Disaster Preparedness in a Resettled Refugee Community: Qualitative Findings.

INTRODUCTION: Under-resourced communities face disaster preparedness challenges. Research is limited for resettled refugee communities, which have unique preparedness needs. STUDY OBJECTIVE: This study aims to assess disaster preparedness among the refugee community in Clarkston, GA. METHODS: Twenty-five semi-structured interviews were completed with community stakeholders. Convenience sampling using the snowball method was utilized until thematic saturation was reached. Thematic analysis of interviews was conducted through an inductive, iterative approach by a multidisciplinary team using manual coding and MAXQDA. RESULTS: Three themes were identified: First, prioritization of routine daily needs took precedence for families over disaster preparedness. Second, communication impacts preparedness. Community members speak different languages and often do not have proficiency in English. Access to resources in native languages and creative communication tactics are important tools. Finally, the study revealed a unique interplay between government, community-based organizations, and the refugee community. A web of formal and informal responses is vital to helping this community in times of need. CONCLUSION: The refugee community in Clarkston, GA faces challenges, and disaster preparedness may not be top of mind for them. However, clear communication, disaster preparedness planning, and collaboration between government, community-based organizations, and the community are possible areas to focus on to bolster readiness.

"God was with me": A qualitative study of Christian meaning-making among refugees.

In this consensual qualitative research study, we investigated the role of refugees' Christian faith in meaning-making coping. High percentages of religiosity in refugee populations support the need to understand the role of religion in their coping processes. Interviews with 20 Christian refugees from 10 African and Asian countries revealed that participants drew heavily from their faith resources to cope with their experiences. Specifically, refugees reported coping practices that included trust in God, prayer, intimacy with God, spiritual surrender, lament, worship, and social support. Although many participants described spiritual struggles, including doubting God, feeling distant from God, and questioning God, most found meaning amid refugee-related suffering and reported perspective shifts, a deepening of faith, seeing suffering as part of God's plan, experiencing a deepened sense of purpose, and growing in the likeness of Christ. Refugees also reported growth through suffering in the form of gratitude, altruism, testimony, and humility. Clinical implications include encouraging the use of religious resources for meaning-making and supporting the resolution of spiritual struggles.

Creating Understandable and Actionable COVID-19 Health Messaging for Refugee, Immigrant, and Migrant Communities.

During the coronavirus pandemic, it was imperative that real-time, rapidly changing guidance on continuously evolving critical health information about COVID-19 be communicated. This case study highlights how understandable and actionable COVID-19 health information was systematically developed and disseminated to support highly vulnerable refugee, immigrant, and migrant (RIM) communities in Clarkston, Georgia. Our approach was grounded in community-based participatory research (CBPR) incorporating Cultural and Linguistically Appropriate Services (CLAS) standards, plain language and health literacy guidelines, and health communication science to improve the understandability and usability of COVID-19 micro-targeted messaging for RIM communities. We followed a centralized systematic approach to materials development and incorporated local needs and existing networks to ensure cultural and linguistic responsiveness as well as understandability for populations with limited literacy skills. Further, iterative development of materials with community members and agencies provided buy-in prior to dissemination. As part of a multi-pronged community-wide effort, effective materials and messaging provided support to community health workers and organizations working to improve vaccination rates among the RIM community. As a result, we saw vaccine rates in Clarkston outpace other similar areas of the county and state due to this community-wide effort.

Cultural and Linguistic Adaptations of Stop the Bleed in Multi-Ethnic Refugee Communities.

INTRODUCTION: Stop the Bleed (STB), and other trainings that promote health education in basic trauma management techniques, is offered mostly in English and Spanish in the United States. Limited access to injury prevention training may contribute to inequities in health outcomes for individuals with limited English proficiency (LEP). Our study aims to determine the feasibility and effectiveness of STB training in 4 languages spoken in a super diverse refugee settlement community, Clarkston, GA. METHODS: Written STB educational materials were culturally adapted, translated, and back translated into 4 languages: Arabic, Burmese, Somali, and Swahili. Four 90-minute in-person STB trainings were conducted by medical personnel with community-based interpreters at a central and familiar location in the Clarkston community. Pre- and post-tests were administered in participant's preferred language to evaluate change in knowledge and beliefs as well as the effectiveness of the training method. RESULTS: A total of 46 community members were trained in STB, the majority of which were women (63%). Participants demonstrated improvement in their knowledge, confidence, and comfort using STB techniques. Participants reported that 2 aspects of the training were particularly beneficial: the presence of language concordant interpreters from the community and small group hands on sessions that allowed for practicing STB techniques. CONCLUSION: Cultural and linguistic adaptation of STB training is a feasible, cost-effective, and effective method for disseminating life-saving information and trauma education to immigrant populations who have LEP. Expansion of community training and partnerships to support the needs of diverse communities is both necessary and urgent.

Health Literacy and Intercultural Competence Training.

Intercultural competence (ICC) and health literacy (HL) are vital components of patient education. The purpose of this study was to determine if an educational intervention that combined ICC and HL was effective at changing second-year nursing students' self-efficacy, beliefs, and knowledge. A total of 157 second-year nursing students in two different programs participated in pre- and post-surveys consisting of the Transcultural Self-Efficacy Tool and Health Literacy Beliefs and Knowledge survey. Students attended a two-part lecture with a moderated panel on ICC and health literacy and began clinical fieldwork. Results were analyzed using Wilcoxon signed-rank test and Pearson correlation. There was a statistically significant difference in all ICC subscales after an educational intervention and clinical fieldwork (cognitive z = 7.681, p < .001; practical z = 7.319, p < .001; affective z = 6.533, p < .001). HL knowledge and belief measures showed statistically significant difference after the intervention (z = 3.037, p < .001). There was a statistically significant correlation between intercultural self-efficacy and HL beliefs (Pearson's r = .486, p < .001). Self-efficacy in ICC and beliefs and knowledge in HL increased over time for nursing students, indicating that it may be beneficial to train students about these two constructs simultaneously. [HLRP: Health Literacy Research and Practice. 2021;5(4):e283-e286.].

