Change in health profile of refugees resettling in New Zealand, 1980-2014.

AIM: To update data previously published on the health profile of the refugees resettling in New Zealand, and to draw attention to the change in health profile over time, with a decline of infectious disease/deficiencies, and a rise of non-communicable diseases, a worldwide phenomenon. METHOD: Comparative data was extracted from (1) written annual reports prepared by medical officers at the Mangere Refugee Resettlement Centre (1978-1991), (2) a Microsoft ACCESS patient management system between 1995 and 1999 and (3) a MEDTECH patient management system between 2010 and 2014. RESULTS: Over the period 1979-2014, the rate of infectious diseases has declined markedly in resettling refugees, and the rate of non-communicable diseases has increased. For example, the incidence of tuberculosis has decreased from 4% to 0.2%, gut parasites from more than 40% to, in some intakes, 15% and iron deficiency from 22% to 10%, while the diabetes rate has gone from 0.1% to 2.7%. CONCLUSION: While management of unfamiliar infectious diseases and deficiencies (especially vitamin D) still remains an important part of the management of refugee health, their management usually involves limited time and expense, and their burden is much less than before. However, refugees now resettling in New Zealand and the rest of the world often present with familiar non-communicable diseases that require long-term management.

Perceived barriers to cervical cancer screening among refugee women after resettlement: A qualitative study.

Background: Cervical cancer screening rates are low among refugee populations who have resettled in Australia, including among Bhutanese women who are at increased risk of cervical cancer. Understanding the barriers to accessing preventive health care is an important starting point to changing health behaviours. Objective: To identify perceived barriers to accessing cervical cancer screening programs among Bhutanese refugee women in Australia. Method: In-depth interviews with 30 Bhutanese refugee women resettled in Melbourne, Australia were analysed using an Interpretative Phenomenological Analysis (IPA) framework. Findings: A strong overarching theme was evident; health-seeking behaviour among the Bhutanese refugee women was strongly associated with symptoms and can be described as 'no symptoms- no check-up'. Three major contributors to health behaviour were: poor knowledge, cultural motivations and refugee experience. Poor knowledge was a consequence of low health literacy and lack of information. Cultural motivations included the notion of the sacred body and related stigmas, and strong faith in doctors. A set of latent themes associated with health professional behaviour was also identified in the experiences women recounted: screening was not offered; opportunistic screening occurred without education; and the use of interpreters was inappropriate and involved a mix of failure to use publicly available trained interpreters and informal use of family members. A contrary theme was also evident among younger educated women: changing awareness. Conclusion: Health professionals in the countries of resettlement need greater awareness of the barriers to health-seeking behaviours among refugee populations: cultural influences and norms; poor knowledge of health services and health systems; and poor practice by health professionals.

Knowledge, attitudes and practices of South Asian immigrants in developed countries regarding oral cancer: an integrative review.

BACKGROUND: Oral cancer is a growing problem worldwide, with high incidence rates in South Asian countries. With increasing numbers of South Asian immigrants in developed countries, a possible rise in oral cancer cases is expected given the high prevalence in their source countries and the continued oral cancer risk behaviours of immigrants. The aim of this review is to synthesise existing evidence regarding knowledge, attitudes and practices of South Asian immigrants in developed countries regarding oral cancer. METHODS: Five electronic databases were systematically searched to identify original, English language articles focussing on oral cancer risk knowledge, attitudes and practices of South Asian immigrants in developed countries. All studies that met the following inclusion criteria were included: conducted among South Asian immigrants in developed countries; explored at least one study outcome (knowledge or attitudes or practices); used either qualitative, quantitative or mixed methods. No restrictions were placed on the publication date, quality and setting of the study. RESULTS: A total of 16 studies involving 4772 participants were reviewed. These studies were mainly conducted in the USA, UK, Italy and New Zealand between 1994 and 2018. Findings were categorised into themes of oral cancer knowledge, attitudes and practices. General lack of oral cancer risk knowledge (43-76%) among participants was reported. More than 50% people were found engaging in one or more oral cancer risk practices like smoking, betel quid/pan/gutka chewing. Some of the participants perceived betel quid/pan/gutka chewing habit good for their health (12-43.6%). CONCLUSION: This review has shown that oral cancer risk practices are prevalent among South Asian immigrants who possess limited knowledge and unfavourable attitude in this area. Culturally appropriate targeted interventions and strategies are needed to raise oral cancer awareness among South Asian communities in developed countries.

