4/13/2015

John R. Kasich, Governor

Tracy J. Plouck, Director

SurendraBir Adhikari,Ph.D.MedSoc
OfficeofQuality,Planning&Research,OhioMHAS

Third Annual Diversity in Public Health Summit

Mental Health Care: the Impact in Diverse Populations.
Multicultural Public Health Student Association
the Ohio State University, College of Public Health.
April 11, 2015, Columbus, Ohio

As Project Director, I wanted to offer special thanks to all the respondents

who took their valuable time to share their personal stories for the study.
Thanks to Community Refugee & Immigration Services (CRIS)

Angie Plummer, JD, Executive Director, overall support

Kelly Yotebieng, MPH, Principal Co-Investigator/Administrator

Jhuma Acharya, MA, Survey Lead/Community

Sarah Miller, MSW, LSW, Logistics

Jaclyn Kirsch, MSW Student Intern/OSU, Data Entry

All youth/adult interviewers recruited from the Bhutanese refugee

community.

4/13/2015

Who the Bhutanese refugees are?

Where the Bhutanese refugees came from before they
were resettled here?
What are some of the health issues surrounding
Bhutanese refugees?
Are the trauma experienced by the Bhutanese refugees
different than those experienced by refugees from Africa,
other nations in S-E Asia, Middle-East or East Europe?
If yes, what comes to mind?
3

1. GainabetterunderstandingofBhutaneserefugeesand
theirpre andpostmigrationmentalhealthstatusand
wellbeing.
2. Learnabouttheprevalenceofmentalhealthconditions,
PTSD,andsuicidalideationamongBhutaneserefugeesin
Ohio.
3. Identifytypesofinterventionsthatcouldbedevelopedto
addresstheunmetmentalhealthneedsoftheBhutanese
refugees.

4/13/2015

People of Nepali origin

living in Bhutan since
19th Century.
Due to Bhutanization
in early 90s, 1/6th of
the Bhutanese fled
Bhutan and resettled
in Nepal.
UNHCR 2013 report
estimated 108,000
Bhutanese refugees in
Nepali refugee camps.

BhutaneseRefugeeCamps/Nepal[Courtesy:CDC]
5

Instrument
SurveyinstrumentadaptedfromCDC2011surveyof
BhutaneseRefugeesinU.S.

Sample
200completesurveys.

Incentives
$15giftcardtoparticipantsforacompletedsurvey.

SurveyDesign
Mixed(Randomlypickedhousehold+RespondentDriven
Sampling[Snowball]);FacetoFace

SurveyInstrument
CDCsurvey(174questions);7added(income=1;general
health=3;andsmoking/tobaccouse=3)=Total181questions.
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4/13/2015

SampleDisparitiesacross:
Gender(n=198):Male,60%;Female,40%
Age:1824,11%;2534,14%;3544,23%;4554,24%;5564,18%;
65+,10%
MaritalStatus:Married,78%;Single,8.5%;Widowed,8%;
Divorced,4%
Education:None,56%;Grade12,9%;SomeCollege,7%
ReadEnglish:Yes,38%;WriteEnglish:Yes,37%
ReadNepali(native):Yes,54%;WriteNepali(native):Yes,54%
HouseholdIncome:80%have$15,000orlessperannumincome
Religion:Hindu,81%;Buddhist,11%;Christian,8%
Ethnicity/Caste:Bahun,42%;Chhetri,27%;Dalit,12%;Janjati,17%
RegularIncomeEarning:51%householdhaveregularincome
earning.
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Variable

Male, n (%)

Female, n (%)

Total N (%)

Generalhealth

(n=118)

(n=80)

(n=198)

Goodtoexcellent

76(65)

41(51)

117(100)

Fair

31(26)

20(25)

51(26)

Poor

11(9)

19(24)

30(15)

Genderdisparitiesinselfreportedgeneralhealthstatus:Of
thoseselfreportinggoodtoexcellenthealth,65%were
malesand35%werefemales.
Asforselfreportedpoorhealth,63%werefemale,followed
bymales(37%).
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4/13/2015

DrugUse/Alcohol:
CurrentAlcoholUse:Yes,20%(n=39)
Standarddrinksofalcoholdaily(n=39):One,34%;23,37%;45,
12%,>5,2.4%
Currentsmokers,25%(n=50):N=200
Smokelesstobaccouseeveryday,23%(n=44):N=192
Dualtobaccouse:About28%smokecigarettesandchewtobacco.
Figure1:DualTobaccoUseBehavior,BhutaneseRefugees,2014

CurrentSmokeralsoChewing
Tobacco(DualUser)

48

192

144

Total

139

118

CurentSmoker(No)

21

53

26

27

No.ofRespondents

CurrentSmoker(Yes)

CurrentSmokernotChewing
Tobacco

Total

SmokingandSmokelessTobaccoUse
9

[N=199]:13%weretoldbyadoctor/MHprofessionalthatthey
haveaMHcondition.
SomeoneinfamilydiagnosedwithMHcondition:Yes,21.4%.
[N=195]:30%(n=58)sufferfromanxiety symptoms.
[N=192]:26%(n=49)reporteddepression.
[N=200]:9%(n=17)haveposttraumaticstressdisordersymptoms.
[ThiscompareswithCDC2012nationalstudyfindingsof:anxiety
symptomsat19%;currentdepressivesymptoms,20%;andPTSD
symptoms,5%]
Source:Ao,T.,SuicideandsuicidalideationamongBhutaneserefugeesUnited
States,20092012.MMWR.2013;62(26):5536.

