Journal of Community Health

, Volume 41, Issue 3, pp 526–534 | Cite as

Help-Seeking Behavior and Health Care Navigation by Bhutanese Refugees

  • Katherine YunEmail author
  • Papia Paul
  • Parangkush Subedi
  • Leela Kuikel
  • Giang T. Nguyen
  • Frances K. Barg
Original Paper


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.


Community health workers Patient navigation Refugees Emigrants and Immigrants Self efficacy Health behavior Health literacy 



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.


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Copyright information

© Springer Science+Business Media New York 2015

Authors and Affiliations

  • Katherine Yun
    • 1
    Email author
  • Papia Paul
    • 1
    • 2
  • Parangkush Subedi
    • 3
    • 4
  • Leela Kuikel
    • 1
    • 3
  • Giang T. Nguyen
    • 5
    • 6
  • Frances K. Barg
    • 5
    • 6
    • 7
    • 8
  1. 1.PolicyLab, Division of General PediatricsThe Children’s Hospital of PhiladelphiaPhiladelphiaUSA
  2. 2.NORC at the University of ChicagoChicagoUSA
  3. 3.Bhutanese American Organization-PhiladelphiaPhiladelphiaUSA
  4. 4.Philadelphia Department of Public HealthPhiladelphiaUSA
  5. 5.Department of Family Medicine and Community Health, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaUSA
  6. 6.Center for Public Health InitiativesUniversity of PennsylvaniaPhiladelphiaUSA
  7. 7.Department of AnthropologySchool of Arts and SciencesPhiladelphiaUSA
  8. 8.Center for Clinical Epidemiology and BiostatisticsPhiladelphiaUSA

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