Socioeconomic Status Among Older Resettled Refugees in the United States: Older Bhutanese Refugees’ Diminished Returns on Cognitive Health

Abstract

Mild cognitive impairment, a precursor of Alzheimer’s disease, poses a significant public health challenge among older adults, particularly those who have experienced forced displacement. Studies indicate that socioeconomic increases can offer protective effects against cognitive impairment; however, the pattern of marginalization-related diminished returns (MDR) demonstrates that these benefits are not universal, with marginalized groups experiencing diminished health returns from socioeconomic advancements. This study examined the relationship between socioeconomic status (SES)—measured by poverty level and educational attainment—and self-reported cognitive difficulty (CD) in a nationally representative sample of older adult refugees, further nuanced by focusing on the moderating effect of Bhutanese ethnicity, chosen for their unique migration and resettlement experiences. Utilizing the 2021 Public Use Microdata Samples of the American Community Survey 5-year estimates and official refugee counts by the U.S. Department of Homeland Security, this study analyzed a sample of 5,666 resettled refugees. Binary logistic regression analysis showed that high school completion was associated with a 48% decrease in the odds of CD among refugees (AOR = 0.52, p < .001, 95% CI [0.39, 0.70]). Bhutanese ethnicity was also significantly associated with a more than threefold increase in odds of CD compared to other refugee groups (AOR = 3.52, p < .001, 95% CI [2.28, 5.44]). The interaction between Bhutanese ethnicity and poverty level suggested that higher income did not protect Bhutanese refugees from CD, providing evidence of the MDR pattern. Findings underscore the importance of nuanced analysis within marginalized groups to uncover specific social determinants of cognitive health.

Cognitive impairment emerges as a significant concern in social work and public health, especially among the older adult population (U.S. Department of Health and Human Services [HHS], 2021). Mild cognitive impairment (MCI), characterized by cognitive changes that are serious enough to be noticed yet do not impair daily activities, affects 12 to 18% of adults over 60 in the United States (Alzheimers Association [AA], 2022). This condition presents a considerable public health challenge due to its potential to progress to Alzheimer’s disease (AD), which has severe public health consequences (AA, 2023a). This progression underscores the importance of understanding the complex relationship between cognitive health and various social determinants of health. Recent trends indicate a sharp increase in AD-related mortality, positioning it as a leading cause of death (AA, 2023a; U.S. Centers for Disease Control & Prevention [CDC], n.d.a) and spotlighting the urgency to address cognitive health in the older adult population. This urgency is further magnified within marginalized populations, particularly among resettled refugees, who frequently report cognitive difficulties (Al-Rousan et al., 2023; Dallo et al., 2021; Kindratt et al., 2022). The association between trauma exposure and subsequent cognitive impairment, notably prevalent in forcibly displaced populations, underscores a critical area for intervention and support (Blackmore et al., 2020; Lynch & Lachman, 2020; Prieto et al., 2022, 2023).

Among these marginalized populations, Bhutanese refugees represent a unique demographic facing compounded challenges, including past trauma (Rinker & Khadka, 2018), language barriers (Gautam et al., 2018), acculturation stress (Parajuli et al., 2019), and lack of access to culturally sensitive healthcare services (Soukenik et al., 2022). This study draws upon the concept of marginalization-related diminished returns (MDR; Assari, 2017) to explore the nuanced interplay between socioeconomic status (SES), ethnicity, and cognitive health among older adults who entered the United States with refugee status. The MDR framework describes a public health pattern in which SES advantages yield smaller health returns for marginalized groups than their counterparts. This concept offers a framework to examine how structural inequities potentially impact health outcomes within marginalized groups such as refugees, who might not benefit equally from SES advancements due to migration experiences and systemic barriers.

Background

Cognitive impairment (CI) significantly impacts the older adult population in the United States (Hale et al., 2020), posing a significant public health challenge (U.S. Department of Health and Human Services [HHS], 2021). Estimates suggest that approximately 6 million older adults live with Alzheimer’s disease (AD; AA, 2023a), and an additional 5 to 7 million live with its precursor, mild cognitive impairment (MCI; AA, 2023b; National Institute on Aging [NIA], 2021). The mortality attributed to AD within the United States has seen a substantial escalation, with deaths more than doubling (145% increase) from 2010 to 2019, making it the seventh leading cause of death among adults (AA, 2023a). This trend underscores the critical nature of addressing cognitive health in older adults. The adverse effects of AD include diminished life quality and heightened risks of social isolation (AA, 2023a), vulnerability to abuse (AA, 2023c; Alon, 2021; NIA, 2023, medication errors (Smith et al., 2017), and premature death (AA, 2023a). These adverse outcomes extend to caregivers, who provided an estimated 18 billion hours of uncompensated care, valued at approximately $39.5 billion in 2022 (AA, 2023a). The projected costs associated with AD, which were anticipated to reach $345 billion in 2023 (AA, 2023a), emphasize the urgent need to address this significant public health concern (HHS, 2021), particularly among marginalized populations within the United States, such as resettled refugees.

