this day people go to church to pray and honor the dead. For Haitians who practice Vodou, the day is filled with music, dancing and lots of celebration.” Another important celebration is Independence Day, celebrated on January 1st, Independence Day marks Haiti’s liberation from French colonial rule in 18049. Flag Day commemorates the creation of the Haitian flag and is marked with patriotic displays reflecting the pride and resilience of Haitian people. Rara is a traditional festival that takes place during the Lent season, characterized by street processions with music, dance and vibrant costumes.

Economic and employment opportunities 

Haiti remains one of the poorest countries in the world and the poorest country in the Western hemisphere, with 78% of people living off $2 a day. Agriculture accounts for roughly two-thirds of the jobs in Haiti. Many farmers focus on growing subsistence crops such as cassava, plantains and bananas, corn, yams, sweet potatoes and rice rather than for sale or profit. Coffee and sugarcane have a long history in Haiti and are still the main cash crops today. Other cash crops in Haiti include mangoes, cacao, avocados and essential oil. Clothing factories also employ thousands of Haitians and produce apparel that are mainly exported to the United States, Canada and Mexico. When interviewing a Haitian newcomer about employment opportunities, he said, “We have universities, but for the moment many young people in Haiti do not go to universities, they prefer to go to a vocational school to learn a manual trade because you can spend five years or more at a university, and when you finish it is impossible for you to find a job.”

Migration drivers

Challenges such as poverty, natural disasters, political crises and insecurity have historically been key drivers of migration from Haiti. The massive earthquake in 2010 displaced 1.5 million people, and the already fragile economy declined by over 5% within the first year following the disaster.

Haiti has been without a leader since the assassination of President Jovenel Moïse on July 7, 2021, which led to no immediate successor taking control, leaving the government and country without strong leadership. This further deepened the country's instability and triggered a surge in gang violence. It is estimated that 80% of Haiti’s capital, Port-au-Prince, is now controlled by gangs. The political instability and growing violence have further worsened an already struggling economy where essential goods and services such as food, water and sanitation are scarce, causing another wave of migration.

Health conditions and healthcare

Although most violence occurs in Port-au-Prince, it has created a humanitarian crisis that affects the entire country. The capital serves as the primary port of entry for goods and services, resulting in significant shortages of food, water, sanitation and healthcare. Nearly half of the population (48%) in Haiti experiences high levels of acute food insecurity. Malnutrition is the leading cause of death among children under five, with one in four children suffering from chronic malnutrition. Even acute malnutrition can hinder children’s physical and cognitive development. Cholera continues to be a public health emergency, worsened by severe water shortages and deteriorating sanitation conditions. 

The country continues to struggle with low childhood vaccination coverage; however, the United Nations Children’s Fund (UNICEF) reports a 10% increase from 2022 to 2023. Vaccines against Diphtheria, Tetanus and Pertussis (DTP) and Measles and Rubella (MR) have increased to 94% or higher and 75% of children under the age of one in some regions have received the Bacillus Calmette-Guérin (BCG) vaccine to protect against tuberculosis. 

Haiti has one of the highest rates of tuberculosis (TB) in the region, driven by overcrowded living conditions and inadequate housing. In 2023, 15% of active TB cases were also living with Human Immunodeficiency Virus (HIV). Furthermore, Haiti accounted for over one-third (38%) of the region's new HIV cases, with children representing 17% of these infections. Other prevalent communicable diseases include human papillomavirus (HPV), dengue fever, malaria, chikungunya, intestinal parasites (such as Endolimax nana, Blastocystis hominis, Giardia intestinalis, Entamoeba coli, and Ascaris lumbricoides), lymphatic filariasis (LF), leptospirosis and hepatitis A and E.

