Kuvura Amajwi, Healing Voices:
Promoting Health Literacy in Low-Literacy Refugee Populations
Amy Richardson
Programs in Public Health
University of Tennessee, Knoxville
[email protected]
Denise C. Bates Ph.D., R.R.T., CHES
Assistant Professor
Programs in Public Health
University of Tennessee, Knoxville
[email protected]
Programs in Public Health
1914 Andy Holt Avenue
373 HPER Building
Knoxville, TN 37996-2710
Allison D. Anders, PhD
Assistant Professor
Department of Cultural Studies
University of Tennessee, Knoxville
[email protected]
Fleurette Sambira, MPH
Programs in Public Health
University of Tennessee, Knoxville
[email protected]
Abstract
Results
As worldwide numbers of displaced persons increase to nearly 33 million (UNHCR, 2007), the
United States experiences one of the highest global refugee resettlement rates, with an estimated
80,000 resettled in 2009 alone (Refugee Council USA, 2008). With increasing numbers, the U.S.
government and resettlement agencies must expand placement to new locations, yet community
agencies may lack the systemic infrastructure and communication skills necessary to address the
anticipated increase in public health services for refugees and their families. Cross-disciplinary
collaboration and new technologies, however, can provide vehicles for bridging these challenges.
The nature of CBPR work in a refugee community requires much flexibility and a willingness
to follow the lead of the community members. Developing, piloting, and implementing the Kuvura
Amajwi project has not advanced as quickly as we had anticipated, yet the refugee community
remains enthusiastic and willing to participate.
Students and faculty in the health division of Healing Transitions: Program Interventions for
Youth Refugees and Families, a community-based service-learning and research initiative that assesses
short and long-term transition needs of refugees, developed the Kuvura Amajwi (Healing Voices)
program to assist in refugee health literacy. When qualitative analysis of focus group interviews with
Burundian refugees revealed cultural misconceptions because of low literacy in English and their
primary language Kirundi, Kirundi mp3 tracks were paired with illustrated pictures to provide health
literacy modules. Innovative and efficient, mp3 modules communicate health information to low
literacy and culturally diverse populations. Modules can be easily transposed into other languages for
use with other refugee communities, and new health modules can be added as needed, making mp3
players a fluid yet effective means of increasing health literacy.
Healing Transitions
Healing Transitions is a multidisciplinary community-based service learning and research
initiative that aims to assess short- and long-term transition needs of refugees and the community in
Knoxville, TN. Some of the main objectives of the project are as follows:
• To assess how social and contextual factors such as assimilation, acculturation, poverty, marital
status, social support, and impact of trauma affect refugees’ healthy adaptation to dominant culture
• To conduct interviews with individuals who interface directly with the refugee population in
Knoxville, Tennessee, to establish perceived needs and level of cultural competency
• To establish an effective intervention model for newly-arriving refugees to promote positive
assimilation behaviors to familial and systemic environments
• To develop directed training interventions based on initial needs assessment data for the refugee
population in Knoxville, Tennessee.
The project is ever-evolving as the community develops a better understanding of the refugees'
needs and as the refugees acculturate into their new environment. Overall, however, the project aims to
facilitate a smooth transition for both the refugees and the resettlement community.
At this point, the tests have only been piloted. They were first pre-piloted among university
colleagues for clarity of the questions and the pictures. Two of the tests were piloted among a small
group of Burundians in a very individualized process by talking through each question so that “it felt
more like a game than a test.” Therefore, learning happened on both sides—with the research team
learning more about Burundians’ understanding of health and nutrition, and the Burundians eagerly
gaining knowledge about healthy living.
Community Investigation & Program Development
Community-Based Participatory Research (CBPR), which is a collaborative research approach
designed to establish structures for the participation of communities affected by the health issue that is
being studied, was conducted in order to identify the needs of the refugee population. The assessment
provided an important baseline and reference point that was significant in the development of learningorientation materials for the refugees.
Interviews and focus groups were conducted as a way to identify the immediate needs of the
Burundian refugees. Interviews (n = 27) involved individuals who interacted with refugees such as
sponsors, resettlement caseworkers, medical professionals, and ESL teachers. Furthermore, six (6)
focus groups, four (4) for men and two (2) for women, were conducted among Burundians. Men (n =
26) and women (n = 13) were recruited using snowball sampling. Questions were delivered in English
and translated into Kirundi, the first language of Burundians. Participants responded in Kirundi. The
focus groups were recorded and later transcribed and translated. Unfortunately, resources did not allow
for back-translation of the data.
Qualitative analysis of both interviews and focus groups indicated that language barrier was the
most prevalent stressor experienced by both the community and the refugee population. The
community has had difficulties helping the refugees due to miscommunication and a lack of
translators. Refugees, however, struggle to gain awareness of available resources and services.
Additionally, although some translated materials are available in their own language (i.e., Kirundi),
these materials are ineffective among many of Knoxville’s Burundians, who have little or no literacy
even in Kirundi.
To respond to the immediate needs of the Burundian refugees, the Healing Transitions students
designed a tool that would benefit both literate and low-literacy refugees. Health education modules
were developed based upon topics of need and using previously developed (and translated) materials
from U.S. Committee for Refugees and Immigrants (USCRI) and Bridging Refugee Youth and
Children’s Services (BRYCS), with their permission. The modules were recorded in both Kirundi and
English, and illustrated pictures accompany most modules.