Recent research demonstrates the link between trauma exposure and CI (Blackmore et al., 2020; Lynch & Lachman, 2020; Prieto et al., 2022, 2023). The empirical evidence indicates that populations who experience forced displacement, including refugees, encounter potentially traumatic events with a prevalence five times higher than observed in the general population (Blackmore et al., 2020). Refugees—individuals outside of their home country due to fear of persecution based on race, religion, nationality, social group membership, or political views, who cannot, or due to fear, choose not to seek protection from that country (United Nations Conference of Plenipotentiaries on the Status of Refugees and Stateless Persons, 1954)—frequently report cognitive difficulty (CD; Al-Rousan et al., 2023; Dallo et al., 2021; Kindratt et al., 2022). While the prevalence of CI in this population remains inadequately explored due to the lack of linguistically and culturally adapted diagnostic tools, the relationship between trauma exposure and subsequent CD is well-documented (A. Chen et al., 2019; Emdad et al., 2005; Johnsen et al., 2011; Shin et al., 2017). Recent research using nationally representative data indicates that foreign-born Arab American older adults from war-affected countries, a group previously identified with a 9.7% prevalence of CD (Dallo et al., 2021), have been shown to exhibit increased odds (41%) of reporting such challenges compared to U.S.-born Arab Americans (Al-Rousan et al., 2023). Specifically, older adults from Iraq were identified as having the highest odds of self-reporting CD among Arab American groups, possibly due to exposure to war and conflict and migration history.

Refugees From Bhutan

Amidst this backdrop of heightened vulnerability, resettled refugees from Bhutan demonstrate the complex interplay between forced displacement, trauma, and potential cognitive health challenges. Bhutanese refugees living in the United States are a linguistically and ethnically Nepali group identified as Lhotshampas (Rinker & Khadka, 2018). The Bhutanese government enacted the “One Nation, One Country” policy in the early 1990s to strip citizenship and rights from ethnically minoritized groups (R. Evans, 2010). This policy culminated in ethnic cleansing, genocide, and the forced displacement of the Lhotshampas population. After fleeing Bhutan, Bhutanese refugees lived in refugee camps in Nepal for approximately 20 years before agreements with the United Nations High Commissioner for Refugees (UNHCR) were reached, and third-country resettlement began in 2006 (United Nations High Commissioner for Refugees, & U.S. State Department, 2020).

Since then, the United States has resettled an estimated 90,000 individuals from Bhutan (UNHCR, 2020). Since arriving in the United States, Bhutanese refugees have faced many post-resettlement challenges. These challenges encompass language and structural barriers, a dearth of culturally sensitive healthcare and social service providers, and various cultural disparities hindering their successful integration into American society (Soukenik et al., 2022). These challenges, coupled with high levels of individual and collective trauma before migration, have led Bhutanese refugees to exhibit alarming rates of mental health concerns, including depression, anxiety, and substance use (Cochran & Geltman, 2012). Additionally, Bhutanese refugees have been found to have elevated rates of suicidal ideation, attempts, and completions, both when living in refugee camps and after resettlement in the United States (Adhikari et al., 2015; CDC, n.d.b; Meyerhoff et al., 2018).

Older adults who have endured forced displacement face additional burdens and challenges that may lead to more psychological distress compared to those who migrate at a younger age (Porter & Haslam, 2005; Tippens et al., 2023; Virgincar et al., 2016). An estimated 6.6% of Bhutanese refugees were considered older adults upon their arrival—a considerably higher number than other resettled groups (Gautam et al., 2018). The number of older adults resettled is often limited as many older refugees stay behind due to constrained choices related to poor health, limited mobility, or a desire to spend their final days in a culturally familiar place. Older Bhutanese adults often found themselves with no choice between staying or resettling, as they faced genocide in their homeland and the closure of camps in host countries (Human Rights Watch, 2007). Consequently, they were compelled to relocate to a third country for resettlement (Gautam et al., 2022). The older age of Bhutanese adults upon resettlement, coupled with protracted stays in refugee camps with poor health infrastructure, has led to increased health needs among the population. Older Bhutanese refugees express that while their lives in the United States are improved compared to their time in refugee camps, they encounter distinct challenges following resettlement (Gautam et al., 2022). These include structural barriers like language and worries about citizenship (Gautam et al., 2018) and cultural challenges unique to older Bhutanese. Im and Neff (2021) interviewed Bhutanese elders who reported feelings of “cultural collision” (p. 104), where the stark differences in cultural norms and values between Nepali culture and the United States led to feelings of culture loss. Additionally, participants reported “cultural bereavement” (p. 105), wherein they felt that younger generations were losing their Nepali and Hindu cultural practices. Other research has had similar findings, including those of older Bhutanese, who reported that community and strong social support are critical protective factors for well-being (Frounfelker et al., 2020; Lewis, 2020).