Heart disease is the most common chronic health condition in Haiti, followed by hypertension, stroke, Type II diabetes, chronic respiratory diseases and cancer, with cervical cancer being the leading cause of cancer deaths. Maternal and infant mortality rates in Haiti are the highest of the Western Hemisphere, making maternal mortality one of the leading causes of death among adolescents and young people. Additionally, gender-based violence continues to rise in Haiti. Many of these health-related issues remain untreated due to limited access to healthcare services. Numerous Haitians are forced to travel long distances to seek care, and even then, they may be denied service due to their inability to pay. The healthcare system in the United States significantly differs from that in Haiti, making it essential to inform Haitian newcomers about how insurance works, how to navigate healthcare access and where to go or what number to call in case of an emergency.

Behavioral health

Many past and present circumstances contribute to this rising mental health crisis, including natural disasters, political instability, poverty, ongoing violence and forced migration. Depression, anxiety, post-traumatic stress disorder and suicidal ideation are the most prevalent mental health disorders among Haitian newcomers. They may be reluctant to seek services due to stigma. Some people may hold beliefs related to mental health or disability as being caused by karma, an imbalance of energy, problems in the spirit realm, witchcraft and more. In Haiti, many people fear that if they receive treatment for a mental health disorder, they will be labeled ‘fou’ or crazy. Once a person is labeled crazy, their cognitive abilities or judgment may never be trusted again. According to a Haitian newcomer, “People don’t typically talk about their mental health, even though many are stressed.”

It is important to continue educating Haitian individuals about behavioral wellness to help break the stigma. Many Haitians look to their spiritual leaders for guidance and may incorporate religious beliefs into their healing practices. Trauma in Haitian newcomers is multigenerational, and it is crucial to focus on both adults and children when supporting families in their healing process.

Healthcare access challenges for Haitians in America

  1. Concept of time. In Haiti, arriving late for appointments is not considered impolite and it is widely accepted that everyone and everything can wait. It’s crucial to emphasize the importance of being on time for medical appointments. Clients may need to be reminded of appointments.
  2. Mistrust and trouble understanding the American healthcare system. Many Haitians are hesitant to seek treatment due to corruption and lack of stability in their own country. This mistrust can lead to delays in seeking care, poor adherence to medical advice and reluctance to use available resources. Haiti also lacks sufficient healthcare resources, making it difficult to find medical treatment. Haitians may need additional help with making appointments and understanding when to seek medical help. 
     

Key cultural considerations for providing care to Haitians in America

  1. Many Haitians are deeply religious and rely on spiritual healing along with formal medical treatment. Many incorporate traditional healing, herbal remedies, spiritual leaders and Vodou practitioners. It is very important to take this all into consideration when providing care. 
  2. Family involvement is very importation when making decisions. Haitians also look to their elder relatives for answers when it comes to decision making. It is important to include any family members they may want present for appointments and decision making. 
  3. Haitians may use indirect communication to avoid confrontation. It is very important to build a trusting relationship and establishing good rapport with the client, so they feel comfortable being open and honest about any care options you give them. Haitians typically turn to their peers for support before considering professional help. This is another reason why building a strong rapport is so critical for these clients.

References

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Geography and background

Afghanistan, home to approximately 40 million people, is a landlocked country in South-Central Asia. It shares borders with six nations: Pakistan to the east and south, Iran to the west and Turkmenistan, Uzbekistan, and Tajikistan to the north, as well as China to the northeast. Rugged mountains, arid plateaus and fertile river valleys dominate the country’s terrain. The Hindu Kush mountain range cuts through the center, with peaks reaching over 24,000 feet, while the Amu Darya River forms part of the northern boundary.

The name “Afghanistan” translates to “Land of the Afghans,” referring to the diverse ethnic groups that inhabit the region, including Pashtuns, Tajiks, Hazaras and Uzbeks. The country is divided into distinct regions shaped by geography and culture: the mountainous northeast, the desert south, the fertile west and the central highlands. Afghanistan’s history stretches back thousands of years, serving as a crossroads for empires and trade routes. It was part of the ancient Silk Road and has seen the rise and fall of rulers from Alexander the Great to Genghis Khan. In 1919, Afghanistan gained full independence from British influence, becoming one of the first nations in the region to assert sovereignty in the modern era.

