time to acculturate to unfamiliar language and food environments in the united states. second, refugee beliefs and home-country culture, in conjunction with postresettlement socioeconomic status (ses; which is often lower), influence what types of food can be purchased and consumed. third, limited information about foods, shopping, and recipes in the united states creates another barrier to purchasing healthy foods. fourth, high intake of processed and energy-dense foods in the united states contributes to chronic disease risk. a study that based its research on the new immigrant survey (nis) found that hispanic immigrants that have been in the united states the longest have experienced greater changes in their diet. of these hispanics with the greater change in their diet since moving to the u.s., the ones who have reported the worst health are the ones who have spent more time in the united states. also, hispanic immigrants who have spent the most time in the u.s. and reported worse health were also more likely to report the use of english language in their workplace. these findings demonstrate some correlation between hispanic-immigrant health and their assimilation to american behavior in the united states. another study reported that only 13% of refugees studied felt they ate generally healthy diets in the united states. they also reported difficulties locating preferred foods. lack of healthy food options in the past shaped their dietary habits and food choices poorly after resettlement. for example, 32% of bhutanese refugees had vitamin b-12 deficiencies, likely due to a scarcity of meat, eggs, and dairy in their nepal diets. women's health refugee women have unique and challenging concerns in terms of accessing healthcare after resettlement in the united states. this includes reproductive and maternal health, mental health, and domestic violence. culturally influenced gender roles may influence health concerns and access to treatment for female refugees, especially within the realm of reproductive, domestic violence, and psychological care. it can be difficult to obtain appropriate preventative or specialized care to treat these medical concerns with the limited healthcare options available to refugee women. this is especially apparent in terms of reproductive healthcare, where there is a low number of women screened for cervical and breast cancer compared to the large women with reproductive health needs. these screenings, in addition to other preventative services like std testing and birth control options are important ways to assess sexual health, but many women are not able to receive these services for cultural or systemic reasons and may develop more serious health conditions as a result. in addition to birth control, female refugees were less likely to access prenatal and maternal care than native-born or other immigrant us populations despite receiving equal coverage in the united states. while refugee mothers are less likely to access prenatal and maternal services due to social and economic barriers, they are often more susceptible to cesarean sections, low birth rates, and other health issues. mental health is another issue faced by many refugee women which may result from their experience in their home country and the process of migrating and settling in the us. in a study conducted by chris brown in 2010, the results highlight that language proficiency, economic stress, and maternal stress all impact the mental health of vietnamese female refugees. they also point out that much of this stress can be associated with the traumatic experiences or the stress to adapt and conform to the new culture of the united states that these women have experienced. while many men, women, and children are exposed to traumatic situations, women are more likely to experience ptsd, anxiety and other mental health conditions as a result because they are more prone to inter-personal trauma such as family separation, domestic violence or rape. another health issue that affects refugee women disproportionately is sexual and gender-based violence. while men also experience sexual violence, women are an especially vulnerable population because of shifting gender roles and power dynamics as they flee their home country and migrate and resettle in a new place. gender-based violence is prevalent in both the home country and the country of resettlement as an instrument of war, in resettlement camps, and in families and communities throughout the resettlement process. this sexual violence is also present for refugee women through the form of trafficking during migration from their home country. refugee women are exposed to many forms of gender-based violence in addition to the experience of domestic violence, and attaining care can be difficult due to failure to report these issues because of cultural taboo or unstable home life and the lack of support and service related to domestic violence and receiving help as reported by the refugee women. in addition to personal and social barriers to reporting their experiences, refugee women simply do not have access to appropriate medical and psychological services needed for treatment, which continues to make them a vulnerable population after resettlement. medical screening for entry to the united states the centers for disease control and prevention provides two major categories of refugee health guidelines: the overseas medical screening guidelines provide panel physicians guidance on the overseas pre-departure presumptive treatments for malaria and intestinal parasites. these screenings are usually conducted days to weeks before the refugee departs from his or her country of asylum. the domestic medical screening guidelines are provided for state public health departments and medical providers in the united states who conduct the initial medical screening for refugees. these screenings are usually conducted 30–90 days post-arrival in the united states. overseas protective actions three medical interventions are either required or recommended in order to contain infectious diseases and reduce the medical burdens that may be associated with refugee resettlement. first is a mandatory overseas screening for all refugees and immigrants, then a recommended domestic screening for refugees, and finally a required medical component to the adjustment of status (green card) process. these medical exams are performed by approximately 400 physicians (called panel physicians) selected by the us department of state (dos) consular officials. the cdc division of global migration and quarantine (dgmq) provides technical instructions and guidance to the physicians conducting overseas exams. the screening is primarily aimed at detecting infectious diseases of public health concern. the overseas exam includes a