that could present a barrier to self-sufficiency adjustment of status exam refugees are eligible to apply for adjustment of status after one year in the us. while most immigrants are required to have a full medical exam at the time of applying for adjustment of status, refugees are an exception. refugees who arrived without a class a condition only require vaccinations with their adjustment of status; the full medical examination is not required. a full medical exam is only required for refugees if a class a condition existed prior to arrival in the us. sample u.s. programs main article: immigrant health care in the united statesbecause each state is responsible for coordinating refugee health screenings, protocols vary by state. a sampling of information about various state refugee health programs is listed below: arizona (http://azdhs.gov/preparedness/epidemiology-disease-control/disease-integration-services/refugee-health/index.php) california (https://www.cdph.ca.gov/programs/pages/refugeehealthprogram.aspx) florida (http://www.doh.state.fl.us/disease_ctrl/refugee/index.html) maryland (http://phpa.dhmh.maryland.gov/oidpcs/oih/pages/home.aspx) minnesota (http://www.health.state.mn.us/refugee/) healthcare barriers resettled refugee communities find themselves particularly vulnerable to healthcare barriers and are often unable to attain and sustain health and wellbeing for themselves and their families due to structural inequities, poor social determinants of health, and a lack of access to health care resources. according to a 2009 study by morris et al., refugees face a higher risk of low birth weight, poor educational outcomes, and higher rates of chronic physical and mental illnesses compared to united states citizens. a 2012 study conducted by kullgren et al. found that the most prevalent reasons for delayed and/or unmet healthcare for adults in the united states were lack of affordability and accommodation. for example, worries about cost and inability to make time due to work or other commitments serve as the most and second most prevalent reasons for inadequate adult healthcare. the study also found that non-financial barriers including those in accommodation, availability, accessibility, and acceptability create more delays in adult healthcare than barriers in affordability. according to a 2011 paper by carrillo et al., healthcare disparities between races and ethnic groups affect health status and access, and healthcare access barriers can play a role in understanding the reasons behind these disparities. the paper described how healthcare barrier models like the health care access barriers (hcab) model provide a framework for analyzing, categorizing, and detailing the determinants of health status. the hcab model categorizes measurable healthcare barriers into financial, structural, and cognitive groups. researchers have used this model to analyze the root causes for refugee health barriers and aid in interventions. for example, a 2016 study conducted by researchers in jordan found that the common perceived structural barriers for syrian refugees in jordan included long waiting times, extensive service procedures and long distances. according to the study, financial barriers consisted of high costs of medical service, medicine and transportation. cognitive barriers consisted of lack of trust, discrimination, and knowledge of the location and structure of the health care systems. these barriers are also stated in refugee studies in the united states and other countries as well. the paper by carrillo et al. also detailed other health care access models like the anderson's behavioral model of health services use and its variations which have also been used to model access barriers. according to a health assessment report based in san diego, the five most major perceived health care barriers consisted of language, transportation, lack of insurance, cultural barriers, and lack of knowledge of the u.s. healthcare system. a 2011 clinical review stated how those barriers apply to many of the three million refugees who have entered the united states over the past three decades. and in just the last decade, around 600,000 refugees have arrived in the united states. a 2018 patient-centered review stated that poor health care access before arrival, discrimination, and trauma have contributed to the increased likelihood of major health issues in refugees as compared to other immigrants. the 2011 study by asgary and segar, which involved interviews with asylum seekers and expert providers/representatives of advocacy organizations, proposed that all levels of the healthcare system from the refugees and providers to the policymakers should work together to address healthcare barriers. to do so, the paper suggested that governmental, non-governmental, medical and legal organizations all work together to provide accessible medical care for refugees. a metropolitan policy program has suggested that the maintenance and formation of local, state, and nationwide health assistance should include health care access and language skills. as a result of the covid-19 pandemic, a survey conducted in 2021 found that refugee communities primarily composed of african and southeast asian were suffering disproportionately from the effects of the pandemic. specifically, 76% reported difficulty paying for food, housing and healthcare, 70% reported lost income, and 58% indicated concern about paying bills. cognitive barriers a woman teaches women's literacy class cognitive barriers include but are not limited to insufficient knowledge, language, communication and health literacy. a 2009 study conducted by morris et al. in california, found that unawareness of the cause and effect relationship between lifestyle choices, preventative actions, and health consequences can also lead to an unhealthy mentality towards health. refugees unfamiliar to the culture and language of the united states face cognitive barriers at all levels of health care access. a 2019 review on healthcare challenges for refugees stated that communication is a prevalent issue. according to the review, adequate communication is needed to understand the reason for patient arrival, the underlying symptoms, the diagnosis, the future diagnostic tests required, and the prognosis and treatment plan. results from a 2011 interview centered study has shown that linguistic and cultural cognitive barriers constitute the biggest hurdles in providing equitable care for refugees. the paper recommended an increase of professional interpreters and intercultural mediators into existing routines is recommended. the 2019 review on refugee healthcare challenges also found that interpreter availability and quality can be directly associated with improved and increased health care use by refugees. the paper recommended professional interpreters for their knowledge on the healthcare system and health care vocabulary over using family and friends due to privacy reasons as well as biases that could impact patient decisions. the 2009 study by