Help-Seeking Behavior and Health Care Navigation by Bhutanese Refugees
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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.
KeywordsCommunity 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.
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.
- 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/
- 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.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.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.Google Scholar
- 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.Google Scholar
- 16.Colorado Patient Navigator Training. (May 5, 2013). Retrieved from http://patientnavigatortraining.org/website/courses.htm
- 20.Chase, L. E. (2011). Coping, healing, and resilience: A case study of bhutanese refugees living in Vermont (Masters dissertation).Google Scholar
- 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.CrossRefPubMedGoogle 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.CrossRefPubMedGoogle 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.CrossRefPubMedPubMedCentralGoogle 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.CrossRefPubMedPubMedCentralGoogle Scholar
- 29.NVivo. Doncaster: QSR International.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.Google Scholar