Conceptual Framework

Considering these profound challenges and the trauma-related health consequences faced by Bhutanese refugees, an exploration of the broader implications of marginalization, such as marginalization-related diminished returns (MDR), becomes critical in understanding disparities in health outcomes (Assari, 2017). The MDR framework represents a pattern in public health research, demonstrating an observed phenomenon wherein economic resources, socioeconomic status, and other forms of capital yield comparatively smaller physical, mental, and cognitive health benefits for individuals within marginalized groups than for those in majoritized populations. This disparity is observable across various dimensions of identity, including racialized groups (Assari, 2014, 2017, 2018a; Assari & Lankarani, 2015), ethnic groups (Assari, 2018b; Assari, Boyce, Bazargan, & Caldwell, 2020; Assari & Bazargan, 2019a), immigrants (Assari, 2020; Assari, Akhlaghipour, Boyce, Bazargan, & Caldwell, 2020; Assari, Cobb, Cuevas, & Bazargan, 2020; Assari, Perez, Johnson, Williams, et al., 2020) indigenous populations (Assari & Bazargan, 2019b); as well as sexual identities (Assari, 2019; Assari & Bazargan, 2019c, 2019d). The phenomenon underscores the complex interplay between social determinants of health and systemic inequities, necessitating a deeper examination of its implications across different population segments.

A study by Assari, Cobb, Cuevas, and Bazargan (2020) utilizing data from the 2015 National Health Interview Survey (NHIS), encompassed over 33,000 participants, both immigrant and U.S.-born adults, and revealed that while high school education correlated with reduced odds of poor self-rated health, this association was moderated by immigration status. Notably, the protective effects of education on health were diminished for immigrants relative to their U.S.-born counterparts. This interaction between educational attainment and immigration status was further explored in subsequent research, which consistently demonstrated reduced benefits of higher education on psychological distress, self-rated health, and prevalence of chronic diseases among immigrants (Assari, Perez, Johnson, Williams, et al., 2020).

Further investigation into the relationship between income levels and psychological well-being in middle to older adults identified a similar pattern of diminished returns among immigrants (Assari, 2020). Higher-income levels were less protective against mental health challenges for immigrants, indicating a significant interaction between economic status and immigration. Bakhtiari (2022) extended the study of MDRs in socioeconomic status on health outcomes to a European context, identifying similar patterns among adults under 65.

According to life course theory, experiencing prolonged stress throughout one’s life is associated with an increased risk of cognitive decline (Glymour & Manly, 2008). In the context of cognitive health, the MDR framework indicates that higher SES may offer smaller protective benefits for marginalized groups. For example, Assari, Akhlaghipour, Boyce, Bazargan, and Caldwell (2020) employed data from the 2016 to 2018 Adolescent Brain Cognition Development Study, which comprised over 4,000 participants aged nine to ten and found that higher parental human capital, as indicated by income level and educational attainment, was associated with improved task-based executive function. However, this protective effect was again less pronounced among immigrant adolescents than their U.S.-born peers.

These findings spotlight the relevance of the MDR framework for clarifying the cognitive health disparities among older refugees. By applying this framework to refugee studies and emphasizing its importance for within-group analyses, researchers can better understand the complex interplay of trauma, marginalization, and health disparities, thus highlighting an urgent need for targeted, culturally sensitive public health interventions tailored to the nuanced experiences of resettled refugees. It is imperative to emphasize the importance of not viewing immigrants and refugees as a monolithic group in such studies. Each refugee population brings unique experiences, cultures, and backgrounds that can significantly influence health outcomes and integration processes (Y. K. Kim et al., 2022; Kirsch et al., 2024). By acknowledging the diversity within these communities, we can better tailor interventions and support services to address different groups’ specific needs and challenges. This approach enriches our understanding of refugee resettlement and integration complexities and fosters a more inclusive and effective public health response.

Study Objectives

This study’s primary objective was to investigate the association between socioeconomic status (SES)—specifically, poverty level and educational attainment—and self-reported cognitive difficulty among older adults (50 years and older) who were born outside the United States and held refugee status upon entry. Additionally, this research examined the moderating effect of Bhutanese ethnicity on these associations. The decision to examine Bhutanese ethnicity, as opposed to other groups, was informed by the second author’s extensive practice experience working with refugees from Bhutan. This direct experience provided invaluable insights into this population’s unique historical, sociocultural, and resettlement challenges, which may exacerbate their vulnerabilities to cognitive difficulties. The focus on Bhutanese refugees is further justified by the literature, which highlights their unique vulnerabilities related to past trauma, language barriers, acculturation stress, and lack of access to culturally sensitive healthcare services, suggesting that they may be particularly susceptible to the diminished returns pattern within the refugee population.

This study is the first to our knowledge to examine the MDR pattern among refugees. We utilized a ratio leveraging official refugee counts (Department of Homeland Security, 2022) and nationally representative individual-level census data (U.S. Census Bureau, 2022) to identify individuals from Bhutan who entered the United States with refugee status to accomplish the study’s objective. The following research questions guided this research: (1) How does SES, measured by poverty level and educational attainment, associate with self-reported cognitive difficulty among foreign born older adults (aged 50 and older) who entered the United States with refugee status? (2) Does Bhutanese ethnicity moderate these relationships and provide evidence of marginalization-related diminished returns within the U.S. refugee population? We hypothesized that SES, through poverty level and educational attainment indicators, would be inversely related to self-rated cognitive difficulty among older adult refugees in the United States. Furthermore, we posited that Bhutanese ethnicity would moderate this relationship, evidencing a diminished returns effect where higher SES does not confer the same protective benefits against cognitive difficulty for Bhutanese refugees compared to other refugee groups. This analysis is critical for understanding how social determinants of health and integration challenges are associated with cognitive health outcomes among resettled refugee cohorts in the United States.