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4/13/2015

25Questions[HopkinsSystemChecklist25]:SelectExamples
Suddenlyscaredfornoreason(n=200):Quiteabit/extremely,
14.5%
Feelingfearful(n=199):Quiteabit/extremely,14.0%
Feelingtensedorkeyedup(n=199): Quiteabit/extremely,
16.1%
Difficultyfeelingasleep,stayingasleep(n=200):Quitea
bit/extremely,33%
Feelinghopelessnessaboutthefuture(n=199):Quitea
bit/extremely,23.1%
Thoughtsofendingoneslife(n=196):Quiteabit/extremely,
4.0%;alittle,4%
Feelingofworthlessness(n=200):Quiteabit/extremely,15.5%
[HSCL25has10statementstomeasureanxiety&15tomeasuredepressionstatements]
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6.2%(n=12)of195respondentswereseriouslythinkingabout
committingsuicide.
Amongthosewhorespondedtothequestionhowoftenthey
hadthesethoughtsinthepastmonth(n=10),4(40%)had
thoughtitacoupleoftimesandaboutonceamonth,with6
(60%)indicatingnoneinthepastmonth.
Ofthe9whorespondedtothequestionhowoldtheywere
thefirsttimetheyhadsuicidalideation,67%(n=6)were50
yearsofageandolderand33%(n=3)were49yearsoldand
younger.
Closeto63%(n=5)of8respondentshadseriouslythought
aboutcommittingsuicideinthepast12months.
Ofthe11whoansweredthequestioniftheyhaveever
attemptedsuicide,27%(n=3)saidyes.
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4/13/2015

Asforresponses(n=121)toifanyoneinthefamilyhasever
committedsuicide,21%(n=25)of121respondentssaidyes.
Thirtyeightpercent(n=43)of114respondentsknewwella
closefriendorneighborwhoevercommittedsuicide.
Of145respondentswhoreportedtheypersonallyknew
peoplewhohavetakentheirownlife,18%(n=26)knewat
leastonesuchperson;followedby26%(n=38)whoknewtwo
tofourpersons;and5%(n=7)knew5ormoreperson.
Figure2:KnewPeoplewhoTookOwnLifeinPast12Months
[N=145]
5%;7

None

26%,38

Knowatleastone
person
Know24persons
18%,26

51%,74

Know5ormore
persons

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12SocialSupportMeasures
SelectExamples:
TherearepeopleIcandependontohelpmeifIreallyneedit
(N=199)
AgreeorStronglyAgree:90.9%(n=181)
ThereisnooneIcanturntoforguidanceintimesofstress
(N=200)
AgreeorStronglyAgree:12.5%(n=25)
Havecloserelationshipsthatprovidemewithasenseof
emotionalsecurityandwellbeing(i.e.,happiness,health,
welfare)(N=199)
AgreeorStronglyAgree:88.9%(n=176)

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4/13/2015

PerceivedSocialSupportScale+.
88%(n=171)of194respondentsselfreportedmediumtohigh
levelsofsocialsupport.[thisisveryencouraging]
PerceivedSocialSupport,BhutaneseRefugees,Ohio,2014
12%,23

Low(039scores)
27%;53

61%;118

Medium(4049
scores)
High(5060
scores)
+Vonnahme,Lankau,Ao,Shetty,andCardozo.2014.FactorsAssociatedwith
SymptomsofDepressionamongBhutaneseRefugeesintheUnitedStates.Journal
ofImmigrantandMinorityHealth.Publishedonline:28October2014.
16

HarvardTraumaQuestionnaire(HTQ)
[N=200]:9%(n=17)wereexperiencingPTSDsymptoms.
[N=199]:extremelyexperiencedsymptomswere:
troublesleeping(13.1%;n=26),
difficultyconcentrating(9.5%;n=19),and
recurrentnightmares(8%;n=16).
16questionswereusedtoassesscurrentlyexperiencedPTSDsymptoms.The
prevalenceofPTSDsymptomwascomputedbyusingascoring algorithmcreatedby
theHarvardRefugeeTraumaGroupbasedonthePTSDcriteriafromtheDiagnostic
andStatisticalManualofMental Disorders,FourthEdition,TextRevision(DSMIVTR).
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4/13/2015

