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Bhutanese Refugees in Vermont: a population health profile and interventionRochelle PaquetteUniversity of PortlandApril 16, 2014PopulationIn 2006, the US government offered resettlement to 60,000 Bhutanese refugees who had been residing in refugee camps in Nepal since the early 1990’s (CDC, 2012). After spending over a decade in seven refugee camps in southeast Nepal, this exiled community of 107,803began resettlement in the US, Australia, Canada, Norway, the Netherlands, New Zealand, Denmark, and the United Kingdom (Shrestha, 2011). This population focused paper will describe the Bhutanese Refugee population living in the United States and the community in Vermont, their demographics, epidemiological data, relevant social and cultural considerations, and health disparities specific to this group. To help mitigate the long term effects of food rationing and life in the refugee camp and to prevent increase of health disparities, a population focused intervention providing nutrition education and Vitamin B12 deficiency screening guidance is also described. The unique and growing needs of the Bhutanese Refugee population provides an opportunity for a culturally tailored community intervention that could provide long term benefits to this developing community. HistoryBhutan, a small country bordered by China to the north and surrounded by India to the west, south and east, officially recognizes four main ethnicities within its country. (Shrestha, 2011). The Lhotsampas, a population of ethnically identifying Nepalese, migrated to Bhutan in the 19th century and inhabited the southern part of the country for several generations (Maxym, 2010). For the focus of this paper, the term Nepali-Bhutanese and Bhutanese refugees will be used interchangeably when describing this population. The Nepali-Bhutanese (Lhotsampas) speak Nepali, have their own customs, religion, and traditionally dress different from the ethnic Bhutanese (Hutt, 1998). Over the years the Nepali-Bhutanese had little contact with the traditionally Buddhist practicing and Dzongka speaking Bhutanese of the north (1998). In 1958 the Bhutanese government granted citizenship to the Nepali-Bhutanese but also made it illegal for more Nepalese to relocate from Nepal to Bhutan (2011). In 1961 the Ngalong’s language, Dzongkha, was established as the national language (2011). The separate cultures lived peacefully for several decades before a national movement known as “One country, one people,” or “Bhutanization,” was introduced in order to create a Bhutanese national identity (2010). During this time, previously granted citizenships were disputed, many Nepali-Bhutanese suffered cultural discrimination, harassment and were denied education, jobs, and healthcare. Some Nepali-Bhutanese organized political protests and were detained, tortured, and forced to leave the county. When protests lead to large clashes and mass arrest, tens of refugees fled from Bhutan through India to Nepal (UNHCR,2014) cites the number of refugees living in Nepal in 2007 as 107,803. As of the 2012 census, the CDC (2012) cites 49,010 Nepali-Bhutanese had been resettled in the US. DemographicsThroughout the US, thousands of refugees are resettled from other countries. The United Nation High Committee on Refugees defines a refugee as “… someone who has been forced to flee his or her country because of persecution, war, or violence. A refugee has a well-founded fear of persecution for reasons of race, religion, nationality, political opinion or membership in a particular social group. Most likely, they cannot return home or?are afraid to do so. War and ethnic, tribal and religious violence are leading causes of refugees fleeing their countries.” (UNHCR) A snapshot provided by UNHCR Health Organization in 2012 puts the overall refugee population in the USA at 262,023 (UNHCR, 2014). Between 2008-2012, the United States government resettled 49,000 Nepali-Bhutanese in 41 states. Figure 1. Age of Bhutanese refugees resettled in the United StatesBhutanese Refugees in Vermont The population in Vermont is approximately 625,740 (Chittenden County Population and Races, 2014). Vermont’s largest county, Chittenden County, has a total population of 156,545. Although the county’s most prevalent race is white, which represent 92.47% of the total population, Vermont Refugee Resettlement program has been working within the community for several decades resettling refugees from multiple continents and diverse backgrounds (Vermont Department of Health, 2010). Starting in 1989, Vermont has resettled 6,365 refugees from around the world to Chittenden County. Since 2008, the amount of Bhutanese refugees resettled in Chittenden County has grown and currently accounts for more than 2/3 of the total yearly refugees resettled to VT (D. Lamoureux, personal