Method

Sample

We used individual-level data from the 2021 Public Use Microdata Samples (PUMS) of the American Community Survey (ACS) 5-year estimates (U.S. Census Bureau, 2022). The ACS is an ongoing survey conducted by the U.S. Census Bureau designed to collect data on individual- and household-level characteristics, including social, economic, housing, and demographic profiles. The PUMS datasets provide a raw subset of the ACS data to examine individual and household characteristics at a more granular level, which is beneficial for the detailed analysis of specific U.S. populations. The 5-year estimates are helpful in analyzing smaller populations as they provide robust and comprehensive data pooled over 5 years (e.g., 2017–2021). This strength allowed us to examine associations between SES and cognitive health among individuals who entered the United States with refugee status by leveraging official refugee counts from the Department of Homeland Security (DHS, 2023)—a method described below—to identify foreign-born individuals with refugee status in the census data. We limited our analysis to older adults (≥50 years) who were born outside the United States and had refugee status upon entry (N = 5,666).

Measures

Independent Variables

We evaluated two primary independent variables related to socioeconomic status: poverty level and educational attainment. We selected these variables given their relevance in the recent literature on marginalization-related diminished returns (MDRs) among immigrant populations (Assari, 2020; Assari, Akhlaghipour, Boyce, Bazargan, & Caldwell, 2020; Assari, Cobb, Cuevas, & Bazargan, 2020; Assari, Perez, Johnson, Williams, et al., 2020). We operationalized poverty as a dichotomous variable, categorizing respondents who reported living above or below 138% of the federal poverty line (≤138% FPL [reference], >138% FPL). We set the cut-off point at 138% of the FPL, aligning with the Medicaid expansion guidelines established under the Patient Protection and Affordable Care Act (2010) We operationalized educational attainment as a dichotomous variable, indicating whether respondents reported having a high school diploma or its equivalency. Those without a high school or equivalent degree served as the reference group.

Moderator

We utilized a refugee concentration ratio (RCR) to identify census respondents with refugee status and determine the study’s moderating variable, individuals from Bhutan with refugee status. The RCR estimates the proportion of foreign-born census respondents from a particular country and year who hold refugee status (W. Evans & Fitzgerald, 2017). This measure leverages individual-level data from the ACS (i.e., foreign-born status, country of birth, and year of U.S. entry) and official refugee arrival counts from the Yearbook of Immigration Statistics (DHS, 2023) by country and year of U.S. entry. We concentrated on the 2021 PUMS ACS 5-year estimates (U.S. Census Bureau, 2022) and refugee counts for fiscal years 1990 to 2021. This metric captured all census respondents who reported entering the United States between 1990 and 2021 with country-year pairings aligned with the DHS data, ensuring accuracy and relevance. The 1990 cutoff date was due to the limitations of the DHS data, which offers official refugee counts beginning in 1990.

The RCR formula requires 2 calculations. Immigrant-country-year (ICT) is derived from the ACS data and captures the number of immigrants (I) from a specific country (C) in a chosen year (T) after applying person weights. Refugee-country-year (RCT) is determined from the DHS refugee counts and defines the number of refugees (R) from a specific country (C) in a given year (T). The RCR is determined by dividing the refugee count from a specific country-year pairing by the total count of immigrants from that same country and year.

$$\mathrm{RCR}=\mathrm{RCT}/\mathrm{ICT}$$

Utilizing the RCR calculation, we created a variable to signify refugee status, which we designated when the calculated ratio reached or exceeded 90%, thus dichotomizing census respondents as refugees based on this threshold. The 90% threshold ensures that the country-year pairings are those in which refugees make up a significant majority of the foreign-born population and minimize the chance of including cases in which unrelated factors inflated the immigrant count. Table 1 provides the 23 countries identified in the 2021 PUMS ACS data with country-year pairings that met the 90% RCR threshold used in this analysis.

Table 1.

Refugees Represented in 2017–2021 ACS with Refugee Concentration Ratio ≥ 0.9.

Country (years)
Afghanistan (1990–1993; 2001; 2003; 2005; 2021)
Albania (1991–1992)
Azerbaijan (2003–2004)
Bhutan (2008–2019)
Bosnia-Herzegovina (1993–2002)
Burma (Myanmar) (2007–2021)
Congo, Democratic Republic (1993; 2000; 2010; 2013–2021)
Congo, Republic (2000–2001)
Czechoslovakia (1990)
Eritrea (2010–2011; 2017–2018; 2,020–2,021)
Ethiopia (1991; 1993)
Iraq (1993–1995; 2008–2011; 2013–2015; 2017; 2020–2021)
Laos (2004–2005)
Liberia (1993; 2004–2006; 2021)
Libya (1991)
Moldova (1999; 2003–2004; 2020)
Rwanda (2003–2004)
Somalia (1991–2001; 2003–2017)
Sudan (1994–1995; 1998–2001; 2003–2004; 2006; 2021)
Syria (2017; 2021)
Ukraine (2020–2021)
Vietnam (1994)
Yugoslavia (1999–2000; 2002–2003)

Dependent Variable

The study’s dependent variable was a dichotomous variable indicating self-reported cognitive difficulty. ACS respondents answered “yes” or “no” to the question, “Because of a physical, mental, or emotional problem, do you have difficulty remembering, concentrating, or making decisions” (U.S. Census Bureau, 2021, 2022). We coded respondents who answered “yes” as having a cognitive difficulty. Those who responded “no” served as the reference group.

