Abstract

INTRODUCTION

In 2013, the USA received 69,909 refugees identified by the UN Refugee Agency (UNHCR).[¹1 The UN Refugee Agency [Internet]. Geneva: The UN Refugee Agency; c2015. Office of the United Nations High Commissioner for Refugees: About Us; [cited 2015 Aug 4]; [about 2 screens]. Available from: http://www.unhcr.org/pages/49c3646c2.html
http://www.unhcr.org/pages/49c3646c2.htm... ,²2 Martin DC, Yankay JE. Annual Flow Report 2013: Refugees and Asylees [Internet]. Washington, D.C.: U.S. Department of Homeland Security Office of Immigration Statistics; 2013 [cited 2015 Feb 14]. Available from: http://www.dhs.gov/sites/default/files/publications/ois_rfa_fr_2013.pdf
http://www.dhs.gov/sites/default/files/p... ] The top countries of origin listed in decreasing frequency were: Iraq (27.9%), Myanmar (formerly known as Burma, 23.3%), Bhutan (13.1%) and Somalia (10.9%). [²2 Martin DC, Yankay JE. Annual Flow Report 2013: Refugees and Asylees [Internet]. Washington, D.C.: U.S. Department of Homeland Security Office of Immigration Statistics; 2013 [cited 2015 Feb 14]. Available from: http://www.dhs.gov/sites/default/files/publications/ois_rfa_fr_2013.pdf
http://www.dhs.gov/sites/default/files/p... ] In 2012, North Carolina ranked in the top ten US states receiving refugees.[³3 Martin DC, Yankay JE. Annual Flow Report 2012 Refugees and Asylees [Internet]. Washington, D.C.: U.S. Department of Homeland Security Office of Immigration Statistics; 2012 [cited 2014 Mar 17]. 8 p. Available from: http://www.dhs.gov/sites/default/files/publications/ois_rfa_fr_2012.pdf
http://www.dhs.gov/sites/default/files/p... ] Guilford County in central North Carolina is estimated to house over 60,000 refugees and immigrants, with more than 120 languages spoken and 140 countries of origin represented in the local school system.[⁴4 The Center for New North Carolinians [Internet]. North Carolina: University of North Carolina; c2015. Immigrant Demographics of Guilford County; 2014 [cited 2014 Mar 17]; [about 3 screens]. Available from: http://cnnc.uncg.edu/immigrant-demographics-of-guilford-county/
http://cnnc.uncg.edu/immigrant-demograph... ] This is of particular concern as newcomer populations arrive with a wide range of unique health and nutrition needs.

Factors influencing refugee health are complex and include conditions and risks from both the country of origin and those faced in the host country (i.e., camp settings) after fleeing their homeland prior to arrival in the USA.[⁵5 U.S. Department of Health and Human Resources [Internet]. Washington, D.C: U.S Department of Health and Human Resources; c2015. Refugee Health. Office of Refugee Resettlement, Office of the Administration of Children and Families. Refugee Health; 2014 [cited 2014 Mar 17]. Available from: http://www.acf.hhs.gov/pro grams/orr/programs/refugee-health
http://www.acf.hhs.gov/pro grams/orr/pro... ] Refugees often suffer from unmanaged acute and chronic conditions, micronutrient deficiencies and mental health issues.[⁵5 U.S. Department of Health and Human Resources [Internet]. Washington, D.C: U.S Department of Health and Human Resources; c2015. Refugee Health. Office of Refugee Resettlement, Office of the Administration of Children and Families. Refugee Health; 2014 [cited 2014 Mar 17]. Available from: http://www.acf.hhs.gov/pro grams/orr/programs/refugee-health
http://www.acf.hhs.gov/pro grams/orr/pro... ] Refugee resettlement in the USA remains steady (e.g., 69,909 in 2013, 58,179 in 2012, 56,384 in 2011), health care systems facing an increasingly diverse population composition with unique health needs.[²2 Martin DC, Yankay JE. Annual Flow Report 2013: Refugees and Asylees [Internet]. Washington, D.C.: U.S. Department of Homeland Security Office of Immigration Statistics; 2013 [cited 2015 Feb 14]. Available from: http://www.dhs.gov/sites/default/files/publications/ois_rfa_fr_2013.pdf
http://www.dhs.gov/sites/default/files/p... ] Despite continuing annual resettlement of new arrivals, research and resources for refugee health and nutrition remain limited. This is of particular importance because refugee populations are at high risk for health disparities. Improved health for these populations falls within the priority objectives of Healthy People 2020, which aims to eliminate health disparities and ensure health care access for all people.[⁶6 Healthy People.gov [Internet]. Washington, D.C.: Office of Disease Prevention and Health Promotion (US); c2014. Disparities; 2014 [cited 2014 Apr 15]; [about 3 screens]. Available from: http://www.healthypeople.gov/2020/about/Disparities About.aspx
http://www.healthypeople.gov/2020/about/... ]