communications, Feb. 14, 2014). Figure 2 demonstrates the total refugee population per year resettled, as well as the growing number of Bhutanese refugees within that population. Although refugees from all over the world have been resettled in Vermont since 1989, the Nepali-Bhutanese is the fastest growing population of refugees Vermont has encountered and is the second largest population resettled in this primary homogenous community (D. Lamoureux, personal communications, Feb. 14, 2014). Figure 2. Refugee resettlement per year in Vermont.Epidemiological DataMany infectious and communicable diseases are endemic in Nepal and in the refugee camps, including tuberculosis (TB), Hansen’s disease, and Hepatitis B (CDC, 2012 ). The World Health Organization estimated a prevalence of 5 million and approximately 3.5 million incident cases of tuberculosis in 2010 in the Southeast Asia region, which is 40% of the worldwide burden of the disease (WHO, 2012). Although, out of the 44,000 refugees screened between 2008-2011, 0.8 % of Nepali-Bhutanese entering the United States were smear or culture positive for Mycobacterium Tuberculosis (CDC, 2012). Although Hansen's disease is endemic in Nepal where the Bhutanese refugees resided for the past 2 decades, fewer than 0.1% of Bhutanese refugees reported a history of Hansen’s disease (CDC, 2012). Hepatitis B is estimated to have infected more than two billion people worldwide (Museru et al, 2010). While this condition is prevalent throughout the developing world, there is little evidence that it is currently prevalent in the Bhutanese community. However, there is no data to connect the prevalence of infectious hepatitis in refugee camps in Nepal. A study conducted in one community reported 45% of Bhutanese refugees testing positive for Hepatitis A antibodies during a 18 month period (CDC, 2012). This data cannot speak to the prevalence of other infectious hepatitis. Considering Hepatitis B’s infectiousness and prevalence worldwide, research into the prevalence in the Bhutanese population could be helpful in establishing if this is a health disparity within this population as it is with other Southeast Asian populations (2010). Chronic illness and disease have not been measured in this population to date, although the CDC does acknowledge from the years 2008-2011, 3% of Bhutanese refugees reported a history of hypertension and the estimated rate of hypertension in adults over 65 (15%) is significantly lower than the same age group in the US (65%) (CDC, 2012). The significant lack of chronic disease information for this group could be due to recently relocating and being in the US for only 5 years. More information will likely become available as some of the estimated 60,000 Bhutanese expected to be resettled in the US seek out healthcare. Health DeterminantsThe Nepali-Bhutanese refugee population is faced with several health determinants as they relocate to the United States. In Bhutan, most Nepali-Bhutanese were exposed to Western Medicine as well as traditional medical practices. Life in refugee camp was different and access to health care was dependent on aid agencies. Many factors play into the access and utilization of healthcare for the Bhutanese refugee community. For refugee populations, the US government provides healthcare for the first eight months of living in the US. For some, after the eight months of healthcare provided by the government ends, lack of insurance leads to no preventative care and waiting until emergencies arise to seek out healthcare (CDC, 2012).Physical and Social Environment The Community Health Centers of Burlington and University of Vermont identified several health determinants in the Vermont Bhutanese (and Burmese) refugee community. Transportation Barriers, including expiration of bus passes after initial government services expired, difficulties locating appointments due to language barriers as major barriers to care (Arscott et al). Language barriers also made scheduling appointments, understanding prescription medication, and asking for directions to appointments barriers to care. The focus group also identified that many Bhutanese were unaware of Vermont’s Medicaid for low income insurance options and most did not understand chronic disease such as hypertension or type two diabetes (Arscott et. al). Health ServicesAfter the initial eight months of Medicaid coverage and services connected with relocation expire, many Bhutanese refugees are required to find adequate health insurance. Utilization of health services can be difficult, as gender roles significantly impact health (Maxym, 2010). To meet this need, organizations such as the Community Health Center of Burlington, which services all adult Nepali-Bhutanese in Vermont for primary care, set up preventative and healthcare orientation programs. Due to lack of familiarity with