Covariates

The study’s covariates included demographic and integration-related variables and health insurance receipt sourced from the ACS data. Demographic variables included age (years), sex (female, male [reference]), race (non-Hispanic white [reference], non-Hispanic Black, Asian, Hispanic/Latine, “other”), and marital status (married, divorced/separated/widowed/never married [reference]). Integration-related variables included length of time in the United States (years), U.S. citizenship status (citizen, non-citizen [reference]) and English proficiency. We operationalized English proficiency as a dichotomous variable based on the respondent’s self-reported ability to speak English. We categorized those who reported speaking English “not well” or “not at all” as having lower proficiency (reference group), while those who reported speaking English “well” or “very well” were categorized as having high proficiency. Health insurance receipt was a derived dichotomous variable in the PUMS ACS data that indicated whether a respondent reported having any form of health insurance. Those who reported not having health insurance served as the reference group.

Statistical Analyses

We calculated descriptive statistics (unweighted) to estimate frequency and percentage for dichotomous variables and mean, standard deviation, and minimum/maximum values for continuous variables. We conducted survey-weighted tabulations, specifying Pearson’s chi-square test for column proportions to evaluate differences in cognitive difficulty (dependent variable) across refugee sub-groups (Bhutanese, non-Bhutanese), as well as poverty level and educational attainment. This approach allowed us to account for the complex survey design, thereby providing more accurate estimates of the population parameters. We calculated Cramer’s V to measure the strength of the association between variables. We then used binary logistic regression to examine the association between poverty level and educational attainment (independent variables) with cognitive difficulty (dependent variable). This model controlled for all covariates and utilized person weights and survey and subpopulation commands to address the complex survey design of the PUMS ACS. We then introduced interaction terms between the independent variables and Bhutanese ethnicity to assess the moderating effect of being a refugee from Bhutan on the association between the independent variables and cognitive difficulty. Lastly, we stratified the data on the significant interaction terms and calculated predictive margins. We performed all statistical tests in Stata 18 (StataCorp, 2023).

Results

Descriptive Statistics

Table 2 provides descriptive statistics for all study variables for the total unweighted sample of refugees ages 50 and older (N = 5,666) and the refugee subgroups. Among the total sample, 12.30% (n = 697) self-reported cognitive difficulty. The average age in our sample was 61.27 years (SD = 9.59), with ages ranging from 50 to 95. There were slightly more females (n = 2,844, 50.19%) than males (n = 2,822, 49.81%), and the majority were married (n = 4,105, 72.45%). The largest segment of the refugee population was non-Hispanic white (n = 2,602, 45.92%), followed by Asian (n = 1,956, 34.52%), non-Hispanic Black (n = 902, 15.92%), and “other” (n = 196, 3.46%). Most refugees lived above 138% of the FPL (n = 4,129, 72.87%) and had some form of health insurance coverage (n = 5,223, 92.18%). Over half of the sample had completed high school (n = 3,633, 64.12%). The average time post-resettlement was 19.00 years (SD = 8.10 [0,31]). While most were U.S. citizens (n = 4,178, 73.74%), just over half reported English language proficiency (n = 2,986, 52.70%).

Table 2.

Unweighted Descriptive Statistics of Study Variables (N = 5,666).

Variable	Refugees	Sub-groups
		Bhutanese Refugees	Non-Bhutanese Refugees
	N = 5,666	n = 330	n = 5,336
Cognitive difficulty a
No (reference)	4,969 (87.70)	208 (63.03)	4,761 (89.22)
Yes	697 (12.30)	122 (36.97)	575 (10.78)
Poverty a
≤138% FPL	1,537 (27.13)	75 (22.73)	1,462 (27.40)
>138% FPL	4,129 (72.87)	255 (77.27)	3,874 (72.60)
Health insurance a
No (reference)	443 (7.92)	22 (6.67)	421 (7.89(
Yes	5,223 (92.18)	308 (93.33)	4,915 (92.11)
High school completion a
No (reference)	2,033 (35.88)	284 (86.06)	1,749 (32.78)
Yes	3,633 (64.12)	46 (13.94)	3,587 (67.22)
Age b	61.27 ± 9.59 [50,95]	62.66 ± 10.37 [50,94]	61.18 ± 9.53 [50,95]
Sex a
Male (reference)	2,822 (49.81)	163 (49.39)	2,659 (49.83)
Female	2,844 (50.19)	167 (50.61)	2,677 (50.17)
Race/ethnicity a
Non-Hispanic white	2,602 (45.92)	—	2,602 (50.62)
Non-Hispanic Black	902 (15.92)	—	902 (17.55)
Asian	1,956 (34.52)	330 (100.00)	1,626 (31.63)
Other	196 (3.46)	—	10 (0.19)
Married a
No (reference)	1,561 (27.55)	75 (22.73)	1,486 (27.85)
Yes	4,105 (72.45)	255 (77.27)	3,850 (72.15)
Years in U.S. b	19.00 ± 8.10 [0,31]	9.72 ± 2.36 [2,13]	19.58 ± 7.98 [0,31]
English language proficient a
No (reference)	2,680 (47.30)	279 (84.55)	2,401 (45.00)
Yes	2,986 (52.70)	51 (15.45)	2,935 (55.00)
U.S. citizenship a
No (reference)	1,488 (26.26)	150 (45.45)	1,338 (25.07)
Yes	4,178 (73.74)	180 (54.55)	3,998 (74.93)