Map of Afghanistan

Culture, family, religious beliefs, traditions and education

Family is the cornerstone of Afghan society, with extended families often living together in multigenerational households. Afghan culture is deeply collectivist, and loyalty to one's family takes precedence over individual needs. Elders hold significant authority, and their guidance is respected in decision-making and social matters. The family structure is traditionally patriarchal, with men serving as primary decision-makers and providers, while women manage domestic responsibilities and child-rearing.

Women in Afghanistan have historically played vital roles in both family and community life, though their public participation has been shaped by cultural norms and political shifts. In urban areas, women have increasingly accessed education and employment, but in many regions, they continue to face restrictions and gender-based inequalities. The Taliban’s resurgence has further impacted women’s rights, particularly in education and public life.

Afghan cuisine reflects the country’s agricultural heritage and regional diversity. Meals often center around bread (nān), rice pilaf, stewed vegetables and meats such as lamb, chicken or beef. Dishes like kabuli pulao (rice with raisins and carrots), mantu (meat dumplings) and ashak (leek-filled dumplings) are popular across the country. Food is typically shared communally, and hospitality is a deeply rooted value; guests are honored with generous servings and warm welcome.

Islam is the dominant religion in Afghanistan, with approximately 90% of the population practicing Sunni Islam and the remainder following Shia Islam or other faiths. Religious beliefs shape daily routines, social norms and gender roles. Practices such as prayer, fasting during Ramadan and modest dress are widely observed. Mosques serve as spiritual, educational and community centers, and religious leaders play influential roles in society.

Afghans are known for their expressive communication and strong sense of honor. Greetings are formal and respectful, often involving handshakes or placing a hand over the heart. Social interactions are guided by codes of conduct that emphasize modesty, respect, and hospitality.

Education in Afghanistan has faced significant challenges due to decades of conflict and political instability. While schools have reopened in many areas, access remains uneven, especially for girls. In rural regions, poverty, distance and cultural norms often hinder school attendance. The official languages of instruction are Dari and Pashto, though many students speak regional languages at home. Literacy rates vary widely, with urban areas showing higher enrollment and achievement than rural communities. As of recent estimates, literacy among youth is improving, but adult literacy remains low, particularly among women.

Economic and employment opportunities

Afghanistan faces significant economic challenges, with much of its population relying on agriculture and informal labor to survive. Roughly 40–60% of Afghans are employed in the agricultural sector, which contributes around 25% of the country’s GDP. Many rural families practice subsistence farming, growing wheat, maize, barley, rice and vegetables primarily for household consumption. Livestock such as sheep, goats and cattle also play a vital role in rural livelihoods.

Afghanistan’s cash crops include saffron, pomegranates, almonds, grapes and apricots, which are increasingly exported due to their high quality. Saffron, in particular, is gaining international recognition as a legal and profitable alternative to opium poppy cultivation. Despite these opportunities, farmers face challenges such as water scarcity, outdated infrastructure and limited access to markets.

Beyond agriculture, agribusiness and food processing are emerging sectors that offer employment in packaging, transport and retail. However, access to vocational training and education remains uneven. Women also contribute significantly to agriculture, often working in livestock care and small-scale farming, though their labor is frequently unpaid or informal.

Migration drivers

Afghanistan’s migration patterns have long been shaped by a combination of poverty, natural disasters, political instability and insecurity. Decades of conflict, including the Soviet invasion, civil wars and the U.S.-led intervention, have displaced millions. The Taliban’s return to power in August 2021 intensified instability, triggering widespread displacement and a surge in humanitarian needs.

Natural disasters such as earthquakes, droughts and floods have further strained livelihoods. In 2024 alone, severe flooding and prolonged droughts impacted food production and forced thousands to flee their homes. Afghanistan remains highly vulnerable to climate shocks, which have now surpassed conflict as the leading cause of displacement.