We Should Know Ourselves: Burmese and Bhutanese Refugee Women's Perspectives on Cervical Cancer Screening.

Refugee women are at increased risk for cervical cancer and have low rates of cervical cancer screening both in their countries of origin and in the U.S. Using the Behavioral Model for Vulnerable Populations as a conceptual framework, we conducted eight focus groups with Burmese and Bhutanese refugee women to gather information about factors influencing cervical cancer screening (31 Burmese and 27 Bhutanese participants). Less than one-third (28%) reported being screened for cervical cancer before coming to the U.S. and only 45% reported being screened after resettling in the U.S. Participants had limited knowledge about cervical cancer and the need for screening, and faced multiple barriers including competing priorities and cost. However, trusted providers and interpreters were seen as means of facilitating screening. Cervical cancer screening among Bhutanese and Burmese refugee women could be improved with culturally tailored health education and increased access to female providers and trained interpreters.

A systematic review of barriers and enablers to South Asian women's attendance for asymptomatic screening of breast and cervical cancers in emigrant countries.

OBJECTIVES: The aim of this review was to identify the cultural, social, structural and behavioural factors that influence asymptomatic breast and cervical cancer screening attendance in South Asian populations, in order to improve uptake and propose priorities for further research. DESIGN: A systematic review of the literature for inductive, comparative, prospective and intervention studies. We searched the following databases: MEDLINE/In-Process, Web of Science, EMBASE, SCOPUS, CENTRAL, CDSR, CINAHL, PsycINFO and PsycARTICLES from database inception to 23 January 2018. The review included studies on the cultural, social, structural and behavioural factors that influence asymptomatic breast and cervical cancer screening attendance and cervical smear testing (Papanicolaou test) in South Asian populations and those published in the English language. The framework analysis method was used and themes were drawn out following the thematic analysis method. SETTINGS: Asymptomatic breast or cervical screening. PARTICIPANTS: South Asian women, including Bangladeshi, Indian, Pakistani, Sri Lankan, Bhutanese, Maldivian and Nepali populations. RESULTS: 51 included studies were published between 1991 and 2018. Sample sizes ranged from 25 to 38 733 and participants had a mean age of 18 to 83 years. Our review showed that South Asian women generally had lower screening rates than host country women. South Asian women had poorer knowledge of cancer and cancer prevention and experienced more barriers to screening. Cultural practices and assumptions influenced understandings of cancer and prevention, emphasising the importance of host country cultures and healthcare systems. CONCLUSIONS: High-quality research on screening attendance is required using prospective designs, where objectively validated attendance is predicted from cultural understandings, beliefs, norms and practices, thus informing policy on targeting relevant public health messages to the South Asian communities about screening for cancer. PROSPERO REGISTRATION NUMBER: CSD 42015025284.

Description of tobacco use and cessation among Bhutanese refugees participating in a tobacco cessation program.

