Assessment of Community-based Service Needs Matteucci 5
Assessment of Community-based Service Needs of
Elderly Bhutanese and Iraqi Refugees Living in Philadelphia
Nicole Matteucci
April 1, 2015
Master of Public Health
Thomas Jefferson University, School of Population Health
Dedication
This project is dedicated to the men and women I have worked with throughout the year who have welcomed me in to their homes and altered my perspective, my education, and my heart in a profound way.
I learned more from this process than I could have ever imagined. The refugees that are resettled in Philadelphia, and in particular the elderly individuals I interviewed, are extraordinarily brave people who have persevered through more adversity than most of us will ever see in our lifetimes. The strength, poise, and grace with which these individuals conduct themselves astound me. Despite how difficult their daily lives are, each of them greeted me with smiles and handshakes and took the time to openly share their stories with me. Every family thanked me for talking with them even though I was the one who was grateful to have been invited into their lives.
My conversations confirmed that elderly refugees are a unique group that is in need of more services catered to their specific needs. My hope is that the results of this study serve as a rationale for putting greater effort toward improving the quality of their lives. Creating the assessment tool, translating the forms, and transcribing and analyzing the responses were well worth the time and energy if in the future we can develop the types of programs that will benefit this community.
I am honored and humbled to have worked with such a special population. Without each of their voices this project would not have been possible.
شكرا & धन्यवाद.
Table of Contents
List of Tables and Figures…………………...…………………………………………………....4
Acknowledgements…………………...…………………………………………………...... 5
Abstract…………………...…………………………………………………...... 7
Introduction & Definition of the Problem…………………...…………………………………....8
Methods…………………...…………………………………………………...... 20
Results…………………...…………………………………………………...... 22
Discussion…………………...…………………………………………………...... 35
Recommendations…………………...…………………………………………………...... 48
Limitations…………………...…………………………………………………...... 56
References…………………...…………………………………………………...... 57
List of Tables
Table 1. Elderly Refugee Characteristics by Ethnicity…………………...………………...……22
Table 2. Elderly Refugee Health & Functional Status…………………...……………………....23
List of Figures
Figure 1. Interconnection of Barriers & Stressors of Elderly Refugees in Philadelphia………...35
Acknowledgements
Nancy Chernett is one of the biggest reasons that this project took place. Nancy co-taught my Cultural Humility and Competence course alongside Martha Romney in the spring of 2014, and this class changed my outlook in such important ways. Over the course of the semester I developed a more comprehensive understanding of the challenges facing particular populations in clinical settings and grasped the relevance of health literacy in the public health field. In February of that year Nancy directed me to Nationalities Service Center, where I fulfilled my clerkship requirement, and later volunteered to serve as the chairperson on my capstone committee. Together we created an assessment tool that I used during my interviews, and Nancy supported me in every way that I could have possibly needed. In addition to being an exceptionally knowledgeable and patient mentor, I have never met anyone more passionate about the geriatric population. Nancy’s enthusiasm and desire to improve the circumstances of elderly refugees in Philadelphia made her the perfect fit for my project. I am so grateful to have worked with a professor and chairperson who truly walked by my side through this entire experience—from my interview for the MPH program in 2013 to the presentation of my capstone project today.
Nationalities Service Center (NSC) is an amazing organization that has been serving immigrants and refugees in Philadelphia since 1921. I am perpetually blessed by my relationship with the staff and clients there. Gretchen Shanfeld, the health coordinator at NSC, served as the supervisor for my clerkship and preceptor for my capstone project. During the summer of 2014 she drew my attention to the gaps in services for elderly refugees and empowered me to pursue research on this topic. Without her guidance and support, none of my work would have been possible. Gretchen is exactly the kind of leader I hope to be, and I am incredibly thankful for the time and effort she has invested in me.
Jarett Beaudoin also played a special and absolutely vital role in this process as he served as the liaison between the clients at NSC and myself. Jarett recruited all of the participants that were included in our study, and he flawlessly scheduled every interview that took place. I am endlessly impressed by the way that he relates to his clients, and I am honored to have been able to work with him over the last 7 months.
Dr. Marc Altshuler, the Director of the Jefferson Center for Refugee Health, is another significant part of this team. He provided valuable insight into both groups during my clerkship and as I prepared to start this project. Dr. Altshuler is also just a remarkable physician who cares deeply about this population, and I am so grateful for the opportunity to work with him and his team throughout the year.
