Abstract
Background:
Poor mental health remains a significant source of morbidity and mortality in the Bhutanese refugee community. Mental Health First Aid (MHFA) is a promising intervention that has been used in other immigrant communities to prepare individuals to recognize and respond to mental health warning signs.
Methods:
This was a non-randomized program evaluation. Using pre- and post-training questionnaires developed for prior evaluations of MHFA, we examined the effectiveness of training offered with and without culturally-appropriate orientation to mental health terminology and concepts (N=458).
Results:
Pre- to post-training improvement in ability to recognize schizophrenia, ability to respond to schizophrenia and depression, and the overall mental health literacy was greater for Bhutanese refugees who attended orientation relative to other participants (P<0.05).
Discussion:
In scaling up MHFA training for other immigrant communities, we recommend developing and systematically evaluating culturally-appropriate orientation materials that introduce mental health vocabulary and contextualize mental health concepts.
Keywords: Bhutanese refugees, Cultural perspectives, Mental health terminology, Stigma
INTRODUCTION
Mental health is a pressing concern for the world’s 25.4 million refugees, people who have fled from their home countries due to a well-founded fear of persecution based on race, religion, nationality, political opinion, or membership in a particular social group [1]. A history of trauma and uncertainty about the future contribute to refugees’ heighted risk of depression, post-traumatic stress disorder [2], anxiety, and emotional distress [3]. For many refugees, poor mental health may persist following resettlement and may even be exacerbated by post-resettlement stressors [4–7]
Bhutanese refugees are a Nepali-speaking ethnic minority who were expelled from Bhutan in the early 1990s amidst political violence and then restricted to refugee camps in rural Nepal before third-country resettlement became an option in 2007. More than 96,000 Bhutanese refugees have resettled in the United States since 2008 [8]. Despite relative safety following resettlement, a large cross-sectional survey of randomly-selected Bhutanese refugee adults in seven U.S. cities found that 21% screened positive for depression, 19% for anxiety, and 4.5% for PTSD [2]. In 2012, the U.S. Centers for Disease Control and Prevention reported that the annual suicide rate in this community was (21.5/100,000) almost double the rate for the overall U.S. population at that time [9]. Victims included both men and women, ranged in age from 16 to 85 years old, and in many cases suicide was believed to be associated with integration, financial, and family difficulties [10,11].
Efforts to address mental health in the Bhutanese community have been multifaceted. Refugee-run nonprofit organizations have sought to leverage resources within the Bhutanese community—including cultural norms that value mutual support and assistance—to help vulnerable community members resolve integration-related challenges [12]. The federal Office of Refugee Resettlement (ORR) has collaborated with Bhutanese community leaders to develop culturally-appropriate suicide prevention video messages [13] and to offer Mental Health First Aid (MHFA) training.
MHFA teaches participants to recognize and respond to mental health warning signs and symptoms in themselves or their fellow community members. It has had promising results with Vietnamese and Chinese immigrant communities in Australia [14,15]. The 8-hour course introduces risk factors, warning signs, and symptoms of various mental illnesses (depression, anxiety, trauma, psychosis, substance use disorders, self-injury and suicidal behaviors). It examines the impact of mental illness on a person’s life and reviews common treatments [14]. Participants learn a five-step action plan, which uses the acronym ALGEE, to help people who present with signs and symptoms of mental illness or are in crisis: (1) Assess the risk of suicide or harm, (2) Listen nonjudgmentally, (3) Give reassurance and information, (4) Encourage appropriate professional help, and (5) Encourage self-help and other support strategies [14,15]. MHFA training methods include didactic presentations, small group activities, and role-playing, e.g., enacting the MHFA action plan with someone experiencing a panic attack.