OBJECTIVES: To compare the tobacco use, exposure, and cessation differences between Bhutanese refugee and non-Hispanic Caucasian tobacco users in a US federally qualified health center tobacco cessation program. DESIGN: A retrospective cohort study reviewing data from 374 patients counseled on tobacco cessation was performed. Demographic information, tobacco use history, exposure to tobacco, and type of tobacco used characterized baseline assessments. The patient record was followed forward in time to evaluate tobacco cessation outcomes as the dependent variable. Data were analyzed using odds ratios and the Mann-Whitney U-test. RESULTS: Data analysis included 318 patients (211 non-Hispanic Caucasian patients and 107 Bhutanese refugee patients). Bhutanese refugees demonstrated a higher likelihood of smokeless tobacco product use than the non-Hispanic Caucasian population (67.3% vs 1%, OR = 214.971, 95% CI 50.429, 916.383), and a greater odds of having household tobacco users (OR = 2.533, 95% CI 1.532, 4.186). Likewise, the non-Hispanic Caucasian population exhibited larger odds of smoking cigarettes vs the Bhutanese population (97.2% vs 26.2%, OR = 96.399, 95% CI 38.449, 241.687), had a higher odds of passive smoke exposure (OR = 12.765, 95% CI 5.36, 30.393), and higher likelihood of a past quit attempt (OR = 9.037, 95% CI 5.180, 15.765). Significant gender differences with regard to type of tobacco used were noted among Bhutanese refugees. Bhutanese refugees demonstrated significantly higher likelihood of tobacco cessation, compared with the non-Hispanic Caucasian population, at all length cutpoints, while showing no difference in number of follow-up visits or median time followed. CONCLUSION: These culture-specific findings, showing unique tobacco use characteristics and increased cessation among the Bhutanese refugee population, provide novel information helpful to professionals identifying and treating these individuals for tobacco cessation. More research is needed to confirm our results and findings.

Adapting an Autism Screening Tool for Use in the DeKalb County Refugee Pediatric Clinic.

BACKGROUND: Minimal literature exists regarding Autism Spectrum Disorder (ASD) among refugee children in the United States. Reliable ASD screening tools, such as the M-CHAT-R/F, have yet to be culturally adapted and translated into some languages spoken in the homes of these children. METHODS: Pediatric refugee patients (n = 13) of caregivers of Bhutanese (Nepali-speaking) descent were screened using a newly translated Nepali M-CHAT-R/F. The M-CHAT-R/F was adapted based on feedback from Bhutanese caregivers and interpreter expertise. Qualitative interviews regarding caregiver awareness of ASD were conducted. RESULTS: Caregivers understood the majority of M-CHAT-R/F items (91%). Four items required revision. Interviews revealed minimal awareness among Bhutanese caregivers regarding ASD or child development. DISCUSSION: The M-CHAT-R/F was adapted into Nepali using a combination of translation protocols, and is publicly available for clinical use. Future validation studies are needed which will aid in clinical screening for and epidemiologic research of ASD in this population.

Results From a Pilot Video Intervention to Increase Cervical Cancer Screening in Refugee Women.

Many refugee women emigrate from countries with high cervical cancer incidence rates and have low rates of cervical cancer screening both before and after resettlement. Refugee women face many barriers to cervical cancer screening, including limited knowledge of cervical cancer and screening recommendations and cultural and linguistic barriers to being screened. Our pilot study aimed to develop and evaluate educational videos to promote cervical cancer screening among Karen-Burmese and Nepali-Bhutanese refugees, two of the largest groups of refugees arriving to the United States in recent years. We developed culturally tailored narrative videos for each ethnic group. Karen-Burmese and Nepali-Bhutanese women ( N = 40) were recruited through community health educators to participate in a pre- and posttest study. We assessed changes in cervical cancer knowledge and intentions to be screened, and satisfaction with the videos. We found that women were significantly more likely to report having heard of a test for cervical cancer and indicated significantly greater intentions to be screened after watching the video. Their knowledge about cervical cancer and screening also improved significantly, and they reported high levels of acceptability with the video. Our results suggest that culturally tailored narrative educational videos were acceptable to the target audiences and may be effective in increasing cervical cancer screening among refugee women. Further research should assess how health care and social service providers could implement video-based interventions to encourage women to be screened for cervical cancer during early resettlement.