The country’s economic collapse, marked by high unemployment, inflation and reduced international aid, has pushed many Afghans to seek opportunities abroad. In 2025, nearly 23.7 million people required humanitarian assistance, with over six million Afghans displaced internally or across borders. Recent forced deportations from neighboring countries like Pakistan and Iran have added to the crisis. In early 2025, over one million Afghans were returned, many arriving in unfamiliar regions with no assets or support systems.

Health conditions and healthcare

Afghanistan’s humanitarian crisis has deeply impacted its healthcare system, leaving millions without access to essential services. Nearly 18 million Afghans require health assistance in 2025. Malnutrition is a leading cause of death among children under five, with 45% of children experiencing stunted growth due to chronic undernourishment. Afghanistan faces frequent outbreaks of communicable diseases, including measles, acute watery diarrhea, dengue fever, pertussis, Crimean Congo Hemorrhagic Fever and malaria. Tuberculosis remains a major concern, particularly in overcrowded urban areas. Maternal and infant mortality rates are among the highest in the world. Every two hours, a woman dies during childbirth in Afghanistan. Chronic conditions such as heart disease, hypertension, diabetes and respiratory illnesses are rising, yet remain largely untreated due to cost and limited infrastructure. Mental health needs are also growing, especially among displaced populations and survivors of trauma, but services are scarce.

Behavioral health

Afghanistan’s mental health crisis is shaped by decades of conflict, poverty, natural disasters and forced displacement. These cumulative stressors have created widespread psychological distress across generations. Common conditions include depression, anxiety, post-traumatic stress disorder and suicidal ideation. Many Afghans have experienced multiple traumatic events, such as violence, loss of loved ones and displacement, which can lead to complex trauma and chronic stress.

Stigma and cultural perceptions

Stigma remains one of the greatest barriers to care. Mental illness is often misunderstood and may be attributed to spiritual imbalance, punishment from God or moral weakness. A common fear is being labeled “deewana” (crazy), which can lead to social exclusion and mistrust of one’s judgment. As a result, individuals may hide symptoms or avoid seeking help altogether. Emotional distress is frequently expressed through physical symptoms (e.g., headaches, fatigue, stomach pain) rather than verbalizing feelings, which can complicate diagnosis and treatment.

Help-seeking behaviors

Instead of formal mental health services, many Afghans turn to religious leaders, family elders or faith-based practices for support. Spiritual healing, prayer and traditional remedies are often integrated into coping strategies. While these practices provide comfort and community support, they may delay access to professional care when needed.

Generational and acculturation stress

Generational trauma is significant. Children often absorb the stress of caregivers, while adults suppress emotions to maintain resilience. For Afghan newcomers in the U.S., acculturation stress adds another layer, navigating a new language, unfamiliar systems and cultural norms while coping with past trauma. This can lead to feelings of isolation, identity conflict and heightened anxiety.

Access barriers

Mental health professionals are scarce in Afghanistan and services are concentrated in urban areas. In rural communities, individuals rely on informal networks or avoid treatment altogether. For Afghan refugees and immigrants in the U.S., barriers include language differences, a lack of culturally competent providers and fear of stigma. Many are unfamiliar with concepts like therapy or counseling and may distrust mental health systems.

Best practices for support

  • Normalize mental health care by framing it as part of overall wellness.
  • Use trauma-informed approaches that prioritize safety, trust and empowerment.
  • Offer culturally sensitive care by acknowledging spiritual beliefs and family involvement.
  • Integrate mental health into primary care to reduce stigma and improve access.
  • Provide interpretation services and translated materials to ensure understanding.
  • Community-based education can help reduce stigma and encourage help-seeking.

Healing must include both adults and children, recognizing the intergenerational impact of trauma and the importance of restoring emotional safety.

Healthcare access challenges for Afghans in America

Afghan newcomers often face multiple, overlapping barriers when accessing healthcare in the United States. These challenges are rooted in cultural norms, systemic differences and the trauma of displacement.