^aFrequency (percentage).

^bMean ± standard deviation [min, max].

The analysis captured a small number of refugees from Bhutan. Among the Bhutanese refugees in our sample (n = 330), the average age was 62.66 years (SD = 10.37), ranging from 50 to 94. Just over half were female (n = 167, 50.61%), and 77.27% were married (n = 255). All Bhutanese refugees self-identified as Asian. Among them, most lived above 138% of the FPL (n = 255, 77.27%) and had some form of health insurance (n = 308, 93.33%). However, most had not completed high school (n = 284, 86.06%). The Bhutanese refugees in our sample had been in the United States for an average of 9.72 years (SD = 2.36 [2, 13]), and just over half were U.S. citizens (n = 180, 54.55%). The majority reported not being proficient in English (n = 279, 84.55%).

Results From Survey-Weighted Pearson Chi-square Tests

Survey-weighted Pearson chi-square analysis showed a significantly higher proportion of Bhutanese refugees who reported cognitive difficulty (19.08%) compared to their representation in the total refugee population (7.18%), indicating a disparity in cognitive outcomes (F(1, 19,642) = 100.51, p < .001). Cramer’s V calculated as 0.072 indicated a small effect size. Despite Bhutanese individuals making up a smaller portion of the refugee population, they were disproportionately represented above the poverty threshold (7.84%) relative to their overall population proportion (F(1, 19,642) = 11.99, p < .001), indicating that Bhutanese refugees are slightly overrepresented above the poverty line compared to non-Bhutanese refugees. The calculated Cramer’s V of 0.035 suggested a small effect size. Furthermore, we found a statistically significant difference in high school completion rates between Bhutanese and non-Bhutanese refugees (F(1, 19,642) = 177.56, p < .001), with a notably smaller proportion of Bhutanese refugees having completed high school (4.54%) relative to their population proportion. Cramer’s V of 0.13 indicated a moderate effect size.

Results of Binary Logistic Regression Analysis

Model 1 results revealed that high school completion was associated with a 48% decrease in the odds of cognitive difficulty among the sample population of refugees (AOR = 0.52, p < .001, 95% CI [0.39, 0.70]), while poverty level was not significant. As shown in Table 3, the increase in odds for cognitive difficulty was over three times as high for refugees from Bhutan compared to other refugees (AOR = 3.52, p < .001, 95% CI [2.28, 5.44]). We introduced interaction terms in Model 2. While the interaction with high school completion was not significant, we found disparate associations between Bhutanese refugees and poverty level. Specifically, interaction terms with poverty level corresponded to increased odds of cognitive difficulty (AOR = 3.30, p = .002, 95% CI [1.53, 7.11]), suggesting that higher income does not serve as a protective factor against cognitive difficulty for older refugees from Bhutan. While the main effect did not indicate a significant protective effect for living above the FPL among the total refugee population, living above the FPL for Bhutanese refugees gave evidence of diminished returns (Figure 1). Stratified analysis indicated that Bhutanese refugees living above the poverty line had a 4.06 increase in odds of cognitive difficulty compared to the total population (AOR = 4.06, p < .001, 95% CI [2.61, 6.34]. This interaction offered evidence for diminished returns among Bhutanese refugees living above the poverty level (Figure 1). Notably, Bhutanese refugees reached an equivalent level of cognitive risk to non-Bhutanese refugees when they had income at or below the federal poverty line.

Table 3.

Adjusted Odds Ratios from Models 1 and 2 for Cognitive Difficulty by Refugee Status: Main and Interaction Effects from Binary Logistic Regression (N = 5,666).

Variable	AOR	P	95% CI
			[LL, UL]
Model 1: Main effects
Bhutan ethnicity	3.52	<.001	[2.28, 5.44]
Age	1.05	<.001	[1.03, 1.06]
Sex	1.17	.269	[0.89, 1.54]
Race/ethnicity	0.76	.001	[0.65, 0.89]
Non-Hispanic Black	0.34	<.001	[0.21, 0.53]
Asian	0.40	<.001	[0.29, 0.54]
Other	1.76	.031	[1.05, 2.95]
Marital status	0.54	<.001	[0.41, 0.71]
Poverty	0.95	.705	[0.73, 1.23]
Health insurance	2.01	.014	[1.15, 3.51]
High school completion	0.52	<.001	[0.39, 0.70]
Years in U.S.	0.99	.239	[0.97, 1.01]
English proficiency	0.26	<.001	[0.20, 0.35]
U.S. citizenship	1.80	<.001	[1.31, 2.45]
Model 2: Interaction effects
Bhutanese ethnicity x poverty	3.30	.002	[1.53, 7.11]
High school completion	0.98	.974	[0.25, 3.86]

Figure 1.