A prior evaluation of conventional MHFA training presented in English for 58 Bhutanese refugees found moderate improvement in the recognition of symptoms of depression, improvement in applying ALGEE to assist a depressed community member, and increased mental health literacy. However, there was no change in negative, stigmatizing beliefs about people with mental illness, and this evaluation was limited to a small, predominantly male sample [16]. The current program evaluation builds upon this work by examining and comparing the effectiveness of bilingual (English/Nepali) MHFA training offered with and without a culturally-appropriate orientation to mental health terminology and concepts used in conventional approaches to mental health care in the United States.
METHODS
The MHFA trainings included in this non-randomized evaluation were conducted in 17 cities in eight states from May 7, 2016, through June 22, 2018. Because our goal was to improve program effectiveness for the Bhutanese refugee community and inform ongoing program planning rather than contribute to generalized knowledge, this project was found to be a program evaluation rather than human subjects research by staff in the Human Research Protection Office at the University of Pittsburgh.
The same pair of bilingual, bicultural Bhutanese MHFA trainers, who were former refugees themselves, led each training using an 8-hour standardized MHFA curriculum offered in a mix of English and Nepali. As described in the Introduction, the curriculum included group exercises, videos, and role-playing to recognize and respond to warning signs and symptoms of mental distress.
A 40-minute, Nepali-language orientation had been developed by the Bhutanese MHFA trainers (and co-authors), who believed that culturally-informed orientation would enhance the effectiveness of the standard MHFA curriculum for this population. The orientation included four components described in detail in the Appendix: “Stories of Hope from Bhutanese Refugees,” mental health terminology, discussion of migration-related social pressures associated with increased suicide risk, and discussion of two case vignettes in which MHFA-trained Bhutanese community leaders intervene to help an individual experiencing a mental health crisis. Mental health terminology was included because many English-language terms (e.g., “schizophrenia”) do not have a direct translation in Nepali, so the trainers felt that establishing a shared vocabulary was important. Orientation training methods included didactic presentations and small group discussions in English and Nepali.
Participants
In each city, local Bhutanese community leaders were asked to invite other Bhutanese adults (≥18 years), especially community leaders and those associated with social service, health care, or community volunteer experience, to participate in MHFA training. Outreach modalities included fliers, emails, phone calls, and announcements at community gatherings. Any interested adult in the Bhutanese refugee community was eligible to participate. We do not have information about those who opted out.
Local Bhutanese community leaders were also asked to invite approximately half of the registered trainees to participate in the Nepali-language orientation offered in the morning prior to each MHFA training (Figure 1). Thus, the individuals participating in the orientation were an opportunistic sample of community members who were easy to contact—generally friends, relatives, or acquaintances of local Bhutanese community leaders—or who lived near the training venue. Those who were not invited to the orientation or who opted not to participate were simply given breakfast at the training venue.
Fig. 1.
Description of the analytic sample: Bhutanese participating in MHFA.
*One participant was excluded from the analysis due to missing information
Survey Instruments
MHFA training participants were invited by the local organizers to complete brief, anonymous, self-administered, pre- and post-training questionnaires offered in both English and Nepali. The trainers informed participants verbally and in writing that completing the questionnaires was voluntary and information would remain confidential and be used to calculate summary statistics. Participant identification numbers linked pre- and post-responses but were not linked back to any personal identifiers. Pre- and post-training questionnaires were adapted from an instrument originally developed for MHFA evaluations in Australia [17,18] and translated by a team of three bilingual Bhutanese former refugees (including two of the authors) using a group consensus process.
In addition to capturing sociodemographic characteristics (pre-test only), the questionnaires assessed participants’ recognition of mental health symptoms, mental health first aid response, self-reported confidence helping someone with mental health symptoms, attitudes towards people with mental illness (stigma), and mental health literacy.
Each questionnaire was scored by a trained team member who was blinded to whether the questionnaire had been administered before or after MHFA training and whether the respondent had or had not participated in orientation.
To assess mental health symptom recognition, participants were asked to read two case vignettes—one about depression and the other about schizophrenia—developed for prior MHFA evaluations and then adapted to better reflect Bhutanese refugee experiences in the United States (Table 1). After reading each case vignette, respondents were asked the following open-ended question, “What, if anything, do you think is wrong with [Rukmini/Karma]?” with responses scored 0 (incorrect) or 1 (correct).