Formidable barriers exist in design and implementation of research with refugee populations due to their unique experiences, vulnerability, and language and cultural differences.[⁷7 Ogilvie LD, Burgess-Pinto E, Caufield C. Challenges and approaches to newcomer health research. J Trans Cult Nurs. 2008 Jan;19(1):64-73.] Many major populations resettling in the USA remain understudied, despite their high numbers. The objective of this study was to examine the environmental, nutrition and health barriers and needs of refugees (defined by UNHCR) resettled in Guilford County, as perceived by individuals providing services to them.

METHODS

Setting

The study site, Guilford County, North Carolina, includes the cities of Greensboro and High Point. Guilford County received the highest number of refugees for the state in 2000. [⁴4 The Center for New North Carolinians [Internet]. North Carolina: University of North Carolina; c2015. Immigrant Demographics of Guilford County; 2014 [cited 2014 Mar 17]; [about 3 screens]. Available from: http://cnnc.uncg.edu/immigrant-demographics-of-guilford-county/
http://cnnc.uncg.edu/immigrant-demograph... ] In response to the influx of refugees, local community-based organizations were founded, including the Center for New North Carolinians, the New Arrivals Institute, and specialized educational programs.

Study design and development

A semistructured guide was developed specifically for this project, its content validated by five experts in the field of refugee health. The guide (Table 1) contained three main sections. The first focused on general information regarding participants’ experience with refugee groups (i.e., position description, length of experience, frequency of interaction with refugees). The second centered on service providers’ perceptions of refugees’ housing and environmental conditions, as well as barriers, concerns and needs related to health and nutrition. Question 12 in the second section was asked for each refugee group with which participants reported regular and frequent interactions. The third section included questions regarding community access and gatekeepers (information not analyzed in this article).

Sampling and recruitment

Most contacts were identified through an Internet search including: local resettlement agencies; community health clinics; Guilford County Health Department; Special Supplemental Food Program for Women, Infants and Children; schools; and community or faith-based groups providing refugee assistance. A website with an index of local refugee service providers was also utilized. Some contacts were made via snowball recruitment. Participants were service providers who had frequent (daily or weekly) and regular interactions (paid and/or volunteer) with local refugees, as defined by UNHCR.[¹1 The UN Refugee Agency [Internet]. Geneva: The UN Refugee Agency; c2015. Office of the United Nations High Commissioner for Refugees: About Us; [cited 2015 Aug 4]; [about 2 screens]. Available from: http://www.unhcr.org/pages/49c3646c2.html
http://www.unhcr.org/pages/49c3646c2.htm... ] They were contacted though public email and/or by telephone. Only one individual contacted refused to participate; the final number interviewed was 40.

Data collection

Between May and December 2013, interviews were conducted at sites preferred by participants, with most choosing their workplace or a public coffee shop. Recruitment continued until no new themes were reported (theme saturation). Interviews were recorded and transcribed verbatim.

Analysis

Participants were assigned an anonymous code (e.g., “CW1”) for each transcription. Deductive content analysis was used to interpret transcriptions as described by Elo and Kyngäs. [⁸8 Elo S, Kyngäs H. The qualitative content analysis process. J Adv Nurs. 2008 Apr;62(1):107-15.] Categories were created based on the focus of the interview guide including: environment, health (conditions, quality/access of care), and nutrition. Each transcript file was initially reviewed to identify quotes and stories within the category (i.e., health, nutrition or housing). Each category file was reviewed twice by the first author and sections related to the category were identified and summarized into subthemes. Subthemes were grouped into larger themes; for example reported incidences of type 2 diabetes and hypertension were subthemes within the theme of “health conditions.” Lastly, frequency of reporting of subthemes was classified: low (LF, 10–25% of participant responses), consistent (C, 25–60% of responses), and high (HF, >60% of responses).