Predictive probabilities of cognitive difficulty by refugee status and federal poverty level.

Discussion

This study explored the associations between socioeconomic status (SES)—specifically, poverty level and educational attainment—and self-reported cognitive difficulty (CD) among older adults (50 years and older) who were born outside the United States and held refugee status upon entry. Additionally, it examined the moderating role of Bhutanese ethnicity on these associations, informed by the marginalization-related diminished returns (MDR) framework. We hypothesized that SES factors would inversely relate to CD, with the exception that Bhutanese ethnicity would moderate this relationship, evidencing a diminished returns effect wherein higher SES does not confer the same protective benefits against CD for Bhutanese refugees as it does for other refugee groups. The subsequent findings, which revealed significant SES disparities and pronounced vulnerability to CD among the Bhutanese, potentially reflect the compounded impact of trauma and unique migration stressors. These observations align with the MDR framework, suggesting that the protective benefits of higher SES are not uniformly experienced across different marginalized groups (Bakhtiari, 2022; Im & Neff, 2021).

Our findings indicated a significant decrease (48%) in the odds of self-reported CD for refugees with a high school education or more, confirming our hypothesis that educational attainment would be inversely related to self-rated CD among older adult refugees in the United States. However, our hypotheses did not extend to the findings associated with income among the total population. Further, we found a significant increase (252%) in the odds of self-reported CD for Bhutanese refugees compared to other refugee groups. Specifically, 36.97% of the unweighted sample of Bhutanese refugees reported experiencing CD—a stark contrast to 10.78% observed in other refugee groups. The pronounced disparities in cognitive outcomes among Bhutanese refugees underscore a critical need for targeted interventions within this population. Despite the Bhutanese constituting only a small proportion of our study’s sample, they reported CD at a rate significantly higher (19.08%) than their proportion in the overall population (7.18%). The more than threefold increase highlights the unique challenges of older refugees from Bhutan and calls for a deeper understanding of how cultural factors interact with cognitive health among marginalized populations. This finding points to a critical gap in the literature on older Bhutanese refugees in understanding how to serve this understudied population, underscoring the importance of culturally sensitive approaches to cognitive healthcare provision and support.

Our results also indicated that Bhutanese refugees are disproportionately represented above the poverty threshold. This finding suggests that being above the poverty line does not uniformly confer expected protective benefits across different refugee groups. This finding highlights the observed significant interaction between Bhutanese ethnicity and poverty level, where Bhutanese refugees living above 138% of the federal poverty line had a marked increase (306%) in the odds of reporting CD. Interpreting these findings through the lens of the MDR framework, it becomes evident that the SES benefits that typically confer protective effects against CD do not uniformly apply across all refugee groups. Specifically, higher incomes for Bhutanese refugees do not appear to mitigate the risk of CD to the same extent that it does for other refugee populations. Despite income indicators that would generally suggest lower risk, the increased odds of CD for Bhutanese refugees underscore the complex interplay between socioeconomic factors, migration experiences, and health outcomes. Despite their high employment rates, refugees are among the most at-risk groups to experience income poverty and limited economic security mainly due to social exclusion and structural barriers in the United States (Naseh et al., 2023). Overcoming these systemic barriers and conforming to the capitalist definition of productivity and value, which is often measured by income, likely entails a considerable burden of stress for Bhutanese refugees. The MDR framework provides a critical perspective on how social determinants of health operate differently across various groups, revealing that the benefits of socioeconomic improvement are not universally experienced.

Acculturation stress, a form of stress experienced during the process of adapting to a new culture, as well as the pressure to conform to capitalist values by working hard and not using assistance to be desirable and live up to the “model minority” stereotype may play a pivotal role in the context of our findings (John et al., 2024; D. Kim, 2021). The efforts to assimilate and achieve upward mobility in the United States could impose substantial psychological and physiological costs akin to those documented in the literature on health disparities among Americans who identify as Black (Assari, 2018). Acculturation stress and/or the pressure of the “model minority” stereotype for Bhutanese refugees involves navigating complex cultural landscapes, learning a new language, and encountering unfamiliar social norms while working hard and being productive at any cost all of which demand considerable cognitive resources and psychological resilience (Hamilton et al., 2015; Im & Neff, 2021; Sriram, 2020). Bhutanese refugees may engage in effortful coping strategies (Sellers & Neighbors, 1999), similar to the concept of John Henryism (James, 1994), which involves a high level of determination to succeed despite chronic stress and discrimination. While such coping mechanisms may facilitate socioeconomic advancement, they can also result in significant health costs (Bennett et al., 2004; Mujahid et al., 2017; Sellers & Neighbors, 2008).