Table 1.
Culturally-adapted case vignettes in MHFA training
| A-1. Original Version Jenny is a 15 year old who has been feeling unusually sad and miserable for the last few weeks. She is tired all the time and has trouble sleeping at night. Jenny doesn’t feel like eating and has lost weight. She can’t keep her mind on her studies and her marks have dropped. She puts off making any decisions and even day to day tasks seem too much for her. Her parents and friends are very concerned about her. Jenny feels she will never be happy again and believes her family would be better off without her. She has been so desperate, she has been thinking of ways to end her life |
| A2. Modified version, changes highlighted in bold Rukmini is a 22 year old who has been feeling unusually sad and miserable for the last few weeks. She is tired all the time and has trouble sleeping at night. Rukmini doesn’t feel like eating and has lost weight. She can’t keep her mind on her work and her monthly income dropped. She puts off making any decisions and even day to day tasks seem too much for her. Her husband, parents, and friends are very concerned about her. Rukmini feels she will never be happy again and believes her family would be better off without her. She has been so desperate, she has been thinking of ways to end her life |
| B1. Original Version John is a 15 year old who lives at home with his parents. He has been attending school irregularly over the past year and has recently stopped attending altogether. Over the past 6 months he has stopped seeing his friends and begun locking himself in his bedroom and refusing to eat with the family or to have a bath. His parents also hear him walking about in his bedroom at night while they are in bed. Even though they know he is alone, they have heard him shouting and arguing as if someone else is there. When they try to encourage him to do more things, he whispers that he won’t leave home because he is being spied upon by the neighbor. They realize he is not taking drugs because he never sees anyone or goes anywhere |
| B2. Modified version, changes highlighted in bold Karma is a 25 year old who lives at home with his parents. He has been attending community college irregularly over the past year and has recently stopped attending altogether. Over the past 6 months he has stopped seeing his friends and begun locking himself in his bedroom and refusing to eat with the family or to have a bath. His parents also hear him walking about in his bedroom at night while they are in bed. Even though they know he is alone, they have heard him shouting and arguing as if someone else is there. When they try to encourage him to do more things, he whispers that he won’t leave home because he is being spied upon by the neighbor. They realize he is not taking drugs because he never sees anyone or goes anywhere |
To assess their mental health first aid response, participants were asked the following open-ended question after each case vignette: “Imagine [Rukmini/Karma] is a person you know. You want to help her/him. What should you do?” Written responses were evaluated for inclusion of each of the five potential ALGEE actions. Each ALGEE action was scored 0 if there was no mention or inadequate response, 1 if there was a superficial response, and 2 if specific details were provided for a maximum score of 10. Respondents were also asked to rate their confidence in helping the person featured in each case vignette (1 = “not at all” to 5 = “extremely”).
To measure personal stigma, meaning the degree to which the survey respondent holds negative beliefs about individuals with mental illness, respondents were asked to rate seven statements following each case vignette using a five-point Likert scale (1 = “strongly agree” to 5 = “strongly disagree”). Scores were summed such that higher scores reflect less stigmatizing attitudes.
Overall mental health literacy was assessed using a 21-item instrument developed for prior MHFA evaluations. Each of the close-ended mental health literacy questions had three possible answers: “Agree,” “Disagree,” and “Don’t Know.” Each item received a score of 1 if correct; otherwise, the score was 0. Higher scores reflect mental health knowledge concordant with those of mental health professionals.
Statistical analyses
We described sociodemographic characteristics for all participants and then compared characteristics of those who attended the orientation and those who did not, applying chi-square tests for categorical variables and t-tests for continuous variables. To measure the effect of the orientation, we compared the average pre- to post-training change in each outcome measure for respondents who attended the orientation to the average pre- to post-training change for respondents who did not attend orientation. Next, we measured the interaction effect between attending orientation and a time dummy for pre-/post-test, applying random effects linear regression models for continuous outcomes and random effects logistic regression models for categorical outcomes. The interaction term allowed us to model the difference between respondents who attended orientation and respondents who did not attend orientation with regards to changes in their pre- and post-training scores. Random effects models account for the correlation of different measures of the same individual over time. Stata/SE, version 14.2, was used for the analysis.