Ethics

The study was approved by the University of North Carolina at Greensboro’s Institutional Review Board. Participants were provided an explanation of how their confidentiality and personal information would be protected in any future publication (e.g., any direct quotes would be listed with codes rather than names, employers or other descriptors) and written informed consent was obtained prior to all interviews.

RESULTS

Demographics

Participants (n = 40) included 28 women and 12 men from a range of positions. Most worked with refugee groups daily or weekly (29 and 10, respectively). Four participants were former refugees. Participants reported the most interaction and experiences with (in order of decreasing frequency) refugees from: Myanmar, Bhutan, various African countries (including those from the Sudan, Democratic Republic of the Congo, Central African Republic, Ethiopia and Eritrea) Iraq, Vietnam (including Montagnards) and Laos (Table 2).

Housing and environment

Several housing-related themes emerged, including: housing conditions and community descriptions; factors influencing initial resettlement location; and factors influencing movement from initial resettlement location (Table 3). Refugees’ housing conditions were consistently reported as suboptimal, due to poor physical conditions and/or location in low-income and/or dangerous areas.

Initial housing placement was reported to be influenced by economic constraints (lack of funding and housing options) and also preference to be close to their own cultural or ethnic group as a source of support.

Consistent factors that influenced refugees’ decision to move from their initial placement included options for improved housing (usually associated with economic improvement) or a decision to stay because of a strong sense of community and/or community benefits; e.g., English support and a tutoring center at one resettlement site. Those who did relocate tended to move to better housing, to be near other families or members of their community, or into public housing.

Nutrition

This theme was divided into five subthemes including: diet trends, access to religious/cultural foods, growing food/gardening, knowledge, and navigation skills for shopping for and purchasing food (e.g., getting to stores, finding products, figuring out how to pay) (Table 3). Dietary trends consistently observed included rapid dietary acculturation, with youth changing the fastest. Consumption of sugary or junk foods was reported with high frequency and some alcohol abuse was reported (less frequently).

Lack of variety or quality in the diet was reported. Household risks such as hoarding, poor budgeting skills and perceived food insecurity were consistently reported.

Despite these challenges, refugees were consistently perceived as having a preference for fresh foods, particularly produce, and were reported (less frequently) as having “healthy” diets.

Access to culturally-familiar foods was perceived to be good. US supermarkets were the least frequently used, with an international grocery store being the most consistently reported. Several barriers were reported to accessing religious or culturally-familiar foods including: cost, inability to use food stamps at a store (some stores were cash only), unavailability of specific products, and transportation constraints.

Refugee use of green space to grow fresh food(s) was consistently reported, with home gardens and community gardens the most frequently identified. Service providers reported that refugee groups possessed strong agricultural skills and knew the social and mental benefits of gardening, yet there was a need for more green space.

Many barriers to using green space were also consistently reported, including hours of operation for community gardens, transportation to community gardens, and limited housing support for using space in apartment complexes.

A variety of nutrition knowledge deficits and navigation barriers were reported; however, no specific concerns were consistently reported. Subthemes included concerns, misperceptions and lack of knowledge about infant formula, other food products (including unfamiliarity with “American foods”), food safety and labeling, and difficulty navigating the food environment in general.

Health

This theme was divided into three major subthemes, including observed conditions, barriers to accessing health care (e.g., lack of insurance, transportation barriers) and barriers to obtaining quality medical care (e.g., lack of translation services during visit) (Table 3). The most consistently reported medical conditions were chronic diseases such as hypertension, type 2 diabetes and weight problems (over or underweight). Dental concerns were also described (less often).

Mental health problems were also reported (but less frequently), with concerns about recent experiences with violence by some groups.

Barriers to accessing health care consistently included difficulty navigating the system as well as Medicaid challenges (e.g., short duration of initial coverage, only eight months). Other barriers included the cost of services and lack of insurance, transportation difficulties, and limited primary care options.

Lastly, culture and language were individually reported as major barriers to obtaining quality care.

Some also reported medical staff as a concern, but less frequently.