Perceptions of Cervical Cancer Screening, Screening Behavior, and Post-Migration Living Difficulties Among Bhutanese-Nepali Refugee Women in the United States.

Bhutanese-Nepali refugees are one of the largest refugee groups to be resettled in the U.S. in the past decade. Cervical cancer is a leading cause of cancer disparity in this population, yet screening rates are suboptimal. Nepali-speaking interviewers administered a community health needs questionnaire to a convenience sample of Bhutanese-Nepali refugees in a Midwestern city between July to October of 2015. Descriptive statistics were used to describe socio-demographic characteristics, Pap smear beliefs, post-migration living difficulties, and screening status. Differences in Pap test uptake between groups were tested using t test and Chi square statistics. Of the 97 female participants, 44.3% reported ever having had a Pap smear. Screening rates were lowest among women who did not know English at all. Most women had positive perceptions of Pap smears (80%) and 44.4% had received a Pap test recommendation from their healthcare provider, family, or friends. Pap testing was significantly higher among those who had positive perceptions (58.3 vs. 11.1% for women of negative perception, p = 0.01) and those who had received a recommendation (87.5 vs. 18.6% for women who had no recommendations, p < 0.001). Significant predictors of having a Pap smear were having a healthcare provider/family/friends recommendation (OR 65.3, 95% CI 11.4-373.3) and greater number of post-migration living difficulties (OR 1.18, 95% CI 1.02-1.37). The results of this study have important implications for the development of cervical cancer prevention programs targeting Bhutanese-Nepali refugees. Providing cancer prevention interventions early in the resettlement process could impact Pap test uptake in this population.

High-risk human papillomavirus infection and abnormal cervical cytology among Nepali and Bhutanese refugee women living in eastern Nepal.

BACKGROUND: Cervical cancer is the leading cause of cancer morbidity and mortality among women in Nepal and Bhutan. Data on high-risk human papillomavirus (HR-HPV) infection and cervical abnormalities among Nepali and Bhutanese women are sparse. The objectives of this study were to assess and compare the prevalence of HR-HPV infection and cervical abnormalities among Nepali and Bhutanese women living in Jhapa District in eastern Nepal; and examine the risk factors for HR-HPV infection and cervical abnormalities in those women. METHODS: Study participants were recruited from a women's health camp organized by NFCC-International, a Nepal-based non-governmental organization, in 2014. Consenting participants were administered a demographic and health questionnaire and cervico-vaginal specimens collected. Both self-collected and clinician-collected cervico-vaginal specimens were tested for HR-HPV infection. Cytologic exam was performed on clinician-collected samples and cervical cytology results were categorized according to the Bethesda classification. A participant was classified as a Bhutanese if they were either born in Bhutan or currently lived in one of the United Nations administered Bhutanese refugee camps in Jhapa; otherwise, the participant was classified as a Nepali. RESULTS: Of the 647 study participants, 15.9% were Bhutanese women living in refugee camps and the overall age (± standard deviation) was 38.8 ± 8.2 years. The prevalence of HR-HPV infection was 8.9% and abnormal cervical cytology was 7.1% respectively, with no significant difference in HR-HPV positivity (p = 0.399) or abnormal cervical cytology (p = 0.698) between Nepali and Bhutanese women. Compared to women whose husbands had not migrated for employment, women whose husbands had migrated outside of the district had 3.30 times (95% Confidence Interval [CI]: 1.13-9.64) the odds of being HR-HPV positive and women whose husbands had migrated outside the country had 2.92 times (95% CI: 1.32-6.49) the odds of having abnormal cervical cytology. CONCLUSIONS: HR-HPV positivity and abnormal cervical cytology were similar among Nepali and Bhutanese women. Husbands migrating for employment within or outside the country was a significant risk factor for high-risk HPV infection and cervical cytology, indicating the important role spousal behavior may play in HR-HPV acquisition and cervical abnormalities among these women.