the state and federal programs and sometimes being cut off from support systems, young and middle aged adults are finding it difficult to access affordable healthcare because this age group does not typically qualify for other assistance (2010). Vermont Refugee Resettlement Program has case managers that assist newly arrived refugees for eight months, and depending on need, can refer them to support organizations such as Vermont Bhutanese Association or the Association for Africans living in Vermont. Both of these organizations assist refugees living in Vermont, regardless of ethnicity, after their initial eight months of government run support is no longer available.Social and Cultural ConsiderationsThere are several social and cultural considerations with the Bhutanese community. The Nepali-Bhutanese living in the US are often bilingual and some speak 3-4 languages including Nepali, English, Hindi, and Dzongkha (CDC, 2012). The family structure is patriarchal and women traditionally move into the husband’s household after marriage. Men often work while women are customarily responsible for household work. The typical household is large, often includes extended family, a strong sense of responsibility, and respect for the elderly population within the family. This family dynamic can be an adjustment for those living in the US, as it may appear to those providing care that living situations are over-crowded. Caste System and Family DynamicSince arrival in the US, the traditional 64 castes, groups and parties previously noted in the refugee camp are declining in some populations (Maxym, 2010). The community traditionally follows a complex caste system, which includes arranged marriages. As families adjust to life outside refugee camp, more women are pursing education and spouses are sharing household responsibilities. Maxym (2010) also noted that spouse choices and marriage outside of the caste system has also evolved since families initially began relocating. For medical providers working with this population, it’s important to recognize men and women don’t touch in public, during meals men are served first and women are untouchable during menstruation. Figure 3. Religious breakdown of Nepali-BhutaneseThe CDC (2012) and Maxym (2010) both recognize this population’s traditional approach to seeking home remedies before seeking out healthcare from medical providers. Preventative health care is a less familiar topic and traditional medical practices include use of home remedies. Maxym (2010) reports that the higher the socioeconomic status the more likely a preference for Western medicine exists, although this is not exclusive. Fear of trauma and persecution may include a fear of police, although in general Bhutanese refugees are trusting of Western medical providers (2010). Nutrition Many Bhutanese refugees are vegetarian; the typical food diet in Nepal was food rations provided by the World Food Program and UNHCR. They consist of rice, lentils, chickpeas, vegetable oil, sugar, salt, and fresh vegetables (CDC, 2012).Health DisparitiesAccording to the “Health Disparities of Vermonters” publication on Race, Ethnicity, and Cultural Identity “While nationally disparities by race can often be observed in incidence or deaths from cancer, and hospitalizations, injuries or deaths from any cause, it is not possible to observe such disparities in Vermont” (Vermont Department of Health, 2010, p. 55). Although the small population in Vermont makes health disparities challenging to quantify, comprehending the history of persecution, torture, life and diet in refugee camp gives insight into the health disparities within this community. In addition to common health disparities associated with living in refugee camps discussed above, the CDC identifies three specific health disparities specifically related to the Bhutanese Refugee community: Anemia, Vitamin B 12 deficiency, and Mental Health (CDC, 2012). Mental Health A significant health disparity noted within this community has been the stigma and prevalence of mental illness. In 2009-2011, the increase in issue suicide brought attention to this issue. The International Organization of Migration (IOM) conducted assessment of the refugees in the camp, while the CDC and refugee health community in the US also began investigations into this concern. The IOM found an association between gender-based violence, history of mental illness and high prevalence of suicide attempts within this population (IOM, 2011). Common resettlement issues such as expectations of relocating to the US, availability of jobs, pressure of bills, lack of secure housing, loss of proximity to neighbors and stigma associated with mental illness have also contributed to this unusually high prevalence of suicide (CDC, 2013). In Vermont the healthcare community has identified some of the challenges