DISCUSSION

Despite strong evidence of the role of environmental factors on health, few studies have looked at the resettlement environment. In our study, we found that initial placement of refugees was constrained due to limited housing options and management inflexibility or disinterest in partnering with resettlement agencies.

Resettled locations were described as older apartment complexes in low-income areas with reports of refugee concerns about safety. Perception of an individual’s community as unsafe has been associated with reduced physical activity.[⁹9 McNeill LH, Wyrwich KW, Brownson RC, Clark EM, Kreuter MW. Individual, social environmental and physical environmental influences on physical activity among black and white adults: a structural equation analysis. Ann Behav Med. 2006 Feb;31(1):36-44.,¹⁰10 Evenson KR, Block R, Diez Roux AV, McGinn AP, Wen F, Rodriguez DA. Associations of adult physical activity with perceived safety and police-recorded crime: the Multi-ethnic Study of Atherosclerosis. Int J Behav Nutr Phys Act. 2012 Dec 17;9:146.] Low physical activity levels and increasing trends of overweight and chronic conditions among refugees have been reported in other studies. [¹¹11 Willis MS, Buck JS. From Sudan to Nebraska: Dinka and Nuer refugee diet dilemmas. J Nutr Educ Behavior. 2007 Sep-Oct;39(5):273-80. 13 Wilson A, Renhazo A. Intergenerational differences in acculturation experiences, food beliefs, and perceived health risks among refugees from the Horn of Africa in Melbourne, Australia. Public Health Nutr. 2015 Jan;18(1):176-88. 14 Rondinelli AJ, Morris MD, Rodwell TC, Moser KS, Paida P, Popper ST, et al. Under and overnutrition among refugees in San Diego County, California. J Immigr Minor Health. 2011 Feb;13(1):161-8. 16 Drummond PD, Mizan A, Burgoyne A, Wright B. Knowledge of cardiovascular risk factors in west African refugee women living in Western Australia. J Immigr Minor Health. 2011 Feb;13(1):140-8. 17 Mulasi-Pokhriyal U, Smith C, Franzen-Castle L. Investigating dietary acculturation and intake among US-born and Thailand/Laos-born Hmong-American children aged 9-18 years. Public Health Nutr. 2012 Jan;15(1):176-85. 18 Hrboticky N, Krondl M. Acculturation to Canadian Foods by Chinese immigrant boys: changes in the perceived flavor, health value and prestige of foods. Appetite. 1984 Jun;5(2):117-26. 19 Smith C, Franzen-Castle L. Dietary acculturation and body composition predict American Hmong children’s blood pressure. Am J Hum Biol. 2012 Sep-Oct;24(5):666-74.–²⁰20 Benbenek MM, Garwick AW. Enablers and barriers to dietary practices contributing to bone health among early adolescent Somali girls living in Minnesota. J Spec Pediatr Nurs. 2012 Jul;17(3):205-14.] Despite concerns expressed about safety and housing conditions, the support and strength of the communities were perceived as factors that reduced migration away from initial resettlement locations. This sense of community was also described as a facilitator in relocation patterns, with multiple families moving simultaneously to maintain community or to be closer to relatives or their own ethnic/national groups.

Providers reported barriers (e.g., transportation) to accessing and consuming both healthy and culturally-familiar foods. Resettlement guidelines place refugees near grocery stores and public transportation; however, these stores are often not appropriate for the cultural or religious food preferences and practices of many groups. Additionally, availability of public transportation in the study’s two major cities is limited, compared to larger metropolitan areas. Other barriers to traditional foods included limited availability or inability to use food stamps at some stores. Many groups were reported to prefer fresh produce or foods, or to grow their own food through the use of a personal or community gardens, but such options were limited due to transportation barriers and management restrictions on use of housing-complex green spaces. The high prevalence of food insecurity cited in other studies[²¹21 Hadley C, Patil CL, Nahayo D. Difficulty in the food environment and the experience of food insecurity among refugees resettled in the US. Ecol Food Nutr. 2010 Sep-Oct;49(5):390-407.–²⁵25 Peterman JN, Wilde PE, Silka L, Bermudez OI, Rogers BL. Food insecurity among Cambodian refugee women two decades post resettlement. J Immigr Minor Health. 2013 Apr;15(2):372-80.] and the preferences and skills to grow and eat fresh foods reported here may support the need for improvements to ensure access to green spaces for refugees resettled in US urban environments.