RESULTS
Social and demographic information for the 458 individuals with evaluable data is presented in Table 2. Just under half of the participants were women (44.8%). The majority had an associate degree or higher. Some participants had attended prior mental health training (11.6%) or had a family member who had experienced mental health problems (16.8%). Among all 458 individuals with evaluable data, 226 attended the orientation and 232 did not. The social and demographic characteristics of individuals who attended orientation were comparable to those who did not, with the exception of current immigration status. More individuals in the non-orientation group were still refugees (11.2% versus 4.9%), meaning they had not yet applied for permanent residency or naturalized citizenship.
Table 2.
Social and demographic characteristics of Bhutanese MHFA trainees, by participation in culturally-appropriate orientation to mental health terminology and concepts
| Total (N = 458) | Orientation (N = 226) | No orientation (N = 232) | p-value | |
|---|---|---|---|---|
| Gender, male (%) | 55.2 | 56.5 | 54.0 | 0.593 |
| Age in years, mean (SD) | 32.2 (8.9) | 31.9 (9.4) | 32.5 (8.5) | 0.467 |
| Educational attainment (%) | 0.103 | |||
| Grade 10 or less | 3.3 | 1.8 | 4.7 | |
| Grade 11–12 | 14.0 | 15.5 | 12.5 | |
| Associate’s degree | 35.7 | 38.9 | 32.8 | |
| Bachelor’s degree | 21.0 | 21.7 | 20.3 | |
| Master’s degree or PhD | 26.0 | 22.1 | 29.7 | |
| Current immigration status (%) | 0.064 | |||
| Refugee | 8.1 | 4.9 | 11.2 | |
| Permanent resident | 43.5 | 46.9 | 40.1 | |
| Naturalized US citizen | 44.3 | 44.3 | 45.3 | |
| Other, e.g., asylee | 3.5 | 4.0 | 3.0 | |
| Previous mental health training (%) | 11.6 | 10.6 | 12.5 | 0.497 |
| Personal experience with mental health problems (%) | 10.5 | 9.3 | 11.6 | 0.396 |
| Family experience with mental health problems (%) | 16.8 | 18.1 | 15.5 | 0.465 |
Table 3 shows baseline (pre-MHFA training) and post-training survey responses for individuals who attended the orientation and those who did not. The baseline survey responses were very similar for the orientation and non-orientation groups. For most outcomes, Bhutanese refugees who attended orientation had a greater change in pre- to post-training scores than refugees who did not attend orientation: They had greater changes in recognition of schizophrenia symptoms (72.4% versus 52.5%), recognition of depression symptoms (52.7% versus 47.6%), mental health first aid response for schizophrenia (4.8 vs. 3.4), mental health first aid response for depression (4.7 versus 3.5), and overall mental health literacy (6.8 versus 4.7). The exceptions were confidence helping someone with symptoms of depression (2.6 versus 2.7), confidence helping someone with symptoms of schizophrenia (2.6 versus 2.6), stigma towards people with schizophrenia (10.6 versus 9.6), and stigma towards people with depression (10.0 versus 9.3), for which there were minimal or no differences between the orientation and non-orientation groups.
Table 3.
