The Role of Culture in Shaping Health Perceptions and Behaviors of Resettled Karen Refugees

Abstract

Introduction:

While the many health vulnerabilities and challenges experienced by refugees have been previously documented, few studies have addressed the strengths-focused response strategies that women refugees, in particular, engage to navigate health systems and experiences associated with displacement. Our study attempts to document this among members of one group, the Karen, who represent a significant proportion of refugees resettled in the United States over the past decade. The purpose of this study was to explore how a sample of resettled Karen refugee women construct meaning around health, particularly in the context of cultural values, community, and migration.

Methodology:

This research took place in a series of ethnographic case studies documenting experiences of resilience, identity construction, and mothering among Karen refugee women from Burma. Data were collected through participant interviews with 12 Karen refugee women living in the United States. Interviews were transcribed, coded, and analyzed to identify themes relating to culturally influenced and newly emerging perceptions of health, identity, motherhood, and migration.

Results:

Participants identified correlates of doing, such as the ability to work and physical energy, as positively related to health, while the inability to do things was negatively related to health. Personal health also encompassed the health of family and community.

Discussion:

Women in this sample drew on broad, culturally informed ways of being to explain their health experiences. Implications of these findings are presented regarding how organizations and health providers can approach their work with refugees in culturally informed and relevant ways.

Introduction

The global presence of refugees and other displaced peoples has drastically increased over the past decade, under the pressures of intrastate and geopolitical conflict, economic instability, and the impacts of climate change (McAuliffe & Ruhs, 2017). At the end of 2018, the United Nations High Commissioner for Refugees estimated that 70.8 million people were internally displaced, were stateless, or had refugee status (United Nations, 2018). In the United States, Karen people make up a substantial portion of newly admitted refugees. Since 2007, approximately one in four refugees resettled in the United States has originated from Burma, and the majority are Karen (U.S. Department of State, 2019). Health care is among the most critical needs for refugees, many of whom have directly experienced violence and trauma, and are more likely to struggle with depression, anxiety, and post-traumatic stress disorder. Women and girls experience particular vulnerabilities related to exposure to physical and sexual violence (Crumlish & O’Rourke, 2010; Mangrio & Sjögren Forss, 2017; Patel et al., 2014; Satinsky et al., 2019).

The experiences of negotiating health and recovery from traumatic experiences, while influenced by individual, place, and circumstance, are often deeply cultural (Shannon, Wieling, et al., 2015). For a newly resettled person, this process can be complicated by the fact that cultural beliefs, traditions, and value systems related to health may not translate or transfer easily to the new country (Abubakar et al., 2018; Keygnaert et al., 2014; Shannon, 2014). High levels of need, complicated by limited resources and communication barriers, mean that receiving culturally relevant health care can be a serious challenge for many (Abubakar et al., 2018; Mangrio & Sjögren Forss, 2017; Morris et al., 2009; Van Loenen et al., 2018; Vega et al., 2015).

It is essential that health professionals have the tools to effectively serve the increasingly complex and diverse needs of this population.

In this study, we attempt to add to a limited but growing body of literature that examines how culture shapes the health perceptions and behaviors of resettled refugees. We focus on the experiences of a specific group of people from Southeast Asia, the Karen, who represent a significant proportion of refugees admitted to the United States. The purpose of this study was to explore how a sample of resettled Karen refugee women construct meaning around health in the context of cultural values, community, and migration.

Background

The Karen in Context

People living in the Karen state of Burma, also known as Myanmar, have been experiencing ethnic conflict, the perpetration of systematic violence, and forced migration for more than 60 years (Davis et al., 2015; Shannon, Vinson, et al., 2015). Human rights violations experienced by the Karen people include a high prevalence of forced labor, theft or destruction of food and homes, displacement, physical assault, and torture. The majority of these violations were perpetrated by the Burmese army (Davis et al., 2015). The existence of ongoing conflict also contributed to poverty, unemployment, and lack of resources for education and health care. In this context, many Karen people fled to refugee camps on the Thailand-Burma border, where they have become the majority ethnic group among the more than 200,000 migrants and 125,000 refugees who live and work there (Fellmeth et al., 2015; Hoffman et al., 2019).