Increasing access to green spaces and fresh foods might reduce negative dietary trends reported across groups. The poor dietary habits (particularly sodas and junk food) observed by these service providers have also been observed in other studies. [¹²12 Vue W, Wolff C, Goto K. Hmong food helps us remember who we are: perspectives of food culture and health among Hmong women with young children. J Nutr Educ Behav. 2011 May-Jun;43(3):199-204.–¹⁵15 Franzen L, Smith C. Acculturation and environmental change impacts dietary habits among adult Hmong. Appetite. 2009 Feb;52(1):173-83.,²⁶26 Patil CL, Hadley C, Nahayo PD. Unpacking dietary acculturation among new Americans: results from formative research with African refugees. J Immigr Minor Health. 2009 Oct;11(5):342-58.–²⁸28 Peterman JN, Silka L, Bermudez OI, Wilde PE, Rogers BL. Acculturation, education, nutrition education and household composition are related to dietary practices among Cambodian refugee women in Lowell, MA. J Am Diet Assoc. 2011 Sep;111(9):1369-74.] Concerns regarding rapid dietary acculturation (particularly in youth), consistently reported here, have been observed in other studies.[¹²12 Vue W, Wolff C, Goto K. Hmong food helps us remember who we are: perspectives of food culture and health among Hmong women with young children. J Nutr Educ Behav. 2011 May-Jun;43(3):199-204.–¹⁵15 Franzen L, Smith C. Acculturation and environmental change impacts dietary habits among adult Hmong. Appetite. 2009 Feb;52(1):173-83.,²²22 Hadley C, Zodhiates A, Sellen DW. Acculturation, economics and food insecurity among refugees resettled in the USA: a case study of West African refugees. Public Health Nutr. 2007 Apr;10(4):405-12. 23 Hadley C, Sellen D. Food insecurity and child hunger among recently resettled Liberian refugees and asylum seekers: A pilot study. J Immigr Minor Health. 2006 Oct;8(4):369-75.,²⁶26 Patil CL, Hadley C, Nahayo PD. Unpacking dietary acculturation among new Americans: results from formative research with African refugees. J Immigr Minor Health. 2009 Oct;11(5):342-58. 27 Garnweidner LM, Terragni L, Pettersen KS, Mosdol A. Perceptions of the host country’s food culture among female immigrants from Africa and Asia: aspects relevant for cultural sensitivity in nutrition communication. J Nutr Educ Behav. 2012 Jul-Aug;44(4):335-42.–²⁸28 Peterman JN, Silka L, Bermudez OI, Wilde PE, Rogers BL. Acculturation, education, nutrition education and household composition are related to dietary practices among Cambodian refugee women in Lowell, MA. J Am Diet Assoc. 2011 Sep;111(9):1369-74.] Perceived food insecurity, difficulty budgeting (e.g., running out of food stamps) and hoarding (not spending allocated food-stamp money) were consistently reported as other risks. In addition, the reported high frequency of barriers to navigating the local food environment is particularly relevant, since poor navigation skills have been associated with increased risk of food insecurity in other studies.[²¹21 Hadley C, Patil CL, Nahayo D. Difficulty in the food environment and the experience of food insecurity among refugees resettled in the US. Ecol Food Nutr. 2010 Sep-Oct;49(5):390-407.–²⁴24 Dharod JM, Croom JE, Sady CG. Food insecurity: its relationship to dietary intake and body weight among Somali refugees women in the United States. J Nutr Educ Behavior. 2013 Jan-Feb;45(1):47-53.]