[N=200]:MostcommontraumaticeventsexperiencedinBhutan
were(thosewithhighresponses):
lackofnationalityorcitizenship(80%;n=160);
havingtofleesuddenly(72%;n=144);
lostpropertyorbelongings,includingseizures bythe
government(Bhutanese)(68%;n=136);and
religiousorculturalpersecution(beingforcedtospeakthe
nationallanguageorwearthenationaldress)(49%;n=98).
[HarvardTraumaQuestionnaire(HTQ)22questionswereusedtoanalyzetraumatic
eventsexperiencedinBhutanbeforebeingsettledinrefugeecampsofNepal.Read:
Mollica RF,CaspiYavin Y,Bollini P,TruongT,TorS,LavelleJ.TheHarvardTrauma
Questionnaire:validatingacrossculturalinstrumentformeasuringtorture,trauma,and
posttraumaticstressdisorderinIndochineserefugees.JNerv Ment Dis1992;180:1116.]
18

Responsessoughton16postmigrationissues:
Examples:mostextremelyexperiencedpostmigrationdifficulties:
littlehelpfromcharitiesorotheragencies(70%);
littlehelpfromgovernment(69.5%);and
languagebarriers(64.8%).
ThiscontraststoCDCstudy[N=404]whichreportedpredominant
difficultiesas:languagebarriers(62%);lackofchoiceoverfuture (46%);
andworriesaboutfamilybackhome (39%).
[Ao,T.,SuicideandsuicidalideationamongBhutaneserefugeesUnitedStates,20092012.
MMWR.2013;62(26):5536]

19

4/13/2015

Copingmethods(5components)#:
Withdrawal[N=196]:24%respondentsavoidedbeingwith
peopleingeneral.
Turningtofriendsorselffocusedproblemsolving [N=196]: 45%
wenttoafriendtohelpthemfeelbetterabouttheproblem.
Entertainment/leisureactivities[N=196]:8%watchedTV.
Religionand/orculture[N=196]:42%visitedatempleorchurch;
and38%(n=74)participatedinsingingHindudevotionalsongs.
Communitysupport[N=195]:48%talkedwithcommunity
leaders;and43%(n=84)joinedcommunitysupportgroups.
#Source:Vonnahme,Lankau,Ao,Shetty,andCardozo.
2014.FactorsAssociatedwithSymptomsofDepression
amongBhutaneseRefugeesintheUnitedStates.Journal
ofImmigrantandMinorityHealth.Publishedonline:28
October2014]
20

Closeto28%(n=53)of192respondentsaredualtobaccousers
(smokingandchewingtobacco)
[achallengefromtobaccocessationstandpoint;needunique
tobaccoquittinginterventions.]
That30%(n=58)sufferedanxietysymptoms;26%(49)reported
depression;and9%(17)of200respondentshavingPTSD
symptoms.
[Thisisreflectiveoftheunmetmentalhealthneedsamong
BhutaneserefugeesinCentralOhio]
Higherratesofattemptedsuicidesandsuicidalideation.
[criticalneedinthebehavioralhealthcommunitytostepup
culturallyandlinguisticallyappropriatesuicidecounselingand
awarenessprogramsintheBhutaneserefugeecommunity.]
21

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4/13/2015

Surveyfoundhighlevelsofexposuretotrauma.
[henceindicativeofahigherdegreeofunmetMHTx needs
whichperhapsmayhavebeenmaskedorunderreported]
62%selfreportedlanguagebarrier.
[mayhavesignificantlyimpactedtheirabilitytoseekand/or
utilizeavailableresourcesandconsequentlycontributedto
higherlevelsofcumulativestressanddepression.]
[Thesecallforappropriatecommunitybasedapproachestocreate
awarenessaboutservicesandresourcesavailabletotheBhutanese
refugeestofosteraneffective/positiveresettlement.]

PerceivedSocialSupportScaleanalysisrevealedthat88%(n=171)
reportedmediumtohighlevelsofsocialsupport.
[thisisveryencouraginggivenhighratesofanxiety
depressionandPTSDsymptoms]
22

Effortsanddialoguehavebeenbegunondevelopingculturally
appropriatementalhealthoutreachstrategiesandinformational
sessionsforBhutaneserefugeesinhealthandwellness.
Federalagencies(e.g.,ACF;SAMHSA)arebeingtappeduntofor
possibleimplementationofmentalhealthtrainingsinBhutanese
refugeecommunitiesinkeycitiesofOhio.
Othermeaningfuloutreachstrategiesarebeinginvestigatedto
addresstheunmetmentalhealthandPTSDtreatmentneeds
withintheBhutaneserefugeepopulation.
AdministrationforChildren&FamiliesfederalgranttoBhutanese
communitywouldhelptobuildcommunitycapacitiesandlaunch
aresourcecentertobenefitthecommunity.
23

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4/13/2015

Socialsupport
structureand
coping
mechanism

Religious
copingand
acculturation
Factorsassociated
withsymptomsof
depression

Socialtiesandmental
health

Trauma
stressand
PTSD
24

John R. Kasich, Governor

Tracy J. Plouck, Director

Surendra.adhikari@mha.ohio.gov
6147526462

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