For the Karen, as for many refugees, the challenges are far from over once the relative safety of a camp is reached. Thailand is a major recipient of refugees and migrants from other countries in Southeast Asia, and resources are continually stretched in refugee camps that are designed to meet only basic and temporary needs (Fellmeth et al., 2015; United Nations, 2018). Long-term residence in refugee camps and an uncertain future leave many people in a state of perpetual limbo, unable to return home and awaiting a resettlement process that can take many years (Fellmeth et al., 2015).

Despite these hardships, people living in refugee camps display incredible resilience and resourcefulness as they work to move through everyday life. Engaging in a livelihood and being able to work is one factor that can provide stability for refugees in the face of the near-constant scarcity, uncertainty, and changing dynamics that are present in a refugee camp (Hoffman et al., 2019). However, although there are extensive networks of formal and informal economies within the camps, it is illegal for refugees to seek more lucrative formal work outside the camps without a national residence permit, which only few have (Hoffman et al., 2017). In some cases, crop production or collecting materials from the areas within and around the camp is also prohibited, further increasing dependence on aid. The lack of opportunities for work experience creates concerns about the ability of refugees to support themselves economically once they leave the camp (Lee, 2014). Thus, the ability to find adequate work and income are key concerns for refugees living in the camps and have myriad implications for their well-being, mental health, and everyday survival.

Culture and Health

Culture and context influence how people experience health care and their expectations of health, as well as how they seek and respond to care (Raingruber, 2011; Sevinç, 2018).

Many fields, including anthropology, sociology, and public health, have explored the complex relationship between culture and health, and how lived experiences and cultural influences shape how individuals assign meaning to health. The pioneering medical anthropologist Cecil Helman (2007) wrote,

The culture and background in which we grow up teaches us how to perceive and interpret the many changes that can occur over time in our own bodies and in the bodies of other people. We learn how to differentiate a young body from an aged one, a sick body from a healthy one... how to perceive some parts of the body as public, and others as private; and how to view some bodily functions as socially acceptable and others as morally unclean. (p. 19)

For resettled refugees, negotiating cultural meanings of health can become a complex part of the already complicated process of navigating life in a new country (Shannon, 2014; Van Loenen et al., 2018). During resettlement, refugees may experience acute and chronic stress, social isolation, and cultural isolation; challenges of financial dependency, economic self-sufficiency, separation from family, and increasing symptomatology of illness can further complicate processes of acculturation and integration (Heiner, 2014). Navigating foreign systems and cultural differences magnify these challenges (Morris et al., 2009). Difficulty in navigating social service and health care systems can be a significant stressor for refugees postresettlement, particularly when access to health is affected by limited mobility and language and cultural barriers (Lytle, 2015). In the clinical encounter, miscommunication, differing expectations of health care, and cultural differences may disrupt trust in the medical system and relationships with providers (Morris et al., 2009; Oleson et al., 2012). For immigrant and refugee populations, cultural accommodation in health care often determines the perception of the quality of care received (Sevinç, 2018). Feeling that cultural values, beliefs, and practices were not accommodated for is not uncommon in immigrant and refugee populations who become clients of a biomedical system of health care (Morris et al., 2009; Shannon, 2014; Weerasinghe & Mitchell, 2007). To meet the needs of refugee and migrant populations, it is incredibly important for health care workers, along with public health and social services workers, to develop an understanding of the cultural factors that may be important to the people they serve.