with providing care for mental illness in this population. There are several programs in place to help reduce this disparity, including ongoing screening of Bhutanese refugee’s by the Community Health Center of Burlington. The Howard Center, an organization geared to meet the needs of mental health diagnosis in the community also has been alerted to this disparity and has been working with families of those identified with mental illness. The University of Vermont’s Connecting Cultures program also provides therapy for identified high risk patients. Naya Pyskacek, the Community Health Center of Burlington’s Associate Director of Behavioral Health identified several resources established this community targeting mental health interventions, including the connecting cultures program, ongoing screening and group stress reduction therapy sessions (Naya Pyskacek, personal communication, March 14, 2014). NutritionVitamin B12. The main causes of Vitamin B12 deficiency include malabsorption from food and dietary deficiency (CDC, 2011). Vegetarians are also at greater risk for B12 deficiency which is common in Hindu religion. The significance of B12 deficiency can be seen in risk for heart disease and elevated homocycstein levels, long term irreversible neurological symptoms, irritability, personality change, memory impairment, depression and psychosis (NIH, 2011). Specifically relating to Bhutanese refugees, the CDC MMRW (2011) described the Vitamin B12 deficiency cause “Although the deficiencies might be multifactorial, the main cause is thought to be the diet consumed by these refugees for nearly two decades in Nepal, which lacked meat, eggs, and dairy products, the major dietary sources of vitamin B12” (pg. 343). The implications for public health practice require providers to be aware of this disparity and provide Bhutanese refugees nutritional advice. Organizations need to be providing adequate screening for serum vitamin b12. If patients do test positive for B12 deficiency, screening for underlying causes and treating is recommended (CDC, 2011). It will be important for future practice that patients needing vitamin B12 treatment are connected with social services, as the weekly and monthly intramuscular treatments require multiple clinic visits and may require further education, work absence letters, continuation of services. Anemia. The prevalence of anemia in the Nepali-Bhutanese refugee population is common, approximately 20% of children under 15 and older than 65 were anemic in a Texas study conducted in 2009-2011 (CDC, 2012). The prevalence in pregnancy was approximately 28%. While the CDC states the most common cause of anemia is iron deficiency, several other conditions specific to this population could also contribute. History of malaria, parasites, Vitamin B12 deficiency and other micronutrients can also play a role. Another survey conducted in 2007 reported anemia present in 13.6% of mothers and 43.3 % of children (CDC, 2008). Community Intervention While disease surveillance among newly arriving refugee provides communicable disease regulation, universal guidelines for follow up medical screenings vary. Based on CDC recommendations that Bhutanese refugees be screened for Vitamin B12 deficiency along with the statistic that 30-60% of Bhutanese refugees who resettled in thef US between 2008-2011 had Vitamin B12 deficiency (CDC, 2012), a nutrition focused community intervention could begin to address the disparity within this community. Intervention ProposalThe proposed intervention would be two fold; primary education to medical professionals providing care for both new and established refugees, and a targeted nutritional education session for women and families in the Nepali-Bhutanese community. Community based interventions could be particularly helpful in the Bhutanese refugee population due to the strong sense of community already established within the population. Family based community interventions promote the family to network within the community and share experiences and problem solve together (DeJong, 2010). Steering the intervention to women in the community while welcoming whole families will be a way to be inclusive but also culturally sensitive; women are traditionally meal preparers and caretakers of children, while the males may be more of the decision makers in the family structure (Mayxam, 2010). Infants of breastfeeding mothers who have vitamin B12 deficiency can develop permanent neurological damage (CDC, 2011). Ensuring that providers and clients are aware of this significant risk factor will be included in both provider and client education. While including screening as a surveillance and medical intervention component, focusing on nutrition based education allows for population focused preventative action. This two-fold approach will address the acute on chronic