Chronic Health Conditions, Physical Activity and Dietary Behaviors of Bhutanese Refugees: A Houston-Based Needs Assessment.

Bhutanese refugees resettling in the U.S. face many challenges including several related to health and health care. Limited health literacy and the relatively complicated US health care system may contribute to health disparities as well. A health assessment was conducted on adult refugees in Houston, Texas to provide healthcare providers, community organizations, and stakeholders baseline data to plan programs and interventions. A convenience sample of 100 participants had a mean age of 38.37 years, 56 % where males, and almost 80 % did not have high school level education. High blood pressure (27 %), dizziness (27 %), and arthritis (22 %) were the commonly identified chronic health conditions and trouble concentrating (34 %) and fatigue (37 %) were also reported. Sixty-two percent of the respondents reported that they consume recommended servings of fruits and vegetables and 41 %reported that they were currently getting at least 20-30 min of aerobic exercise per day. The assessment concluded with recommendations on how better provide care and services for the refugees.

Hepatitis B screening and prevalence among resettled refugees - United States, 2006-2011.

Globally, more than two billion persons have been infected at some time with the hepatitis B virus (HBV), and approximately 3.5 million refugees have chronic HBV infection. The endemicity of HBV varies by region. Because chronic hepatitis B is infectious and persons with chronic infection benefit from treatment, CDC recommends screening for HBV among all refugees who originate in countries where the prevalence of hepatitis B surface antigen (HBsAg; a marker for acute or chronic infection) is ≥2% or who are at risk for HBV because of personal characteristics such as injection drug use or household contact with an individual with HBV infection. Currently, almost all refugees are routinely screened for hepatitis B. However, prevalence rates of HBV infection in refugee populations recently resettled in the United States have not been determined. A multisite, retrospective study was performed to evaluate the prevalence of past HBV infection, current infection, and immunity among refugees resettled in the United States; to better characterize the burden of hepatitis B in this population; and to inform screening recommendations. The study incorporated surveillance data from a large state refugee health program and chart reviews from three U.S. sites that conduct medical screenings of refugees. The prevalence of HBV infection (current or past as determined by available titer levels) varied among refugees originating in different countries and was higher among Burmese refugees than among refugees from Bhutan or Iraq. Current or past HBV infection was also higher among adults (aged >18 years) and male refugees. These data might help inform planning by states and resettlement agencies, as well as screening decisions by health care providers.

Chronic Disease Burden Among Bhutanese Refugee Women Aged 18-65 Years Resettled in Northeast Ohio, United States, 2008-2011.

The purpose of this community-based study was to assess the prevalence of chronic diseases among 18-65 year old Bhutanese refugee women resettled in Northeast Ohio, United States (US). A Nepali-language questionnaire was administered in a face-to-face mode. Anthropometric measurements included height, weight, and hip and waist circumferences. The overall prevalence (95 % confidence interval) of self-reported hypertension, diabetes, asthma, heart disease, and cancer were 15.3 % (9.2-23.4), 6.4 % (2.3-10.9), 5.5 % (2.0-11.5), 2.7 % (0.6-7.8), and 1.8 % (0.2-6.4), respectively. Overweight/obesity was observed in 64.8 % of the women; 69.5 and 74.1 % had waist circumference >80 cm and waist-to-hip ratio ≥85, respectively. Length of time in the US was not associated with the prevalence of the chronic conditions. This study suggests chronic conditions may be significant health issues among US resettled Bhutanese refugees and a larger population-based study to confirm the findings is warranted.

Update: vitamin B12 deficiency among Bhutanese refugees resettling in the United States, 2012.

