Skip to main content

Advertisement

SpringerLink
Log in

Help-Seeking Behavior and Health Care Navigation by Bhutanese Refugees

  • Original Paper
  • Published:
Journal of Community Health Aims and scope Submit manuscript

Abstract

The objective of this study was to document barriers to care, help-seeking behaviors, and the impact of a community-based patient navigation intervention on patient activation levels among Bhutanese refugees in the U.S. Data sources comprised 35 intake and 34 post-intervention interviews with program participants, 14 intake and 14 post-intervention interviews with patient navigators, and 164 case notes. Textual data were analyzed using the constant comparison method. Patient activation level was assessed at both time points. Participants had limited English proficiency (97 %), limited literacy (69 %), and the lowest level of patient activation (69 %). Participants routinely experienced complex insurance access, coverage, and payment problems and had limited healthcare-related life skills. Help-seeking began within social networks, with high reliance on bilingual, literate family members perceived to have experience with “the system.” Help-seeking was not stigmatized and was instead consistent with societal norms valuing mutual assistance. Participants preferred helpers to act as proxies and required repeated social modeling by peers to gain confidence applying healthcare-related life skills. Following the intervention, only one-third reported the lowest level of patient activation (35 %) and one-third were highly activated (32 %). Bhutanese refugees overcome healthcare access barriers by seeking help from a network of support that begins within the community. Community health workers serving as patient navigators are readily sought out, and this approach is concordant with cultural expectations for mutual assistance. Community health workers serving immigrant groups should model healthcare-related life skills in addition to providing direct assistance.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Goodnough, A. (2012, 6/12/2012). Navigating the health care maze, New York Times. Retrieved from http://www.nytimes.com/2012/06/13/us/navigating-the-health-care-maze.html?_r=0

  2. Gordon, E. (2014, 2/17/2014). Librarians find new purpose helping uninsured navigate health care, PBS Newshour/WHYY. Retrieved from http://www.pbs.org/newshour/updates/librarians-find-new-purpose-helping-uninsured-navigate-health-care/

  3. Wharam, J. F., Graves, A. J., & Kozhimannil, K. B. (2015). Navigating the rise of high-deductible health insurance: Childbirth in the bronze age. JAMA, 313(3), 245–246.

    Article  PubMed  Google Scholar 

  4. Kyanko, K. A., Curry, L. A., & Busch, S. H. (2013). Out-of-network physicians: How prevalent are involuntary use and cost transparency? Health Services Research, 48(3), 1154–1172.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Kyanko, K. A., Pong, D. D., Bahan, K., & Curry, L. A. (2013). Patient experiences with involuntary out-of-network charges. Health Services Research, 48(5), 1704–1718.

    PubMed  PubMed Central  Google Scholar 

  6. Madden, E. F. (2015). Cultural health capital on the margins: Cultural resources for navigating healthcare in communities with limited access. Social Science and Medicine, 133, 145–152.

    Article  PubMed  Google Scholar 

  7. Mirza, M., Luna, R., Mathews, B., Hasnain, R., Hebert, E., Niebauer, A., & Mishra, U. D. (2013). Barriers to healthcare access among refugees with disabilities and chronic health conditions resettled in the US Midwest. Journal of Immigrant and Minority Health, 16(4), 1–10.

  8. Riggs, E., Davis, E., Gibbs, L., Block, K., Szwarc, J., Casey, S., et al. (2012). Accessing maternal and child health services in Melbourne, Australia: Reflections from refugee families and service providers. BMC Health Services Research, 12(1), 117.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Department of State. (2015). Worldwide refugee admissions processing system: Admission and arrivals customized report 01/2008-08/2015. Department of State, Bureau of Population, Refugees, and Migration, Refugee Processing Center. Retrieved September 1, 2015, from www.wrapsnet.org

  10. Centers for Disease Control and Prevention. (2014, February 24, 2014). Bhutanese refugee health profile. Retrieved August 11, 2015, from http://www.cdc.gov/immigrantrefugeehealth/profiles/bhutanese/background/index.html

  11. UNHCR/World Food Programme. (2012). Assistance to refugees from Bhutan in Nepal: United Nations High Commissioner for Refugees/World Food Programme.