Frounfelker et al. (2020) highlighted cognitive reappraisal as a key strategy among older Bhutanese refugees who resettled in the United States. This coping strategy involves reinterpreting past traumas and stressors to fit into a new narrative that can be integrated with their current experience. Reframing is a powerful form of effortful coping that can affirm one’s collective identity and foster personal growth in adversity. However, the ability to reappraise situations positively is likely compromised when individuals face continuous stress without adequate support systems. Life course theory highlights the negative impacts of daily sustained stress on health, specifically cognitive health (R. Chen et al., 2020). Socioeconomic stability, often seen as a buffer against stress, may not suffice as a protective factor for the cognitive health of Bhutanese refugees. Their efforts to adjust to a new social context, strive for upward mobility despite structural barriers, and seek meaning in their resettlement experiences can exact a significant toll on cognitive functioning if not supported by culturally congruent social networks and resources.

The significantly increased odds of self-reported cognitive difficulty among Bhutanese refugees underscore the imperative for nuanced analysis within marginalized groups to uncover the specific social determinants driving health disparities. These findings also point to an urgent need for cognitive assessment tools that are both linguistically adapted and culturally tailored to specific refugee populations in the United States, including the Bhutanese community. Social workers, trained in culturally responsive assessment and strengths-based engagement, are well-positioned to lead or collaborate on the development and implementation of such tools. By centering the unique cultural and cognitive frameworks of the Bhutanese population, practitioners can help ensure that evaluations are accurate, meaningful, and aligned with community needs—laying the foundation for responsive and effective interventions.

These findings also highlight the need for integrated, culturally informed strategies across social work and public health to address the distinct challenges facing Bhutanese refugees. Social workers must play a central role in designing and delivering health promotion efforts and cognitive health interventions that not only address language and cultural barriers but also consider the cumulative impacts of daily stress, trauma, and systemic exclusion. The profession’s commitment to social justice and its community-based approach position social workers to advocate for and implement programs that build resilience and foster well-being.

There is a clear mandate to mobilize social support systems that buffer the stressors associated with acculturation, structural barriers, and the pursuit of upward mobility. Community-based programs—facilitated or supported by social workers—that promote social connections within the Bhutanese population and with the broader community can serve as critical sources of emotional and instrumental support. Peer support networks, culturally anchored community-building activities, and interventions that strengthen family cohesion (Betancourt et al., 2020) offer promising avenues to enhance well-being and potentially protect against cognitive decline.

Finally, our study reinforces the need for policy frameworks that extend beyond resource provision to address systemic barriers and reduce the cognitive and emotional toll of integration. Social workers, as policy advocates and systems navigators, are essential in shaping and implementing policies that promote access to culturally competent healthcare, mental health services, and housing and community supports. These efforts must be informed by an understanding of the cultural and linguistic needs of refugee populations and grounded in a commitment to equity and inclusion.

Limitations

The reliance on cross-sectional data from the PUMS ACS constrains our ability to discern causal relationships between socioeconomic indicators and cognitive health outcomes in refugee populations. Additionally, our method of identifying refugee status through official refugee counts may introduce inaccuracies due to the limitations of using proxy measures. The study’s dependence on self-report measures also raises the potential for response bias, possibly affecting the reliability of our findings. However, there is evidence that perceived cognitive difficulty can predict Alzheimer’s disease and related dementias (Verdelho et al., 2011). Furthermore, the use of a single self-report question to assess cognitive difficulty may not capture the full complexity and range of cognitive impairments experienced by older refugees, highlighting the need for more comprehensive and validated cognitive assessment tools in future studies. Moreover, compared to the larger refugee population, the relatively small sample size of Bhutanese refugees might not fully represent the diverse experiences within this group, as indicated by the wide confidence intervals in our analysis. These limitations collectively highlight the need for longitudinal studies that incorporate variables directly related to refugee status and cognitive assessment to capture the complexities of the refugee experience and its impact on cognitive health outcomes.

Conclusion

This study revealed the increased odds of cognitive difficulty among older Bhutanese refugees, highlighting a critical gap in the protective effects of income level that is particularly pronounced in this population. Through the lens of the marginalization-related diminished returns (MDR) framework, our findings underscore the nuanced ways in which structural and systemic barriers—often perpetuated through social exclusion, limited access to resources, and chronic stress—diminish the health returns of socioeconomic advancements for marginalized groups, including refugees. These findings are especially relevant to the social work profession, which is uniquely positioned to address the intersecting impacts of trauma, aging, and resettlement on cognitive health. The disproportionate prevalence of perceived cognitive difficulty among Bhutanese refugees highlights the urgent need for culturally and linguistically responsive cognitive assessment tools. Social workers, particularly those working in aging services, refugee resettlement, and community health, have a vital role in advocating for and implementing assessments and interventions that reflect the lived experiences and cognitive frameworks of older Bhutanese adults. Addressing these disparities requires a coordinated approach across public health, social work, and policy sectors—grounded in cultural humility and community engagement. Our study reinforces the utility of the MDR framework in uncovering within-group differences among refugee populations, challenging the often-homogenous treatment of those born outside the United States. By recognizing these nuanced disparities, social work researchers and practitioners can contribute to more equitable, person-centered care and system-level reforms that better meet the needs of diverse aging refugee populations.