circumstance of vitamin B12 deficiency experienced by this group, as well as the anemia and micronutrient deficiencies that have been documented as health disparities. The CDC recommends that all Bhutanese refugees be provided with nutritional counseling that emphasizes eating foods containing vitamin B12 and should receive oral supplementation for a minimum of 30 days upon arrival in the United States (2011). The CDC also recommends this population be screened for clinical signs and symptoms of the deficiency and those exhibiting the symptoms be evaluated for underlying causes. Because universal screening has not been part of the process at the Community Health Centers of Burlington until this intervention, it will be important to include newly arrived and already established community members. An attempt to collaborate with the University of Vermont’s nutrition program and Vermont Refugee Resettlements volunteer program could be a great place to solicit more volunteers if needed. Part 1: Provider EducationBased on the CDC’s 2011 report Vitamin B12 deficiency in resettled Bhutanese refugees a flyer will be developed for education on targeted screening. Because the community in Chittenden County, VT is relatively small, targeting the primary care offices that work with underserved populations such as the Community Health Centers of Burlington, Winooski Primary Care and Fletcher Allen Comprehensive Care, would likely catch most Bhutanese Refugees living in VT. The Community Health Centers of Burlington is the only Federally Qualified Health Center in the area contracted to see newly arrived adult refugees in Chittenden County (and all of VT). Winooski Health Center and Fletcher Allen will also see members of this population after their government provided Medicaid insurance expires. Nurses will offer lunch time education sessions and will hand out the CDC’s report on B12 deficiency, provide a brief education session on Bhutanese refugees and health disparities using the CDC’s Bhutanese Refugee Profile, and answer culturally specific questions as needed. Also provided will be the vitamin B 12 information sheet that is available at in both English and Nepali (translated version is available). Medical providers can use this as a quick reference for symptomology of B12 deficiency. This information sheet can also be distributed to new and established patients as an education tool. The Minnesota Department of Health’s B12 screening flow sheet could be a guidance tool if providers requested screening suggestions (). Lunchtime education sessions are common in primary care settings and are a way of capturing large audiences of healthcare works at one time. Although clinics in Minnesota, British Columbia and Australia have also chosen screening interventions to treat this health disparity, a literature view provided no outcomes of their programs. Part 2: Nutrition Education Nutrition classes as a health promotion and community intervention may not help those with severe B12 deficiency which is why the primary screening intervention is also suggested. Although, established malnutrition problems from many years of food rationing and food insecurity can be exacerbated by the cultural and language difficulties associated with relocation. (Palermo et al, 2012). Several benefits exist to a community focused nutrition class in this population. By bringing together families in the community and fostering a relationship between them the class could to re-establish cultural and religious traditions that may have been disrupted by the resettlement process (Burns, 2000). The class could also improve acculturation process by exposing new arrivals to local food and cultural practices (2000). Recommendations by the CDC (2011) that newly arrived refugees receive nutrition education and the history of malnutrition, anemia and vitamin B12 deficiency provide strong rational for a culturally competent nutrition education class for Bhutanese refugees in Chittenden county. A review of literature provided no tailored intervention for Bhutanese Refugees specifically, although many nutrition focused tools have been developed for refugee populations in the US. Bhutanese refugees in Chittenden County will be recruited to tailor the nutrition class to local needs. Burns et. al (2000) explored using a focus group to tailor their food and nutrition program for newly arrived refugees. Their focus group explored food beliefs, food practices, issues related to children’s food habits, food supply, food preparation and changes in food related issues that had occurred since arriving in the US and established this was helpful in developing a food and nutrition program for newly arrived refugees. This focus group will help ensure the material is culturally competent and relevant. With input from this focus group and use of the U.S. Committee for