Health and Karen Culture

Previous research provides valuable insights into some of the ways in which culture shapes perceptions of health for Karen refugees (Hoffman et al., 2019; LaMancuso et al., 2016; McCleary & Wieling, 2017; Oleson et al., 2012). As in all studies of the relationship between health and culture, it is important to take a mindful approach to such findings. No culture or community is homogenous; individuals interpret experiences in vastly different ways, and they may or may not adhere to identified cultural themes and norms (DelVecchio Good & Hannah, 2015). Nevertheless, it is useful for health care practitioners to be aware of commonly held beliefs and experiences that have shaped a community, in order to provide care that is as culturally informed and tailored to recipients as possible.

In resettled Karen refugee populations, culturally mediated understandings of health can translate into beliefs and patterns of behavior around the efficacy of medicines, when to seek care, and mental health (Mitschke et al., 2011; Oleson et al., 2012). Previous research has found that some Karen people, similar to people in other immigrant and refugee groups, combine elements of traditional and Western medicine in their care-seeking practices after resettlement (Oleson et al., 2012). People may use Western medications because they do not have access to traditional ones that they prefer, and they may at the same time rely on the theories and principles of traditional medicine when access to health care is limited by availability and cost (Oleson et al., 2012). They may not see a binary divide between Western and traditional medicine at all but rather make use of what is available and perceived to be effective.

Mental health, perhaps more than any other facet of health, is particularly subject to interpretation based on cultural norms and values (Helman, 2007). High levels of exposure to traumatic events mean that Karen refugees, like many other refugee groups, are more vulnerable to mental health problems such as anxiety, depression, and post-traumatic stress disorder (Mangrio & Sjögren Forss, 2017; Satinsky et al., 2019; Shannon, Vinson, et al., 2015). One study of Karen refugees living in the United States found that over 80% of the participants have experienced war trauma; over 27% have experienced primary torture, and over 51% have experienced secondary torture (Shannon, Vinson, et al., 2015).

One of the most common ways in which Karen people may describe mental illness is in terms of excessive worry and “thinking too much,” which can be considered both a symptom and a cause of poor health. People may also describe a sense of “losing control” or “going crazy” when describing mental health symptoms (Brink et al., 2015; Fellmeth et al., 2015; Hinton et al., 2015). People may initially present with reports of somatic symptoms, such as headaches, heart palpitations, and body tension, rather than specific mental health concerns. Feelings of muscle tightness all over the body, which must be relieved by being massaged by others, may also be common (Fellmeth et al., 2015; Shannon, Wieling, et al., 2015).

With this is mind, we explore some of the ways in which Karen refugee women specifically construct meanings of health and well-being in the context of migration and resettlement.

Method

In the clinical and policy setting, qualitative research is useful for understanding and asking questions about people’s lived experiences, which can inform appropriate interventions for policy and practice (Moon et al., 2013). Data used in this analysis were collected as part of a series of qualitative ethnographic case studies documenting the experiences of Karen refugee women who have been forcibly displaced by violence and ethnic conflict (Hoffman, 2016). Data collection was conducted using the ethnographic methods of participant observation and participant interviews with two cohorts: women currently living in refugee camps along the Thailand-Burma border and women who had previously lived in the camps and had gone through the resettlement process in the United States (Hoffman, 2016). In this analysis, we focus on the data gathered during participant interviews with the second group. The institutional review board of the University of Minnesota reviewed and approved the study.

Study Sample and Setting

Karen refugee women resettled in Minnesota were recruited to participate in the study via established connections with local Karen community organizations. Participants were included if they self-identified as Karen and came to the United States with the U.S. refugee resettlement program. Twelve women took part in the study, ranging in age from 23 to 61 years. Although the sample size was relatively small, it is within the range considered acceptable and efficacious for qualitative research (Guest, Bunce, & Johnson, 2006; Moon et al., 2013). Of the 12 women, 11 were mothers and expressed primary caregiving responsibilities for spouses, children, grandchildren, siblings, and/or parents. All but one participant identified as ethnic Karen. This individual was raised within a Karen community, her spouse was Karen, and she spoke Karen as her primary language. A number of participants in this study stated that before resettlement in the United States, they had lived in a refugee camp for more than a decade, sometimes for as long as 20 years. The range of time spent postresettlement in the United States was 9 months to 15 years. Minnesota was the state of initial resettlement for nine of the participants; three were secondary migrants from other states.