medical history inquiry, physical exam, chest x-ray for persons older than 14 years of age (southeast asian refugees older than 2 years of age), and specific lab tests. testing routinely includes screening for syphilis and hiv in people over 15 years of age. laws the cdc's division of global migration and quarantine is responsible for providing the us department of state and the united states citizenship and immigration services (uscis) with medical screening guidelines. the guidelines are developed in accordance with section 212(a)(1)(a) of the immigration and nationality act (ina), which outlines the reasons an alien is ineligible for a visa or admission to the united states, specifically based on health grounds. "the health-related grounds include those aliens who have a communicable disease of public health significance, who fail to present documentation of having received vaccination against vaccine-preventable diseases, who have or have had a physical or mental disorder with associated harmful behavior, and who are drug abusers or addicts." medical conditions recognized in refugees are categorized as class a or class b and are described below. if a refugee is found to have an inadmissible health-related condition, a waiver is required for the applicant to come to the us. class conditions the health-related grounds for the exclusion of refugees and immigrants set forth in the law are implemented by a regulation, "medical examination of aliens" (42 cfr, part 34). the regulation lists certain disorders that, if identified during the overseas medical examination, are grounds for exclusion (class a condition) or represent such significant health problems (class b condition) that they must be brought to the attention of consular authorities. the purpose of the medical examination is to determine whether an alien has 1) a physical or mental disorder (including a communicable disease of public health significance or drug abuse/addiction) that renders him or her ineligible for admission or adjustment of status (class a condition); or 2) a physical or mental disorder that, although not constituting a specific excludable condition, represents a departure from normal health or well-being that is significant enough to possibly interfere with the person's ability to care for themselves, or to attend school or work, or that may require extensive medical treatment or institutionalization in the future (class b condition). class a conditions class b conditions conditions which preclude entry to the us, including communicable diseases of public health significance, mental illnesses associated with violent behavior, and drug addiction conditions identified as amounting to a substantial departure from normal well-being. if a class a condition is indicated, refugees must undergo treatment before they are eligible for entry to the u.s. if a class b condition is indicated, refugees will likely receive treatment prior to departure from their country of origin, as well as follow-up care upon arrival in the u.s. active or infectious tuberculosis untreated syphilis untreated chancroid untreated gonorrhea untreated granuloma inguinale untreated lymphogranuloma venereum human immunodeficiency virus (hiv) hansen's disease (leprosy) addiction or abuse of a specific substance without harmful behavior and/or any physical or mental disorder with harmful behavior or history of such behavior, along with the likelihood that the behavior will recur inactive or noninfectious tuberculosis treated syphilis other sexually transmitted diseases pregnancy treated, tuberculoid, borderline or paucibacillary hansen's disease sustained, full remission of abuse of specific substances (including amphetamines, cannabis, cocaine, hallucinogens, inhalants, opioids, phencyclidines, sedative hypnotics and anxiolytics) and/or any physical or mental disorder (excluding addiction or abuse of specific substances, but including other substance-related disorders) without harmful behavior or a history of such behavior considered unlikely to recur domestic preventative actions when refugees enter the united states, they must enter through one of the authorized ports of entry that have quarantine stations. at these locations, us public health service personnel review refugees' medical documents and perform limited inspections to look for obvious signs of illness. through an electronic notification system maintained by the cdc, state health officials in the destination state are notified and sent copies of the overseas medical exam. upon arrival in the us, it is recommended that refugees complete a domestic health screening that seeks to reduce health-related barriers to successful resettlement and protect the health of the us population. domestic health exams focus on infectious disease screening, but can also offer diagnosis and treatment for other health conditions identified. the parameters of the screening are based upon the 1995 office of refugee resettlement medical screening protocol, but new guidance is forthcoming. laws the refugee act of 1980, which amended the immigration and nationality act to establish a domestic refugee resettlement program, has outlined several public health activities with regards to refugee resettlement. first, all state or local health officials are to be notified of each refugee's arrival so that they can provide timely treatment for health conditions of public health significance identified overseas. the director of orr has the authority to make grants to state or local health agencies to help them meet the costs of providing medical screening and initial medical treatment to refugees. in this way, states can provide domestic health assessment services with federal refugee funding support. to qualify for this funding, the state health assessments need to be in accordance with orr requirements and approved by the orr director. it is recommended that a refugee receive a health screening within 90 days of entering the united states. the screening protocols are left to state health officials with the approval of orr. domestic health assessment a medical screening protocol for newly arriving refugees was developed by orr in collaboration with cdc in 1995. many states have added requirements in addition to the orr protocol. dhhs is now drafting guidance for an expanded domestic protocol for screening refugees. the scope of the domestic health exam includes: follow up (evaluation, treatment and/or referral) of class a and b conditions identified during the overseas medical exam identification of persons with communicable diseases of potential public health importance that were not identified during, or developed subsequent to the overseas exam introduction of incoming refugees and eligible clients to the us healthcare system, and identification of conditions