The interpreters were absolutely essential to my capstone. Each person who sat alongside me as I asked his or her mothers and fathers questions was patient, kind, and generous. Thank you for volunteering your time and making my dream for this study a reality.
A special thank you to Bethea Eichwald of PCA and Melissa Fogg of Philadelphia Refugee Mental Health Collaborative, who also contributed to this project through key informant interviews.
Abstract
The purpose of this study was to identify the areas of life that cause resettled elderly refugees to experience stress and determine the types of programs they need to improve their quality of life. A convenience sample of 6 Iraqi and 6 Bhutanese refugees age 60 and above, who had been resettled in the past 3 years, were interviewed in their homes in Philadelphia. The interviewer explored five domains: 1) demographics; 2) health and functional status; 3) social roles and activities; 4) sources of stress since immigrating to the U.S; and 5) knowledge of and access to programs for seniors. A priori themes were determined before the interviews took place, and thematic analysis was conducted following the interviews. Language barriers, difficulty managing health conditions, and mobility issues emerged as the most significant problems amongst participants. Investigators determined that these challenges lead to two larger, overarching issues, including chronic dependency on family members and social isolation. Based on participants’ responses, key informant interviews, and previous research, recommendations for resettlement agencies were generated and include community-based services, such as a senior center for regular programming, the specialization of ESL and health education classes, and the use of community health workers. Immediate next steps should involve the strengthening of partnerships between resettlement agencies and the aging services network in Philadelphia, cultural competence training for providers, and future research involving the caregivers of elderly refugees.
Introduction
According to the definition established during the 1951 Convention relating to the status of refugees, “a refugee is any person who owing to well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political pinion, is outside the country of his nationality and is unable, or owing to such fear, is unwilling to avail himself of the protection of that country; or who, not having a nationality and being outside the country of his former habitual residence as a result of such events, is unable or, owing to such fear, is unwilling to return to it” (United Nations High Commissioner for Refugees, 1967). In response to the issue of internal displacement the UNHCR Resettlement Handbook identifies resettlement as one of three durable solutions along with voluntary repatriation and local integration (2011). Resettlement is referred to as, “the transfer of refugees from the country in which they have sought asylum to another State that has agreed to admit them as refugees and to grant them permanent settlement and the opportunity for eventual citizenship.” In order to be granted resettlement an applicant must be considered to be a refugee by UNHCR with an absence of other long term options and meets one or more of the resettlement conditions, i.e. legal and protection needs, family reunification, women and girls at risk, survivors of torture, medical needs, children and adolescents at risk, and lack of a foreseeable solution. UNHCR reports, “In 2011, UNHCR submitted the files of some 92,000 refugees for consideration by resettlement countries. The main beneficiaries of UNHCR-facilitated resettlement programs were refugees from Iraq (20,000) and Bhutan (13,000)” (2014). The United States is currently the world’s top resettlement country and is currently accepting a high number of both Iraqi and Bhutanese refugees.
The US Department of State reports that 126,142 Iraqi refugees have registered with UNHCR since December 2012. Iraq has experienced political instability, economic stagnation, and violence following the 2003 U.S. invasion. In fact, it has been determined that an estimated 1.3 million Iraqi individuals remain internally displaced since the Samarra Mosque bombings in February of 2006 (2013). According to The Cultural Orientation Resource Center’s Backgrounder Iraq’s issues with security, breaches of human rights, and the inability to protect its citizens excludes the possibility of voluntary repatriation as a “humane solution”. Integration of displaced Iraqis within countries of asylum also has poor chance of being successful. (Ghareeb, Ranard, & Tutunji, 2008). Therefore, resettlement appears to be the only sustainable solution for a large portion of the affected population. Through the Department of Homeland Security and Resettlement Support Centers (RSCs) like the International Organization for Migration (IOM), the U.S. has accepted approximately 73,000 Iraqi refugees. Some resettlement challenges that are particular to Iraqi refugees include battles with Post Traumatic Stress Disorder, cultural differences, and frustration with the level of ESL classes that are offered to refugees, as well as “unrealistic expectations regarding housing, resettlement agency services, and employment opportunities” (Ghareeb, Ranard, & Tutunji, 2008).