Concept of Time and Scheduling

In Afghanistan, time is viewed more flexibly, and arriving late to appointments is not considered disrespectful. This cultural norm can lead to missed or delayed medical visits in the U.S., where punctuality is expected, and late arrivals may result in canceled appointments. Afghan clients may benefit from gentle reminders, clear explanations of scheduling expectations and assistance with transportation logistics to ensure timely attendance.

Mistrust and Unfamiliarity with the U.S. Healthcare System

Many Afghans come from regions where healthcare is underfunded, inconsistent or inaccessible. Experiences with corruption, gender-based restrictions, and lack of medical infrastructure can foster deep mistrust of formal systems. In the U.S., this may result in hesitation to seek care, difficulty navigating insurance and reluctance to disclose health concerns. Afghan newcomers often need extra support in understanding how to access services, when to seek help, and how to advocate for themselves within a complex system.

Language and Communication Barriers

Dari and Pashto are the primary languages spoken by Afghan newcomers and many have limited English proficiency. This can lead to misunderstandings about diagnoses, medication instructions or appointment procedures. Access to trained interpreters, translated materials and culturally responsive providers is essential for effective care.

Gender Norms and Cultural Expectations

In Afghan culture, modesty and gender roles may influence healthcare decisions. Some women may prefer female providers or may be uncomfortable discussing certain health issues with male clinicians. Restrictions on women’s autonomy in Afghanistan may also affect how they engage with care in the U.S. Providers should be aware of these dynamics and offer gender-sensitive options whenever possible.

Practical Strategies for Providers

  • Offer clear explanations of appointment expectations and consequences of missed visits.
  • Provide language access services, including interpreters and translated materials.
  • Ensure gender-sensitive care options, such as female clinicians for women who request them.
  • Integrate mental health education into routine care to reduce stigma.
  • Use community health workers or cultural navigators to build trust and guide patients through the system.

Key Cultural Considerations for Providing Care

Providing effective healthcare to Afghan newcomers requires more than clinical expertise; it demands cultural understanding and sensitivity. Afghan patients often bring deeply rooted traditions, values and beliefs that influence how they perceive illness, make decisions and interact with providers. 

Gender Norms and Cultural Expectations

In Afghan culture, modesty and gender roles may influence healthcare decisions. Illness may be attributed to divine will, spiritual imbalance or the “evil eye.” Many Afghans incorporate prayer, Quranic verses and traditional remedies alongside medical treatment. Providers should respect these practices and, when possible, integrate them into care plans. Asking open-ended questions like, “Are there any spiritual or traditional practices you would like us to consider?” can build trust and reduce resistance to treatment. 

Family-Centered Decision Making

Afghan culture places a high value on family loyalty and hierarchy. Elders, especially male relatives, often make final decisions about healthcare. Patients may defer to family members during appointments, and women may prefer to have a trusted relative present. Including family in discussions and acknowledging their role can foster trust and improve compliance. For example, when discussing treatment options, providers might say, “Would you like your family to be part of this conversation?”.

Communication Style and Modesty

Afghans often use indirect communication to avoid confrontation or disrespect. Patients may nod or agree out of politeness, even if they do not fully understand or accept a recommendation. Providers should check for understanding by asking patients to repeat instructions in their own words. Modesty norms also influence interactions, especially across genders. Female patients may prefer female clinicians and may feel uncomfortable during physical exams with male providers. Offering gender-concordant care whenever possible is essential.

Privacy and Personal Honor

Preserving personal honor is deeply important in Afghan culture. Patients may be reluctant to disclose sensitive information, particularly about mental health, reproductive health or trauma. Creating a safe, private environment and using trauma-informed approaches can help patients feel comfortable sharing concerns. Providers should avoid rushing conversations and reassure patients that confidentiality will be maintained.

Dietary and Religious Practices

Food and religious observances are integral to Afghan identity. Many Afghans follow halal dietary laws and avoid pork and alcohol. During Ramadan, patients may fast from sunrise to sunset, which can affect medication schedules and treatment plans. Providers should ask about fasting and offer culturally appropriate alternatives, such as adjusting medication timing or providing halal meal options in hospitals.

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