Each participant was interviewed up to three times over the 9-month study period. Interviews were conducted with the support of an experienced Karen interpreter who also coordinated scheduling, facilitation, and follow-up. All interviews were conducted in participants’ homes. Interview questions centered on perceptions and definitions of health, both in relation to past and present experiences and more specifically to the process of resettlement and negotiating life in a new country.

Data Analysis

Interviews were transcribed and coded by the study team, which followed a deductive analysis approach integrating multiple strategies of content analysis (Hsieh & Shannon, 2005). A data-driven code book was developed collaboratively through a multistep process (DeCuir-Gunby et al., 2011), and at least two independent analysts coded each transcript. The study team then reconciled the code book by referencing notes, excerpts, and code definitions to ensure consistency in the use and understanding of each code. Codes were grouped into higher order categories, and primary themes were identified.

Results

In conversations with participants, the broad relationships between culture, health, motherhood, social relationships, identity, and resettlement were considered. Ultimately, two primary categories emerged from the data: that of Doing and Collectivism.

Doing

Doing summarizes an underlying notion of motion, energy, and action that women communicated as they constructed postresettlement narratives of health: “Health, from my perspective, is important. If you have good health, whatever you want to do, however you want to work, wherever you want to go, you can do everything you want.” A direct connection was drawn between personal health and one’s ability to do things. Health and doing were connected to a sense of independence, functionality, economic stability, and positive self-concept. In contrast, poor health or sickness was described as “thinking too much” and related to stress and worry. Several subcategories emerged around this concept, which are distinct but interconnected in the narratives: the ability to work, physical energy, and the inability to do.

The Ability to Work.

The ability to work was described by multiple members of the sample as the primary determining factor for their health. The various connections described by Karen women in the sample between health and the ability to work were clear and conveyed a similar essential meaning: “If you’re not healthy, in a good health condition, you cannot work.” Work was valued and broadly served as a means to provide for the family, attain economic self-sufficiency and independence, and achieve personal well-being. There were nuances in the ways in which individuals in the sample assigned value to work. These included a recognition of the purely financial reasons to support their families. Others described work as a means of maintaining health: “If you’re not working, if you’re just lying down, watching TV, not doing anything, I think that would be a problem to have a health issue. So working makes you healthy too.” Within the narratives of the health of women included in the sample, work was a way to understand health, define health, and move toward health.

Physical Energy.

Participants described health as having good physical energy, and feeling low in energy would be an indication to seek health care: “Physical energy is, if you can work, you have energy.” Similar meanings of physical energy surfaced as participants used it to gauge their own health and define sickness: “If we are not well or if we are sick, we don’t have ... we’re weak. We don’t have a good energy.” Women in the sample discerned physical energy from work in that physical energy was a representation of how individuals interpreted personal health—for example, the ability to follow their daily routine of activity. Work remained a more concrete factor in the determination of health and the ability to provide for family.

Inability.

This subcategory was explicitly included to emphasize this distinct cultural perception of health behaviors and ill health as the Karen women described these concepts. Women in the sample articulated a cultural perception specific to the inability to do. One participant stated, “This cultural tradition, we already believe it. If you’re sick you can’t do anything but stay away or rest. If you’re well, just to work to the farm or go work again.” She went on to explain that a fear of inability prompted health maintenance behaviors. On the other hand, inability had the potential to become part of a circular relationship with depression, thinking too much, or experiencing heaviness in the heart. Some women described how a person who is not able to do might become more prone to these issues of ill health, which in turn contribute to inability to do.

