Nepali Translation, Validity and Reliability Study of the Cohen-Hoberman Inventory of Physical Symptoms for Utilization With Bhutanese Refugees.

BACKGROUND AND OBJECTIVES: Language-appropriate outcome measurements help to improve health equity. The purpose of this study was to translate and validate the Cohen-Hoberman Inventory of Physical Symptoms (CHIPS) in Nepali for Bhutanese refugee utilization. METHODS: English-Nepali forward and back translations of CHIPS were completed by an official translator and evaluated by three content experts. A scaled rubric measured the following constructs: neurogenic stress response (NSR), somatic stress response (SSR), and visceral stress response (VSR). Data were analyzed using SPSS 26.0. RESULTS: The Nepali version of CHIPS reported good content validity, strong internal consistency (Cronbach's α  = .94), and inter-rater reliability (ICC = 0.91). Kappa statistic reported 88% to 96% agreement. Constructs of NSR (0.91), SSR (0.94), and VSR (0.94) reported strong internal consistency. CONCLUSIONS: The Nepali translated version of CHIPS showed strong validity and reliability for utilization in the Bhutanese refugee population and improves health access to outcome measurements for a vulnerable population.

Conceptualisations of pain amongst resettled Nepali-speaking Bhutanese adults in rural and regional Australia.

INTRODUCTION: Nepali-speaking Bhutanese refugees have been subject to one of the largest resettlement programs in the world and experience higher rates of chronic pain when compared to the general population. The purpose of this study was to explore qualitative conceptualisations of chronic pain among a group of Nepali-speaking Bhutanese adults with a refugee background who relocated to rural and regional Australia. METHODS: Participants included 22 individuals (females n=15) with chronic pain, who took part in structured qualitative focus groups exploring their experiences of chronic pain. Data were analysed using thematic analysis and five main themes were developed. RESULTS: The themes were: (1) pain is persistent and creates suffering, (2) pain is subjective and poorly understood, (3) pain is a biomedical problem that needs to be solved, (4) pain is complex and more than a biomedical problem, and (5) coping with pain is multi-faceted.Some participants viewed pain through a predominantly biomedical lens, and some recognised social and psychological factors as contributors to pain. Overwhelmingly, the participants believed pain is complex and multifaceted, requiring active and passive strategies for management, some of which are culturally informed. CONCLUSION: The experiences of resettled Nepali-speaking Bhutanese refugees living with pain are important to elucidate to improve healthcare inequalities among this marginalised group. This research will inform future assessment guidelines and treatment programs for Nepali-speaking Bhutanese adults living with chronic pain.

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.

Perceptions Toward Mental Illness and Seeking Psychological Help among Bhutanese Refugees Resettled in the U.S.

This study examined perceptions toward mental health and seeking psychological care among Bhutanese refugees in a large Midwestern U.S. city. Bhutanese adults (n = 201) completed a community health needs assessment. Survey questions addressed beliefs toward mental health and seeking psychological care. Perceptions toward mental illness and receiving psychological help were generally negative among participants. Over 71% believed others would look unfavorably on a person who sought out a counselor. Participants who had less than a high school education, were 35 years and older, and lived in refugee camps for more than 20 years had significantly greater negative beliefs toward mental illness. Over one-third (34.8%) of participants reported access to counseling services as being somewhat of a problem or a serious problem. These findings may inform future research and interventions aimed at improving mental health among Bhutanese refugees.

Sociocultural Perceptions and Enablers to Seeking Mental Health Support Among Bhutanese Refugees in Western Massachusetts.

This qualitative study aimed to identify cultural influences on seeking mental health support among Bhutanese refugees resettled in Western Massachusetts. Bhutanese refugees aged 18 years or older were recruited for eight focus group discussions, organized by age and gender ( N = 67, 49.3% female, mean age = 38, SD = 15.9). The PEN-3 cultural model was used as the theoretical framework to examine the roles of cultural perceptions that influence mental health-seeking behaviors. Focus group discussions were audio taped to facilitate the thematic-analysis. Younger participants (<35 years) reported experiencing stressors relating to economic hardships and difficulties in developing academic and social skills as they juggle breadwinner and care-giving responsibilities for their families. Older participants reported frustration with the difficulties in learning English and increased dependence on their children. Family members provided the initial frontline support to persons with mental health problems. If family support did not work, they consulted with their relatives and trustworthy community members for further assistance. Psychological factors such as fears of emotions, social norms, beliefs, and self-esteem associated with cultural norms and values influenced seeking mental health support. All participants expressed the need to have a culturally tailored intervention to develop acquired skills to improve their self-esteem and self-efficacy in order to integrate into their new social and cultural environment. Because family members make important decisions about seeking mental health support, involving family members in developing and delivering culturally appropriate skill development interventions could be a potential strategy to reduce their stress and increase resilience in this refugee community.