Pre- and post-training survey results for Bhutanese MHFA trainees, by participation in culturally-appropriate orientation to mental health terminology and concepts
| Orientation |
No Orientation |
|||||
|---|---|---|---|---|---|---|
| Pre-test score | Post-test score | Change | Pre-test score | Post-test score | Change | |
| Schizophrenia | ||||||
| Correct recognition (%) | 7.2 | 79.6 | 72.4 | 6.2 | 58.7 | 52.5 |
| First aid response | 1.1 | 5.8 | 4.8 | 1.1 | 4.5 | 3.4 |
| Confidence helping | 1.6 | 4.2 | 2.6 | 1.7 | 4.2 | 2.6 |
| Stigma | 19.0 | 29.6 | 10.6 | 18.9 | 28.5 | 9.6 |
| Depression | ||||||
| Correct recognition (%) | 37.7 | 90.3 | 52.7 | 32.3 | 79.9 | 47.6 |
| First aid response | 1.2 | 5.9 | 4.7 | 1.2 | 4.6 | 3.5 |
| Confidence helping | 1.9 | 4.5 | 2.6 | 1.8 | 4.5 | 2.7 |
| Stigma | 19.6 | 29.6 | 10.0 | 19.0 | 28.3 | 9.3 |
| Mental health literacy | 6.3 | 13.2 | 6.8 | 5.9 | 10.6 | 4.7 |
First aid response (ALGEE) was scored 0–10 with higher scores corresponding to a more appropriate MHFA response to someone with symptoms of schizophrenia or depression. Confidence helping (self-reported) was scored 1–5, with 1 indicating “not at all” confident helping someone with symptoms of schizophrenia or depression and 5 indicating “extremely” confident. Stigma was scored 7–35 with higher scores corresponding to less negative and stigmatizing beliefs about individuals with symptoms of schizophrenia or depression. Mental health literacy was scored 0–21 with high scores indicating greater familiarly with conventional US mental health diagnoses, concepts, and norms.
Random effects linear regression models and random effects logistic regression models without and with adjustment for covariates are shown in Table 4. Compared to individuals who did not participate in orientation, the adjusted pre- to post-training change in correct recognition of schizophrenia was greater for those who attended orientation. There was no difference between groups with regards to the magnitude of improvement in recognition of depression. Compared to individuals who did not participate in orientation, the adjusted pre- to post-training change in appropriately responding to someone with symptoms of schizophrenia and depression were greater for those who attended orientation. There was no difference between groups with regards to changes in self-rated confidence helping someone with schizophrenia or depression or in stigmatizing beliefs. Finally, the adjusted, pre- to post-training improvement in mental health literacy was greater for orientation participants compared to non-orientation participants.
Table 4.
The impact of culturally-appropriate orientation before MHFA training: applying random effects linear regression and random effects logistic regression and models
| Crude model | Adjusted model | |||
|---|---|---|---|---|
|
| ||||
| Coefficient | S. E. | Coefficient | S.E. | |
| Schizophrenia | ||||
| First aid response (ALGEE) | 1.35*** | 0.31 | 1.34*** | 0.31 |
| Confidence helping | 0.03 | 0.11 | 0.03 | 0.11 |
| Stigma | 0.92 | 0.66 | 1.06 | 0.66 |
| Depression | ||||
| First aid response (ALGEE) | 1.27*** | 0.28 | 1.27*** | 0.28 |
| Confidence helping | − 0.12 | 0.11 | − 0.13 | 0.11 |
| Stigma | 0.75 | 0.65 | 0.71 | 0.66 |
| Mental health literacy | 2.11*** | 0.52 | 2.12*** | 0.53 |
| OR | 95% CI | OR | 95% CI | |
|
| ||||
| Schizophrenia | ||||
| Correct recognition | 2.68* | 0.98, 7.35 | 2.79** | 1.01, 7.69 |
| Depression | ||||
| Correct recognition | 2.18 | 0.93, 5.10 | 2.15 | 0.91, 5.03 |
Correction recognition of schizophrenia and depression in case vignettes was scored 0 (incorrect) or 1 (correct). First aid response (ALGEE) was scored 0–10 with higher scores corresponding to a more appropriate MHFA response to someone with symptoms of schizophrenia or depression. Confidence helping (self-reported) was scored 1–5, with 1 indicating “not at all” confident helping someone with symptoms of schizophrenia or depression and 5 indicating “extremely” confident. Stigma was scored 7–35 with higher scores corresponding to less negative and stigmatizing beliefs about individuals with symptoms of schizophrenia or depression. Mental health literacy was scored 0–21 with high scores indicating greater familiarly with conventional US mental health diagnoses, concepts, and norms
Covariates of the adjusted random effects models: time, gender, age, education, immigration status, previous training, personal experience of mental health issues, family members’ experience of mental health issues
S.E. standard error
Significance:
p < 0.05,
p < 0.01,
p < 0.001
DISCUSSION
This is the largest evaluation of MHFA training for Bhutanese refugees in the United States and the first evaluation of MFHA augmented by a culturally-appropriate orientation session. The findings support using culturally-appropriate orientation to enhance the immediate impact of MHFA training for this population.