Collectivism

Collectivism captures the notion of health that extends beyond the individual, to the family or the community. As one woman stated, “In order to have good health, it depends on your family too.” The sense of connectedness between individual health and the health of the community created a shared narrative. This relationship was leveraged by women in the sample and influenced perceptions and movement toward health.

Family Health.

Karen refugee women in our sample connected individual health to the health of the family: “So the importance for [me] to have physical health, good physical health, it depends on the whole family. If your family is doing good, happy, your physical will be healthy.” Women explained their roles in sustaining the health of the family. Women are taking care of the whole family: “If my children sick, so I better to know how to take my children to check.” Women articulated a similar responsibility for the health of their spouse. There was consensus among the women in the sample about their role in facilitating access to health services for their spouses. One participant indicated, “Men are more—how do you say? ... They’re not going to see a doctor right away. Not like women; women are more active.” The sense of responsibility these women felt when a family member was ill was a source of stress: “He ... always complain about the pain, so make me feel bad.” Women in the sample discussed the value in the quality of relationships held within the family: “Like a family household, if we are not fighting, we are loving each other. That is health.” Women in the sample articulated the ways in which strained collective and familial relationships affected individual health.

Community Connection.

Community connection was an important part of health for the Karen refugee women in our sample. Central within post-resettlement narratives was the connection across the Karen community in terms of seeking out help and sharing resources. Karen women relied on each other for help, resources, and guidance in the face of problems: “I have to contact my clinic and I can’t speak English, you know? My friend can speak English, so we are connected to each other ... Maybe she can help just for speaking or making appointments.” The ability to ask for help was balanced with the willingness to offer help to others: “I think they would be looking for someone to help them or they come to me and I will send them to the person that I know, that resources that I have already experienced.”

Prayer, specifically community prayer, embodied collectivism as it related to health. Women in the sample identified prayer as an important part of the healing process for themselves when they or a family member became ill. Prayer was also an individual practice, but women particularly emphasized the value of community prayer. For example, one participant stated,

Praying together makes me have more courage, make me feel a lot stronger, not afraid. We also request for individual prayer, too, but gathering together and praying here makes me get more support, care from people. The belief is stronger.

Participants prayed for others, at times describing circumstances of doing so before praying for themselves:

As I pray, I pray for everybody, pray for the country, pray for the people, pray for my community, even pray for my doctor ... I pray for other things first ... so I’m the last person I pray for.

Prayer facilitated connectedness.

The practice of leveraging personal connection to help others as well as to receive help is present in the context of Karen refugee health. This practice stems from not only building connection through courtesy but also connecting over cultural heritage and shared experiences: “I think those are the strengths within our community—that we respect one another and we trust and rely on one another, and also our bond. Wherever we go and we see a Karen person, we just get the connection.” Another participant expanded this idea: “We make connections by helping each other. Then that connection or that culture goes on and on ... When we need help we just go directly to them to ask for it.” These interactions reflected cultural ways of being and were perceived by Karen women in the sample to influence the health of family and community.

Discussion

These narratives provide insight into the role of culture in constructing meaning around health for Karen refugee women. Use of recontextualization was noted in how women applied broad cultural ways of being to make sense of health in the context of everyday life, while also negotiating changing circumstances in a new country. While our interviews were focused on a specific population, there are potentially broad implications for how government agencies, NGOs, health care providers, and other groups can work together with refugee communities to support health, wellness, and success in the resettlement period and beyond by integrating cultural understandings into practice (Murray et al., 2010).