  12. Perry, H. B., Zulliger, R., & Rogers, M. M. (2014). Community health workers in low-, middle-, and high-income countries: An overview of their history, recent evolution, and current effectiveness. Annual Review of Public Health, 35, 399–421.

    Article  PubMed  Google Scholar 

  13. Kangovi, S., Mitra, N., Grande, D., White, M. L., McCollum, S., Sellman, J., et al. (2014). Patient-centered community health worker intervention to improve posthospital outcomes: A randomized clinical trial. JAMA Internal Medicine, 174(4), 535–543.

    Article  PubMed  Google Scholar 

  14. Access Alliance Multicultural Community Health Centre. (2005). The early years peer outreach training curriculum for newcomer women. Toronto: Access Alliance Multicultural Community Health Centre.

  15. Battaglia, T. A., Parker, V. A., McCoy, M. E., Caron, S. E., Leyson, J., Bak, S. M., & Freund, K. M. (2012). The Boston Medical Center patient navigation toolkit (1st ed.) Boston: Boston Medical Center.

  16. Colorado Patient Navigator Training. (May 5, 2013). Retrieved from http://patientnavigatortraining.org/website/courses.htm

  17. O’Brien, M. J., Squires, A. P., Bixby, R. A., & Larson, S. C. (2009). Role development of community health workers: An examination of selection and training processes in the intervention literature. American Journal of Preventive Medicine, 37(6), S262–S269.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Spiro, A., Oo, S. A., Marable, D., & Collins, J. P. (2012). A unique model of the community health worker: The MGH Chelsea Community Health Improvement Team. Family and Community Health, 35(2), 147–160.

    Article  PubMed  Google Scholar 

  19. Bandura, A. (1998). Health promotion from the perspective of social cognitive theory. Psychology and Health, 13(4), 623–649.

    Article  Google Scholar 

  20. Chase, L. E. (2011). Coping, healing, and resilience: A case study of bhutanese refugees living in Vermont (Masters dissertation).

  21. Chase, L. E., & Bhattarai, D. (2013). Making peace in the heart-mind: Towards an ethnopsychology of resilience among Bhutanese refugees. European Bulletin of Himalayan Research, 34, 144–166.

    Google Scholar 

  22. Tanjasiri, S. P., Kagawa-Singer, M., Foo, M. A., Chao, M., Linayao-Putman, I., Nguyen, J., et al. (2007). Designing culturally and linguistically appropriate health interventions: The “Life Is Precious” Hmong breast cancer study. Health Education and Behavior, 34(1), 140–153.

    Article  PubMed  Google Scholar 

  23. Hibbard, J. H., Stockard, J., Mahoney, E. R., & Tusler, M. (2004). Development of the Patient Activation Measure (PAM): Conceptualizing and measuring activation in patients and consumers. Health Services Research, 39(4p1), 1005–1026.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Silove, D., Sinnerbrink, I., Field, A., Manicavasagar, V., & Steel, Z. (1997). Anxiety, depression and PTSD in asylum-seekers: Assocations with pre-migration trauma and post-migration stressors. The British Journal of Psychiatry, 170(4), 351–357. doi:10.1192/bjp.170.4.351.

    Article  CAS  PubMed  Google Scholar 

  25. Cella, D., Riley, W., Stone, A., Rothrock, N., Reeve, B., Yount, S., et al. (2010). The Patient-Reported Outcomes Measurement Information System (PROMIS) developed and tested its first wave of adult self-reported health outcome item banks: 2005–2008. Journal of Clinical Epidemiology, 63(11), 1179–1194.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Flaherty, J. A., Gaviria, F. M., Pathak, D., Mitchell, T., Wintrob, R., Richman, J. A., & Birz, S. (1988). Developing instruments for cross-cultural psychiatric research. The Journal of Nervous and Mental Disease, 176(5), 260–263.