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.

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.

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.

Effectiveness of Primary Health Care Services in Addressing Mental Health Needs of Minority Refugee Population in New Zealand.

Many people are displaced from their country of origin and become refugees, mostly due to armed conflicts, political violence and human rights abuse. Refugees have complex mental, physical, and social health problems related to their traumatic background and the experiences they have endured during their refugee journey. The aim of this qualitative exploratory study was to examine the effectiveness of primary health care services in addressing mental health needs of Bhutanese refugee women resettled in New Zealand. This study included focus group discussion with Bhutanese women and men followed by interviews with health service providers. The findings of this study highlighted inadequacies and constraints in addressing Bhutanese refugee women's mental health needs in New Zealand and provided evidence for recommendations to address these inadequacies.

Help-Seeking Behavior and Health Care Navigation by Bhutanese Refugees.

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.

Building Social Capital Through a Peer-Led Community Health Workshop: A Pilot with the Bhutanese Refugee Community.

Despite the high health and mental health care needs, resettled refugees often face cultural and linguistic challenges that hinder the access to appropriate and timely interventions and services. Additionally, such concepts as preventive health or mental health treatment are foreign to this population, which creates additional burdens to the refugee community that already have difficulty navigating a complex health care system in the U.S. To address multiple and complex gaps in health and mental health support for the refugee community, requested is an innovative approach that can convey culturally responsive and effective interventions for health promotion, such as peer-based health education. Few studies have been conducted on the effectiveness of peer-led community health interventions with refugee populations in the U.S. resettlement context. However, peer-led interventions have been shown to be effective when working with cultural minorities and interventions in an international context. Adopting a social capital framework, the current study conducted qualitative evaluation on the impact of a pilot peer-led community health workshop (CHW) in the Bhutanese refugee community. A hybrid thematic analysis of focus group discussion data revealed the improvement in health promotion outcomes and health practice, as well as perceived emotional health. The results also showed that the peer-led CHW provided a platform of community building and participation, while increasing a sense of community, sense of belonging and unity. The findings posit that a peer-led intervention model provides culturally responsive and effective tools for building social capital and promoting community health in the refugee community.

Use of maternal health services: comparing refugee, immigrant and US-born populations.

Objectives To determine use of recommended maternal healthcare services among refugee and immigrant women in a setting of near-universal insurance coverage. Methods Refugee women age ≥18 years, who arrived in the US from 2001 to 2013 and received care at the same Massachusetts community health center, were matched by age, gender, and date of care initiation to Spanish-speaking immigrants and US-born controls. The primary outcome was initiation of obstetrical care within the first trimester (12 weeks gestation). Secondary outcomes were number of obstetrical visits and attending a postpartum visit. Results We included 375 women with 763 pregnancies (women/pregnancies: 53/116 refugee, 186/368 immigrant, 136/279 control). More refugees (20.6 %) and immigrants (15.0 %) had their first obstetric visit after 12 weeks gestation than controls (6.0 %, p < 0.001). In logistic regression models adjusted for age, education, insurance, BMI, and median census tract household income, both refugee (odds ratio [OR] 4.58, 95 % confidence interval [CI] 1.73-12.13) and immigrant (OR 2.21, 95 % CI 1.00-4.84) women had delayed prenatal care initiation. Refugees had fewer prenatal visits than controls (median 12 vs. 14, p < 0.001). Refugees (73.3 %) and immigrant (78.3 %) women were more likely to have postpartum care (controls 54.8 %, p < 0.001) with differences persisting after adjustment (refugee [OR 2.00, 95 % CI 1.04-3.83] and immigrant [OR 2.79, 95 % CI 1.72-4.53]). Conclusions for Practice Refugee and immigrant women had increased risk for delayed initiation of prenatal care, but greater use of postpartum visits. Targeted outreach may be needed to improve use of beneficial care.

Addressing health disparities in the mental health of refugee children and adolescents through community-based participatory research: a study in 2 communities.

OBJECTIVES: We sought to understand the problems, strengths, and help-seeking behaviors of Somali Bantu and Bhutanese refugees and determine local expressions of mental health problems among youths in both communities. METHODS: We used qualitative research methods to develop community needs assessments and identify local terms for child mental health problems among Somali Bantu and Bhutanese refugees in Greater Boston and Springfield, Massachusetts, between 2011 and 2014. A total of 56 Somali Bantu and 93 Bhutanese refugees participated in free list and key informant interviews. RESULTS: Financial and language barriers impeded the abilities of families to assist youths who were struggling academically and socially. Participants identified resources both within and outside the refugee community to help with these problems. Both communities identified areas of distress corresponding to Western concepts of conduct disorders, depression, and anxiety. CONCLUSIONS: There are numerous challenges faced by Somali Bantu and Bhutanese youths, as well as strengths and resources that promote resilience. Future steps include using culturally informed methods for identifying those in need of services and developing community-based prevention programs.