Contrary to the results of a prior exploratory evaluation of English-language MHFA training for Bhutanese refugees, we also found that bilingual MHFA training improved (decreased) stigmatizing beliefs about individuals with symptoms of depression or schizophrenia both for those who participated the orientation session and those who did not. Multiple studies have identified stigma as one of the primary reasons refugees in the United States may not seek mental health care [10,16,19]. It also discourages community members from helping people with mental health problems [20]. Hence, interventions that reduce mental health-related stigma are believed to be of great importance for refugee communities.
Orientation establishes a shared, Nepali-language vocabulary for the mental health terminology used during MHFA training. Additionally, it situates mental health symptoms within the context of the community’s struggle to integrate following resettlement in the United States. Thus, orientation may have enhanced the effectiveness of MHFA training by ensuring that it was both comprehensible and relevant to adult learners from the Bhutanese community, thereby increasing engagement with the training material.
Orientation also had a greater impact on recognition of schizophrenia and attitudes towards someone with symptoms of schizophrenia relative to depression. This may reflect the fact that depression is more familiar to Bhutanese refugees [21], many of whom have undergone education about or screening for depression while overseas or after arrival in the United States [9,22]. In contrast, severe psychosis and schizophrenia are rarely discussed in the Bhutanese community [23], and individuals with these diagnoses would generally be hidden from people outside the family. Therefore, orientation may have been particularly helpful for establishing a shared vocabulary and understanding of current Western concepts of psychosis and schizophrenia.
Limitations
The primary limitations of this evaluation are non-randomized group assignment and lack of long-term follow up. Opportunistic group assignment (rather than randomization) was selected for pragmatic reasons due to resource limitations. However, this means that results may not be generalizable to the larger Bhutanese refugee community in the US, and the evaluation design cannot account for non-program influences. While we note that the orientation and non-orientation groups were relatively similar with regards to measured sociodemographic characteristics and baseline (pre-training) survey results, unmeasured differences between groups may confound our results. While this evaluation demonstrated meaningful improvement in training outcomes immediately after bilingual MHFA training, it does not speak to whether or not improvements were sustained over time. Finally, we note that unintended crossover occasionally occurred when participants belonging to the non-orientation group nonetheless joined orientation sessions. However, crossover would bias our results towards the null.
CONCLUSIONS
Our findings support the results from a prior evaluation suggesting that MHFA training is a promising intervention for improving knowledge and attitudes about mental health among Bhutanese refugee in the US [16]. Ideally, ongoing MHFA training for this community should be accompanied by culturally-appropriate orientation materials that introduce mental health vocabulary and contextualize mental health concepts. In sum, our study offers a rationale and guidance for scaling up MHFA training for Bhutanese refugees, especially when supplemented by culturally-tailored orientation.
Supplementary Material
ACKNOWLEDGMENTS
We thank Anthony Francis Jorm, and Tomas Matza for their guidance, Keshav Acharya and Asmita Gurung for the data entry, and Bhutanese community leaders in the US for outreach and implementation of the survey. Dr. Yun was supported by NIH grant 5K23HD082312. Mental Health First Aid training was supported by the Office of Refugee Resettlement and their local partners.
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