Karen refugee women communicated an understanding of health as both a determining and motivational factor relative to their ability to work. Achieving economic self-sufficiency is the primary indicator of successful resettlement in the United States from a policy perspective (Brown & Scribner, 2014; Kenny & Lockwood-Kenny, 2011). Karen women were aware of this external expectation; at the same time, our analysis describes a culturally constructed pursuit of livelihoods that is intrinsic, particularly when it serves as a motivation for individuals to maintain health. However, despite high motivation to work and the focus on early job placement for refugees, factors like illiteracy, lack of formal education, and lack of work experience make work and employment a challenge for many (Kenny & Lockwood-Kenny, 2011; Li et al., 2016). Available employment frequently takes the form of low-wage, labor-intensive jobs, in which people find it difficult to make ends meet (Kenny & Lockwood-Kenny, 2011). Additionally, the high-risk nature of such labor and the tendency toward overwork and high levels of stress and burnout present challenges to health in and of itself.

Policies to better support refugees during the resettlement process could take into account this strong cultural valuation of work. Programs should focus on literacy, language, and job training that promotes gainful, meaningful employment rather than prioritizing immediate employment in jobs that might actually make the path of self-sufficiency longer and more difficult (Kenny & Lockwood-Kenny, 2011; Kim, 2016). Refugees who have experienced injuries as a result of conflict and torture may have limitations that should be appropriately accommodated, allowing them to participate in work and regain this facet of health. Health care providers should also be alert to the environmental hazards of dangerous work and long hours and to the mental health impacts of being unable to work (Kim, 2016; Li et al, 2016).

The study results also inform how this population might apply cultural connectedness to their experiences of health and how familial and community networks enhance the ability of refugee women and families to navigate crises and cope with problems (McCleary, 2017; O’Mahony et al, 2012). A strong sense of connectedness with family or community is an essential facet of successful resettlement in terms of building a strong social support system and fostering well-being (Heiner, 2014; Kenny & Lockwood-Kenny, 2011; Lacroix & Sabbah, 2011; Li et al, 2016; Mitschke et al, 2011). The results also demonstrated how activities like prayer can be a response strategy utilized to manage stress. Women in the sample described how members of the Karen community often pray before, during, and after seeking and receiving medical care. Community prayer, which engaged both spiritual and community support systems, was a particular strategy engaged by Karen refugees to maintain well-being in the face of stress related to refugee and resettlement experiences (Hoffman, 2016; Lytle, 2015; Oleson et al., 2012).

For nurses and other health care providers, asking about sources of community and faith-based support can be a key point of connection with refugee clients, demonstrating an openness and acknowledgement of key priorities and social facets of a person’s life (Murray et al., 2010). In situations where clients do not have strong community support, providers might suggest and help facilitate opportunities to identify and build these resources.

Limitations

The use of an interpreter during the interview process was an intrinsic limitation of the study. In an attempt to strengthen credibility of the data, peer debriefing, extensive participant observation, and prolonged engagement were practiced during the data collection process (Hoffman, 2016; Lincoln & Guba, 1985). The qualitative nature of this study, along with a small sample size, also inherently presents limitations to the generalizability of the findings. Future studies would benefit from an external audit for dependability. Our team-based approach to coding and analysis broadens opportunities for a rigorous examination of the data, which might then be transferable to comparable groups (Fonteyn et al., 2008).

Conclusion

We found that Karen refugee women explained the intersection of culture and health through two broader themes, Doing and Collectivism. Recontextualization, leveraging what is understood and shifting that knowledge to new context, served that process. Members of our sample identified health as being connected to the ability to do things, particularly to work and provide for the family, and to physical energy. Community connection, family, and prayer were important resources used to seek and maintain health.

The results of this study reinforce the importance of seeking to understand the ways in which individuals and communities construct meanings of health in order to comprehensively address health concerns. This inquiry is of high importance when working with resettled refugee populations, as they have unique and complex health needs resulting from their particular experiences. For nurses and other health care providers, including questions about work and physical energy in the clinical interview can aid in relationship building and opening the door for critical health interventions. Addressing concerns about family health, recognizing that the definition of family may be broad, should also be incorporated into the clinical encounter. Next steps in our work include the inclusion of men in our study of the role of culture on health, as well as a comparison of health outcomes in tailored versus standard care environments.