Refugees and Immigrants Nutrition Outreach Toolkit : Healthy Eating, Healthy Living Flip Chart, a toolkit that explores health in the US as well as food in the US, a nutrition health book in English and Nepali language.Recruitment for the nutrition classes would involve several organizations. The Community Health Centers of Burlington, Vermont Refugee Resettlement Program, Fletcher Allen Health Care, The Association for Africans Living in Vermont, The Vermont Bhutan Association, Fletcher Free Library and City Market would all be given flyers to put up and information on the time and location. The nurse would contact the State Refugee Coordinator, Denise Lemeroux, requesting she also distribute the flyer to local organizations that support refugee resettlement. In a study conducted by the Vermont Office of Minority Health five main shopping stores used by refugees were identified; with their permission flyers would be left to be put up there as well. The nurse would need to solicit the help of a Nepali-English translator for both development of the flyer and for the class. The materials from USCRI and B12 information handout are already translated into Nepali. Ideal recruitment would mean that all in the community are interested will be alerted between word of mouth and flyers. Location for education session could be The Community Health Centers of Burlington’s conference room, as they typically encourage community wellness initiatives and have held education classes in the past. Requesting a volunteer interpreter from the Vermont Refugee Resettlement Program whom is both Nepali and English speaking would also be required. The idea that a new topic based on the Nutrition Outreach Toolkit could be presented each week, with time after for discussion based on topics identified by the focus group. The decision to offer an ongoing weekly class vs. a monthly class would depend on interest, attendance and availability of interpreters. Evaluation In an ideal setting, evaluation of this intervention would include a notable increase in B12 deficiency surveillance and subsequent treatment, subjective input from the community that they have an understanding of the symptoms of B12 deficiency, how to seek out care and an idea of healthy nutrition and increased sense of community support around nutrition health. With the limited funding and resources, follow up would likely be limited to subjective information from the community and input from providers on their surveillance. Vermont is unique in its single payer healthcare system, and many refugees who might have lacked insurance may now be eligible for Medicaid if they are not working. A secondary outcome from this nutrition education initiative would be community members might seek out healthcare proactively, which is a culture shift from previously identified health determinants, and reconnect with healthcare. Refugee populations are a particularly vulnerable group due to a myriad of influences: traumatic experiences living in and escaping their country of origin, difficulty or violence while living in refugee camps, adjustment challenges in country of resettlement, loss of family members and country identity are contribute to health issues (Ater, 1998). The Nepali Bhutanese community is particularly at risk for mental health and nutritional health disparities. Although focusing on vitamin B12 deficiency and community nutrition is one part of the journey wellness, it’s a great launching point to improved community relationships and health. Improving nutrition health and increasing local healthcare provider’s health disparities knowledge such as B12 deficiency supports the Bhutanese refugee community in Chittenden County and provides an excellent example for other organizations throughout the United States to follow. Arscott T, et al. Identifying barriers to care in the Burmese and Bhutanese refugee populations of Burlington, Vermont. Univeristy of Vermont and Community Health Centers of Burlington. Retried from: Benson, J., Maldari, T., & Turnbull, T. (2010). Vitamin B12 deficiency - why refugee patients are at high risk. Australian Family Physician, 39(4), 215-21Burns, C., Webster, K., Crotty, P., Ballinger, M., Vincenzo, R., & Rozman, M. (2000). Easing the transition: food and nutrition issues of new arrivals. Health Promotion Journal Of Australia, 10(3), 230-236.Centers for Disease Control and Prevention (2008). Malnutrition and micronutrient deficiencies among Bhutanese refugee children. MMWR: Morbidity & Mortality Weekly Report, 57(14) 370-372Centers for Disease Control and Prevention (2011) Vitamin B12 deficiency in resettled Bhutanese refugees United States, 2008--2011. MMWR: Morbidity & Mortality Weekly Report, 60(11), 343-346.Centers for Disease Control and Prevention. (2012).??Population Movements. 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