    Article  Google Scholar 

  27. Weidmer, B., Hurtado, M., Weech-Maldonado, R., Ngo-Metzger, Q., & Bogen, K. (2006). Guidelines for translating CAHPS surveys. Washington, DC: Department of Health and Human Services, Agency for Healthcare Research and Quality.

    Google Scholar 

  28. Harris, P. A., Taylor, R., Thielke, R., Payne, J., Gonzalez, N., & Conde, J. G. (2009). Research electronic data capture (REDCap): A metadata-driven methodology and workflow process for providing translational research informatics support. Journal of Biomedical Informatics, 42(2), 377–381.

    Article  PubMed  PubMed Central  Google Scholar 

  29. NVivo. Doncaster: QSR International.

  30. Haun, J. N., Valerio, M. A., McCormack, L. A., Sorensen, K., & Paasche-Orlow, M. K. (2014). Health literacy measurement: An inventory and descriptive summary of 51 instruments. Journal of Health Communication, 19(sup2), 302–333.

    Article  PubMed  Google Scholar 

  31. Betancourt, T. S., Frounfelker, R., Mishra, T., Hussein, A., & Falzarano, R. (2015). Addressing health disparities in the mental health of refugee children and adolescents through community-based participatory research: A study in two communities. American Journal of Public Health, 105, S475–S482.

Download references

Acknowledgments

This program was funded in part by the Center for Public Health Initiatives at the University of Pennsylvania and the Hindu American Foundation. Dr. Yun’s time and effort were supported by a grant from the Agency for Healthcare Research and Quality (K12HS021706-02). The NORC at the University of Chicago and the Philadelphia Department of Public Health were not involved in this study. The authors wish to thank the following organizations for sharing information about their community health worker programs: Access Alliance, Toronto, CAN; MGH Chelsea Healthcare Center, Chelsea, MA; the Penn Center for Community Health Workers, Philadelphia, PA; and Puentes de Salud, Philadelphia, PA.

Author Contributions

All authors conceptualized the study and contributed to the final manuscript. K.Y., P.P., L.K., and P.S. collected data. K.Y., P.P., L.K. analyzed the results. K.Y., P.P., and P.S. drafted the manuscript.

Author information

Authors and Affiliations

  1. PolicyLab, Division of General Pediatrics, The Children’s Hospital of Philadelphia, 3535 Market St, Rm 1539, Philadelphia, PA, 19104, USA

    Katherine Yun, Papia Paul & Leela Kuikel

  2. NORC at the University of Chicago, Chicago, IL, USA

    Papia Paul

  3. Bhutanese American Organization-Philadelphia, Philadelphia, PA, USA

    Parangkush Subedi & Leela Kuikel

  4. Philadelphia Department of Public Health, Philadelphia, PA, USA

    Parangkush Subedi

  5. Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA

    Giang T. Nguyen & Frances K. Barg

  6. Center for Public Health Initiatives, University of Pennsylvania, Philadelphia, PA, USA

    Giang T. Nguyen & Frances K. Barg

  7. Department of Anthropology, School of Arts and Sciences, Philadelphia, PA, USA

    Frances K. Barg

  8. Center for Clinical Epidemiology and Biostatistics, Philadelphia, PA, USA

    Frances K. Barg

Authors
  1. Katherine Yun
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Papia Paul
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Parangkush Subedi
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Leela Kuikel
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Giang T. Nguyen
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Frances K. Barg
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Katherine Yun.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Yun, K., Paul, P., Subedi, P. et al. Help-Seeking Behavior and Health Care Navigation by Bhutanese Refugees. J Community Health 41, 526–534 (2016). https://doi.org/10.1007/s10900-015-0126-x

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10900-015-0126-x

Keywords

Search

Navigation