morris et al. found that most refugees rely on family and friends for interpretation rather than professional services which can lead to misinterpretation issues. as a solution, refugee serving organizations have proposed that healthcare providers and clinics provide professional interpretation services. both healthcare providers and refugee serving organizations face difficulties in establishing this service due to factors like cost and inconvenience. other suggestions include at&t language line services, improved interpretation quality, increased english language classes, and video interpretation services to name a few. according to multiple studies on refugee language proficiency, language barriers can hinder appointment scheduling, prescription filling, and clear communications, and have been associated with health declines, which can be attributed to reduced compliance and delays in seeking care. doctor patient interactions can become strained through the use of unfamiliar medical jargon. the immigrant access to health and human services project states that the persistence of these cognitive barriers may be due in part to the lack of strong health care, social, and provider networks. it found that knowledge of services is primarily spread through word of mouth, so limited networks can constitute a significant barrier. a 2019 public health review found that the limited networks and lack of knowledge that refugees have on the u.s. healthcare system leave them with inequalities in healthcare access. currently, it states that there are not many policies or practices aimed at overcoming these cognitive barriers for refugees. it recommends that communication strategies and services targeted at these inequalities should be put in place. the united states does have federal legislation on culturally and linguistically appropriate standards (clas), which is legislation aimed at reducing healthcare inequities through culturally competent care. the 2011 study by asgary and segar stated that even with this legislation, many refugees are hesitant to access those resources for fear of being misunderstood or being unable to access quality interpretation services for their language. it also found that no legislative bodies hold hospitals up to the standards of clas, and the enforcement of laws relies on complaints. the 2019 review on healthcare challenges for refugees and migrants found that health care and health literacy could be compromised without knowledge on the healthcare system. a 2019 study on healthcare access barriers found that many refugees do not understand the structure of western medical appointments and thus are unfamiliar with what concerns to bring up and when to conclude their session with their healthcare provider. in terms of health literacy, many refugees don't understand the importance of a healthy diet and exercise in managing and preventing chronic diseases like diabetes. the study recommended programs emphasizing preventative care through cultural and age appropriate means can improve health literacy. structural barriers a refugee man sleeps on a shelf a qualitative 2018 study by sian et al. stated that structural barriers include transportation, geographical distance, waiting times, service availability, and general health infrastructure and organization. all of those barriers could physically hinder health access. a 2012 research brief found that structural barriers could also overlap with economic and cognitive barriers. for example, lack of interpretation services and the literacy to pass a drivers test would constitute as both structural and cognitive barriers. the immigrant access to health and human services project found that both rural and urban areas may lack adequate public transportation systems or be too expensive to navigate through taxis. according to the study conducted by asgary and segar, patients often do not have the time off work to access healthcare services. they found that refugees often prioritize employment, shelter and food over healthcare services. a book on nursing research states that clinic structure and hours constitute a structural barrier because they overlap with working hours and require long waiting times that exceed what refugees can set aside. the immigrant health project stated that providers are often unable to understand a refugee's specific experiences and style and language of communication. they suggest the inclusion of research based education for providers to better empathize with their patients. common characteristics of refugee communities include larger families living in crowded housing, low-paid front line workers in a variety of industries, limited english skills, poor access to and use of healthcare services, high degrees of financial and food insecurity, low rates of health insurance and high degrees of stress. factors such as these exemplify the poor social determinants of health that may lead to adverse health outcomes in resettled refugee populations. the healthy migrant effect the "healthy migrant effect" is a phenomenon wherein first-generation born immigrants arrive in the united states with an overall better quality of health than u.s. born citizens of the same racial or ethnic background. a longitudinal study conducted in 2001 by singh et al. found that immigrant men and women had significantly lower risks of mortality than their u.s. born counterparts. a 2002 study that compared the hospital utilization records and mortality rates of foreign born and u.s. born new york residents discovered that immigrants were healthier and had longer life expectancies than u.s. born citizens. however, structural inequities faced by refugees such as lack of access to housing, employment, education, and healthcare eventually reduce the immigrant health advantage, leaving them with worse health outcomes than the general population. financial barriers resettled refugees face financial barriers to food, housing, and healthcare which can result in adverse health outcomes. data has shown that approximately 21 percent of immigrant children in the u.s. live in poverty as opposed to 14 percent of native-born children. the low socioeconomic status of refugees is associated with numerous health risks such as malnutrition, smoking, injuries, unemployment, family dysfunction, psychosocial stress, and more. a 2016 study on refugee insurance access stated that financial barriers for refugees made healthcare less accessible and affordable and could include differing state health insurance coverage policies, inadequate income, and insurance restrictions by employers. for the first eight months, most refugees have access to a health insurance called refugee medical assistance (rma). other refugees may be eligible for more long term coverage through health insurance plans like medicaid or the children's health insurance program, which last for several years. to allow refugees to look for cheaper health insurances, the affordable care act created the marketplace. according to the 2016 study, policies like the patient