In 2008, clinicians performing routine medical examinations in the United States reported high rates of hematologic and neurologic disorders caused by vitamin B12 deficiency in resettled Bhutanese refugees. To confirm this finding, CDC screened Bhutanese refugees' serum samples for vitamin B12 levels and found vitamin B12 deficiency in 64% (n = 99) of samples obtained before departure and 27% (n = 64) of samples obtained after arrival in the United States. In response, CDC recommended that arriving Bhutanese refugees receive oral vitamin B12 supplements and nutrition advice. In 2012, based on anecdotal reports of decreasing rates of vitamin B12 deficiency in this population, CDC worked with select domestic refugee health programs to determine if the recommendations had reduced the vitamin B12 deficiency rate among Bhutanese refugees.

Knowledge, attitudes, and practices for cervical cancer screening among the Bhutanese refugee community in Omaha, Nebraska.

Cervical cancer is the second most common cause of cancer mortality among women with the vast majority of patients in developing countries. Bhutanese refugees in the United States are from South Central Asia, the 4th leading region of the world for cervical cancer incidence. Over the past few years, Bhutanese refugees have increased significantly in Nebraska. This study evaluates current knowledge of cervical cancer and screening practices among the Bhutanese refugee women in Omaha, Nebraska. The study aimed to investigate cervical cancer and screening knowledge and perceptions about the susceptibility and severity of cervical cancer and perceived benefits and barriers to screening. Self-administered questionnaires and focus groups based on the Health Belief Model were conducted among 42 healthy women from the Bhutanese refugee community in Omaha. The study revealed a significant lack of knowledge in this community regarding cervical cancer and screening practices, with only 22.2 % reporting ever hearing of a Pap test and 13.9 % reporting ever having one. Only 33.3 % of women were in agreement with their own perceived susceptibility to cervical cancer. Women who reported ever hearing about the Pap test tended to believe more strongly about curability of the disease if discovered early than women who never heard about the test (71.4 vs. 45.0 %, for the two groups. respectively). Refugee populations in the United States are in need for tailored cancer education programs especially when being resettled from countries with high risk for cancer.

Prevalence and patterns of hazardous and harmful alcohol consumption assessed using the AUDIT among Bhutanese refugees in Nepal.

AIMS: This study sought to ascertain the prevalence of hazardous and harmful alcohol consumption among Bhutanese refugees in Nepal and to identify predictors of elevated risk in order to better understand intervention need. METHODS: Hazardous and harmful alcohol consumption was assessed using the Alcohol Use Disorder Identification Test (AUDIT) administered in a face-to-face interview in a census of two camps comprising ∼8000 refugees. RESULTS: Approximately 1/5 men and 1/14 women drank alcohol and prevalence of hazardous drinking among current drinkers was high and comparable to that seen in Western countries with longstanding alcohol cultures. Harmful drinking was particularly associated with the use of other substances including tobacco. CONCLUSIONS: Assessment of the alcohol-related needs of Bhutanese refugees has permitted the design of interventions. This study adds to the small international literature on substance use in forced migration populations, about which there is growing concern.

High success rate of TB treatment among Bhutanese refugees in Nepal.

SETTING: Camps for refugees from Bhutan in south-east Nepal. OBJECTIVES: To evaluate the outcome of treatment of tuberculosis (TB) cases in the refugee camps. DESIGN: Cohort analysis of results of treatment of cases started on treatment from mid-July 1999 to mid-July 2004. RESULT: A total of 1214 patients with TB were notified in the programme. Among these, 631 (52%) were new smear-positive pulmonary tuberculosis (PTB) cases, 175 (14%) new smear-negative PTB cases, 290 (24%) new extra-pulmonary TB (EPTB) cases and 118 (10%) smear-positive retreatment cases. Treatment success was achieved in 1061 (94%). The proportion of new non-smear-positive cases who died on treatment was significantly higher than the corresponding figure for new smear-positive cases (RR 7.57, 95%CI 3.74-15.32 for new smear-negative and 4.22, 95%CI 2.08-8.55 for EPTB). CONCLUSION: High cure rates and low bacteriological failure rates can be achieved in refugee settings if there is close coordination and collaboration between the local health agencies and the National Tuberculosis Programme of the host country.