Bhutanese refugees are another group that is being accepted to the U.S. in large numbers. According to an article produced by UNHCR, 99.4% of total submissions for resettlement came from Nepal in 2013, and the U.S. has accepted approximately 66,134 of the Bhutanese refugees that were referred (Gurung, 2013). Almost all of the Bhutanese refugees coming to the U.S. are ethnic Nepalis who have been living in seven refugee camps in Nepal since they were exiled from Bhutan in the early 1990s (Centers for Disease Control and Prevention, 2014). These individuals are descendents of Lhotsampas, a group that immigrated to Southern Bhutan in the late 1800s who were shunned by the Druk Buddhist majority that resided in the north. Under Bhutan’s Nationality Law of 1958, Lhotsampas maintained Bhutanese citizenship. However, as a result of a fear of the growing Lhotsampa population in the 1980s, Bhutan’s king and the ruling Druk majority introduced a policy known as Bhutanization that enforced adherence to Tibetan-based Bhutanese culture and stigmatized the ethnic Nepali community (Cultural Orientation Resource Center, 2007). During a census conducted in 1988 many ethnic Nepalis were labeled as illegal immigrants, and in the early 1990s violent anti-government protests erupted while thousands of ethnic Nepalis were forced to flee Bhutan (BBC News, 2014). Because Nepali government still denies refugees the freedom of movement and the right to work, neither local integration or repatriation can take place. Although many Bhutanese refugees express the desire to return to Bhutan, some welcome the opportunity to resettle in a new country. According to the Cultural Orientation Center, many of these refugees will struggle to learn English, as they have had little to no exposure to the language (2007). Finding and maintaining employment may also serve as a challenge for rural refugees who have not worked while living in the camps.
UNHRC notes that elderly refugees have increasingly become a population of major concern. In its policy on geriatric refugees, UNHCR states, “Three major problems facing most refugees, in particular older refugees, are: social disintegration, negative social selection and chronic dependency” (2000). Thus, elderly refugees have been identified as an exceptionally vulnerable group that requires more specific services in order to address the challenges of resettlement and aging. The literature supports further exploration of the specific needs of elderly refugees as well as the gaps in services experienced by this particular population.
In an article on migration and aging from the Hellenic Journal of Psychology, Hatzidimitriadou outlines the reasons elderly refugees are more likely to struggle during the migration process, why the needs of this population are often overlooked, and what actions need to be taken by policymakers to address the disparities experienced by this group. Hatzidimitriadou reports that in addition to the trauma refugees may experience while fleeing their country of origin and their transition during resettlement, elderly refugees also face physical and mental health problems, including mobility issues, management of chronic health conditions, and limited resources and support systems. Furthermore, those from lower income families experience even greater barriers to resources that create obstacles to achieving independence and good quality of life. In order to draw more recognition to the diverse needs of elderly refugees, Hatzidimitriadou advocates for a stronger definition of “old age” and better distinctions between migrant groups such as refugees and asylum seekers. She calls for recognition of the differing reasoning behind and experiences of migration, because not all refugees have fled for the same reasons nor do all refugees want to be resettled in a third country. Moreover, Hatzidimitriadou argues that a lack of interest in the population as well as policymakers’ assumptions that their needs have already been met through regular resettlement services has resulted in a gap in the welfare system and inadequate service provision. Elderly refugees are a special population with a specific set of needs that are not necessarily met by the standard programs or financial services provided to the general refugee population.
Hatzidimitriadou concludes, “Moreover after the initial settlement period, long-term integration of older refugees in a host community is a significant challenge and it depends heavily upon opportunities for them to maintain their status within family networks and to become active members of their cultural group and wider community” (2010, p. 2). Wrobel, Farrag, and Hymes (2009) also observe the challenge of adjusting to the environment of a different host culture in their study of acculturation stress and depression among 200 Arab-Americans over the age of 60. They report that the age of an immigrant or refugee may serve as an indicator for how well he or she adjusts and deals with acculturation, because younger subjects reported higher levels of acculturation and fulfillment in their lives compared to older Arab American immigrants. The concept of acculturation is defined as the psychological adjustment that occurs when two or more groups of different cultural backgrounds meet (Trimble, 2003). Thus, in addition to the changes in physical environment, political climate, technology, and personal identity and behavior, immigrants and refugees experience acculturation stress during the actual process of acculturation when they encounter new experiences, customs, and languages (Williams & Berry, 1991).