Reported environmental and dietary risks in this study may increase chronic disease risk and poor health outcomes and in fact overlap with reports—consistent across groups—of chronic conditions such as type 2 diabetes, hypertension and weight problems (over or under weight). Prevalence and concerns regarding mental health needs of refugees have been reported in several other studies in the USA and elsewhere.[²⁹29 Marshall GN, Schell TL, Elliott MN, Berthold SM, Chun CA. Mental health of Cambodian refugees 2 decades after resettlement in the United States. JAMA. 2005 Aug 3;294(5):571-9. 30 Tufan AE, Alkin M, Bosgelmez S. Post-traumatic stress disorder among asylum seekers and refugees in Istanbul may be predicted by torture and loss due to violence. Nord J Psychiatry. 2013 Jun;67(3):219-24. 31 Gerritsen AA, Bramsen I, Devillé W, van Willigen LH, Hovens JE, van der Ploeg HM. Physical and mental health of Afghan, Iranian and Somali asylum seekers and refugees living in the Netherlands. Soc Psychiatry Psychiatr Epidemiol. 2006 Jan;41(1):18-26.–³²32 Filippi MK, Faseru B, Baird M, Ndikum-Moffor F, Greiner KA, Daley CM. A Pilot study of health priorities of Somalis living in Kansas City: laying the groundwork for CBPR. J Immigr Minor Health. 2014 Apr;16(2):314-20.]

Added to these problems were many perceived barriers to accessing health services and obtaining quality health care. Difficulty navigating the system and Medicaid limitations (short duration of initial Medicaid coverage; limited access to medical providers accepting Medicaid) were consistently reported as major barriers. The reported lack of transportation, of insurance (and/or high cost of services) and of affordable primary care becomes even more poignant when coupled with the fact that the community clinic serving almost all refugee patients closed during the study period. Barriers to obtaining quality care consistently included barriers of language, culture and medical staff attitudes. Resources such as help lines were often perceived as ineffective because clients could not always make their requests in English or indicate the language needed.

Other studies have likewise reported diet-related chronic conditions; dental concerns; transportation, financial and insurance barriers; poor navigation skills (e.g., making appointments, filling prescriptions, paperwork); language, literacy and cultural barriers; and mental health disorders.[³²32 Filippi MK, Faseru B, Baird M, Ndikum-Moffor F, Greiner KA, Daley CM. A Pilot study of health priorities of Somalis living in Kansas City: laying the groundwork for CBPR. J Immigr Minor Health. 2014 Apr;16(2):314-20. 33 Renzaho AMN, Bilal P, Marks GC. Obesity, type 2 diabetes, and high blood pressure amongst recently arrived Sudanese refugees in Queensland, Australia. J Immigr Minor Health. 2014 Feb;16(1):86-94.–³⁴34 Morris MD, Popper ST, Rodwell TC, Brodine SK, Brouwer KC. Healthcare barriers of refugees post-resettlement. J Community Health. 2009 Dec;34(6):529-38.] The combination of barriers to health services and quality care, poor diet and limited navigation skills likely increases risk of poor health outcomes for resettled refugees. However, these communities have strengths, both cultural and in terms of social cohesion, on which future research and interventions may focus.

The study has limitations. Service provider perceptions are by definition subjective and open to bias, but many of the patterns reported here have been observed in other studies. This study sought to evaluate patterns associated with health and quality of life for a diverse local refugee community, so its results may not be applicable to some refugee groups. Lastly, Guilford County’s large immigrant and refugee population has led to greater availability of refugee- and immigrant-specific service organizations (e.g., Center for New North Carolinians, New Arrivals Institute) and marketplaces (e.g., grocery stores, clothing stores), in addition to cultural and religious support, resources that resettlement communities elsewhere in the USA may not have.

CONCLUSIONS

Service providers’ perceptions of environmental, nutritional and health issues and barriers for resettled refugees in Guilford County need to be corroborated by other methods, including direct observation and surveys of refugees themselves. Potential environmental risks and barriers (e.g., housing safety, lack of green space) and their effects on health (e.g., physical inactivity, chronic disease, mental health issues) should be further investigated, particularly in light of the limited power and language barriers faced by refugee groups. Despite reported concerns, many strengths (e.g., preference for fresh foods, skills and interest in growing food, sense of community/family) were also described and may offer promise of improvements in reducing food insecurity, poor dietary habits, physical inactivity and mental health problems.

Moreover, the potential mental health benefits of working outdoors and growing fresh, traditional foods and replication of many groups’ previous agrarian lifestyles should be further investigated. Development of targeted resources or training for resettled refugees could improve navigation of health services and the local food environment.

The strong sense of community reported within resettled communities suggests potential for training lay health educators to assist in meeting resettled refugees’ nutrition and health needs.

REFERENCES

Publication Dates

History