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.

Merging perspectives: obstacles to recovery for youth from refugee backgrounds with comorbidity.

OBJECTIVE: This research aimed to identify challenges encountered by young people from refugee backgrounds with co-existing mental health (MH) and alcohol and other drug (AOD) problems (comorbidity) and sought to compare the perspectives of refugee youth and service providers in a metropolitan region of Adelaide, South Australia. METHODS: Semi-structured interviews were conducted with two groups of participants: young people from refugee backgrounds (African, Afghan, Bhutanese) and workers from MH, AOD and refugee support services. RESULTS: The refugee youth reported that the biggest difficulty they face once they develop MH and AOD problems is social disconnectedness. They lacked awareness that services are available to support them. In contrast, clinicians rated difficulty accessing and receiving culturally competent comorbidity care as the greatest challenge. Other reported challenges were relatively consistent across both groups. CONCLUSIONS: This study has implications for how we engage these young people in services, prioritise areas of care and effectively treat and support refugee youth experiencing comorbidity. These findings emphasise the need for a combined therapeutic casework approach, addressing needs such as social connectedness, housing, education and employment.

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.

'Excuse me, do any of you ladies speak English?' Perspectives of refugee women living in South Australia: barriers to accessing primary health care and achieving the Quality Use of Medicines.

Reforms to the Australian health system aim to ensure that services are accessible, clinically and culturally appropriate, timely and affordable. During the reform consultation process there were urgent calls from stakeholders to specifically consider the health needs of the thousands of refugees who settle here each year, but little is known about what is needed from the refugee perspective. Access to health services is a basic requirement of achieving the quality use of medicines, as outlined in Australia's National Medicines Policy. This study aimed to identify the barriers to accessing primary health care services and explore medicine-related issues as experienced by refugee women in South Australia. Thirty-six women participated in focus groups with accredited and community interpreters and participants were from Sudan, Burundi, Congo, Burma, Afghanistan and Bhutan who spoke English (as a second language), Chin, Matu, Dari and Nepali. The main barrier to accessing primary health care and understanding GPs and pharmacists was not being able to speak or comprehend English. Interpreter services were used inconsistently or not at all. To implement the health reforms and achieve the quality use of medicines, refugees, support organisations, GPs, pharmacists and their staff require education, training and support.

Occupational performance and self-determination: the role of the occupational therapist as volunteer in two mountain communities.

BACKGROUND/AIM: Occupational therapists involved in volunteer programmes do so as either a volunteer or as a professional working with volunteers. This study outlines two such programmes: one in regional Queensland, with refugees settling into a life in Australia, and one in Bhutan, with an organisation assisting families of children with disabilities. In both instances, the author has been involved as a volunteer, drawing on her occupational therapy skills, the Person-Environment-Occupation Model and self-determination theory as theoretical frameworks. METHOD: This report offers an insight into two geographically and culturally different volunteer programmes, and outlines the potential for occupational therapists to be involved in cross-cultural experiences, within Australia and abroad. In the Australian setting the author is working with newly arrived refugees from Africa, Iran and Iraq in a local community group the Toowoomba Refugee and Migrant Service. Within the Bhutanese setting the author is working with the Ability Bhutan Society, an organisation established by a group of local parents with the initial aim of sharing experiences and information relating to their children with disabilities. RESULTS: The descriptions of each volunteering experience outline the opportunities for facilitating the development of independence, self-determination and acquisition of new roles in two cross-cultural communities by an occupational therapist working as a volunteer. CONCLUSION: An occupational therapist's ability to assess the interaction between a person or organisation's skills, the environment in which that person or organisation is functioning, and the desired occupational outcomes of that person or organisation, enables a unique and valuable contribution as a volunteer.

Suicide and suicidal ideation among Bhutanese refugees--United States, 2009-2012.

During the period February 2009-February 2012, the Office of Refugee Resettlement of the U.S. Department of Health and Human Services reported 16 suicides among the approximately 57,000 Bhutanese refugees who had resettled in the United States since 2008. In 2012, the office requested assistance from CDC and the Massachusetts Department of Public Health's Refugee Health Technical Assistance Center to identify risk factors that might be associated with suicidal ideation among Bhutanese refugees. In collaboration with the Massachusetts refugee health center, CDC conducted a survey of randomly selected Bhutanese refugees in four U.S. states with large populations of resettled refugees. The results indicated significant associations between ever having expressed suicidal ideation and current self-reported symptoms of mental health disorder (e.g., anxiety, depression, or posttraumatic stress disorder) and postmigration difficulties (e.g., family conflict or inability to find work). The findings highlight the need for development of culturally appropriate community-based interventions for suicide prevention and standard procedures for monitoring and reporting suicides and suicide attempts in the Bhutanese refugee population.