Adaptation and implementation of a parenting curriculum in a refugee/immigrant community using a task-shifting approach: a study protocol.

BACKGROUND: Delivering evidence-based interventions to refugee and immigrant families is difficult for several reasons, including language and cultural issues, and access and trust issues that can lead to an unwillingness to engage with the typical intervention delivery systems. Adapting both the intervention and the delivery system for evidence-based interventions can make those interventions more appropriate and palatable for the targeted population, increasing uptake and effectiveness. This study focuses on the adaptation of the SafeCare© parenting model, and its delivery through either standard implementation methods via community-based organizations (CBO) and a task-shifted implementation in which members of the Afghans, Burmese, Congolese community will be trained to deliver SafeCare. METHOD: An adaptation team consisting of community members, members of CBO, and SafeCare experts will engage a structured process to adapt the SafeCare curriculum for each targeted community. Adaptations will focus on both the model and the delivery of it. Data collection of the adaptation process will focus on documenting adaptations and team member's engagement and satisfaction with the process. SafeCare will be implemented in each community in two ways: standard implementation and task-shifted implementation. Standard implementation will be delivered by CBOs (n = 120), and task-shifted implementation will be delivered by community members (n = 120). All interventionists will be trained in a standard format, and will receive post-training support. Both implementation metrics and family outcomes will be assessed. Implementation metrics will include ongoing adaptations, delivery of services, fidelity, skill uptake by families, engagement/completion, and satisfaction with services. Family outcomes will include assessments at three time points (pre, post, and 6 months) of positive parenting, parent-child relationship, parenting stress, and child behavioral health. DISCUSSION: The need for adapting of evidence-based programs and delivery methods for specific populations continues to be an important research question in implementation science. The goal of this study is to better understand an adaptation process and delivery method for three unique populations. We hope the study will inform other efforts to deliver health intervention to refugee communities and ultimately improve refugee health.

Strengthening Culturally Competent Health Communication.

Vulnerable refugee communities are disproportionately affected by the ongoing COVID-19 pandemic; existing longstanding health inequity in these communities is exacerbated by ineffective risk communication practices about COVID-19. Culturally and linguistically appropriate health communication following health literacy guidelines is needed to dispel cultural myths, social stigma, misinformation, and disinformation. For refugee communities, the physical, mental, and social-related consequences of displacement further complicate understanding of risk communication practices grounded in a Western cultural ethos. We present a case study of Clarkston, Georgia, the "most diverse square mile in America," where half the population is foreign born and majority refugee. Supporting marginalized communities in times of risk will require a multipronged, systemic approach to health communication including: (1) creating a task force of local leaders and community members to deal with emergent issues; (2) expanding English-language education and support for refugees; (3) including refugee perspectives on risk, health, and wellness into risk communication messaging; (4) improving cultural competence and health literacy training for community leaders and healthcare providers; and (5) supporting community health workers. Finally, better prepared public health programs, including partnerships with trusted community organizations and leadership, can ensure that appropriate and supportive risk communication and health education and promotion are in place long before the next emergency.

The Relationship Between Refugee Health Status and Language, Literacy, and Time Spent in the United States.

BACKGROUND: There are 3 million refugees living in the United States today whose health and wellbeing may be diminished by not being able to understand and use health information. Little is known about these barriers to health in multiethnic refugee communities. OBJECTIVE: This present study examined (1) the relationship between English proficiency, health literacy, length of time in the US, and health status; and (2) differences in poor health status caused by limited English proficiency and low health literacy individually and in combination to better understand which barriers might be addressed by improving refugee health. METHODS: Refugees (N = 136) age 18 to 65 years were recruited using health clinics and refugee resettlement agencies. Survey questions included demographics, health status, health literacy, English language proficiency, social determinants of health, and barriers to getting health care. Interpreters were used as necessary. We used a cross-sectional study with purposeful sampling. KEY RESULTS: There is a high correlation (Pearson's r = 0.77) between health literacy and English proficiency; they were moderately correlated with health status (r = 0.40 and 0.37, respectively). Length of time in the US only modestly correlated with health status (r = 0.16). Health literacy and English proficiency taken individually were strong predictors of health status (health literacy odds ratio [OR] = 4.0; 95% confidence interval [1.6-9.9], English proficiency OR = 3.6, confidence interval [1.5-9.0]) but not significant. Their interaction, however, was significant and accounted for most of the effect (log odds for interaction = 1.67, OR = 5.1, p < .05). CONCLUSIONS: English proficiency and health literacy individually and in combination facilitate poor health and present health-related barriers for refugees. Length of time in the US for refugees may not correlate with health status despite studies that suggest a change in health over time for the larger immigrant population. [HLRP: Health Literacy Research and Practice. 2020;4(4):e230-e236.] PLAIN LANGUAGE SUMMARY: The combined effects of limited English proficiency and low health literacy can create significant barriers to good health outcomes in refugee populations. Length of time in the US for refugees may not correlate with health status despite studies that suggest a change in health over time for the larger immigrant population.