At this point, developed modules for Kirundi speakers include:
Over the Counter (OTC) Medicines
Refugee Profile
1972 Burundians in Knoxville, TN
In 2007, the U.S. began resettling a group of refugees know as the “1972 Burundians.” These
individuals are predominantly “ethnic Hutus” who fled Burundi to other countries in the Great Lakes
region in response to widespread violence in 1972 (CORC, 2007). The Burundians who have been
resettled in the U.S., mostly in 2007 and 2008, lived in refugee camps in Tanzania. Although primary
school educations were available for children in the camps, they were poorly equipped, and many of
the 1972 Burundians are uneducated with low literacy skills. Furthermore, most of them do not have a
profession or job skills outside of farming experience. (CORC, 2007).
Between January, 2007 and August, 2009, Bridge Refugee and Sponsorship Services, Inc.
resettled 34 families of 1972 Burundians in Knoxville, Tennessee. At the time of their resettlement,
these 34 families were comprised of 137 individuals, and their ages ranged from infants to elders
(Bridge, 2009). These families reside in three general areas of Knoxville, and the school-age children
attend several public schools. Some Burundians have obtained jobs, though they tend to be low-wage
and devoid of fringe benefits (e.g., health insurance) (Bridge, 2008). With the assistance of at least two
local churches, some of these Burundians maintain vibrant faith communities (Bridge, 2008).
References
Bridge Refugee Services, personal communication, 2008 and 2009.
Costello, A. & Bebic, S. (2006). Cultural orientation for refugees. Online Digest. Center for Applied Linguistics.
Cultural Orientation Resource Center [CORC] (2007). The 1972 Burundians. COR Center Refugee Backgrounder (2).
What To Do When Your Child Is Sick
Nutritious Food (USCRI materials)
Women’s Health (USCRI materials)
Raising Children in a New Country (BRYCS)
To test refugees’ knowledge, the team developed pre- and post-tests for each module. Due to the
low literacy of the population, the tests uses pictures rather than words. The test is designed to be read
aloud in Kirundi, while participants circle pictures to correspond with their responses. The refugees
then listen to the mp3 modules, and a post-test can assess the gain in knowledge. The modules will
eventually be tested to assess long-term (6 month, 1 year) knowledge gain.
Another finding revealed the difficulty of using mp3 players. The difficulty of finding
affordable players that are easy for low-literacy populations to use, combined with the dilemma of
retrieving all the players back (in working condition) has led the team to lean towards the use of
portable CD players. New modules can simply be burned onto CDs and easily distributed throughout
the community.
Technological Advantages
All refugees being resettled into the U.S. receive an overseas orientation covering 11 essential
topics as defined by the U.S. State Department that lasts from 2 – 30 hours. Once refugees reach the
U.S., they receive additional orientation, usually via a case management model within the first 90
days of resettlement (Costello & Bebic, 2006). Traditional orientation methods tend to provide a lot
of information in a short amount of time.
The use of mp3 players would allow refugees to take this information with them and revisit it
whenever necessary. For instance, they could walk through the grocery store without a case manager
and make healthy decisions for purchasing their families’ meals that week.
Using mp3 players in conjunction with tradition orientation and training methods will bolster
cultural and educational learning, and it may support essential English language learning as well.
Because translators are costly and sometimes difficult to attain, providing refugees with their own
learning resources not only decreases the financial costs but also empowers the refugees in their
assimilation and acculturation processes.
Remaining Challenges
Although dozens of adult Burundians in Knoxville have participated in ESL classes at various
times, their English speaking and literacy rates remain low, severely constricting their options for
advanced education and employment. Furthermore, the Burundians expressed frustration over what
they perceived as a forced choice between either education or work. The pressure to pay rent usually
resulted in their choosing work over the optional two-day per week English class. Even those who had
time to attend English classes were often limited by the lack of reliable transportation to those classes.
Another challenge is improving the Burundians’ access to healthcare. Because the majority of
adult Burundians have been in Knoxville for longer than eight months, they are no longer recipients of
public health insurance. Not surprisingly, for these Burundians, accessing primary care services has
proved difficult. Furthermore, despite the recommendation that 1972 Burundians have access to mental
health services (CORC, 2007), Burundians in Knoxville, particularly the men, have struggled to
overcome the stigma and logistical difficulties of receiving mental health care, although they have
seem some recent improvements.
Two additional facts overshadow and contribute to the challenges described above. First, there is
a dearth of co-sponsors. Upon arrival, only 8 of the 29 Burundian families resettled in Knoxville from
2007-2008 were co-sponsored by a community group (Bridge, 2008). Consequently, these refugees
were deprived of a potentially-significant source of social support. Second, because nearly all of the
Burundians in Knoxville were received more than six months ago, they have surpassed their period of
intensive case management services. Thus, despite their low rates of English speaking and literacy,
they are expected to be financially self-sufficient.
Future Implications
In the future, Healing Transitions plans to adapt the mp3 modules into other languages to
serve the other refugee communities in Knoxville. Additionally, based on other focus group and
interview responses, other learning modules are being developed. Not only will the mp3 project make
orientation material available to newly-arriving refugees, but it will be used outside the classroom to
reinforce ESL lessons.
In addition to this programming tool, further successes include foundational benefits such as
building community capacity amongst the refugees. The project has allowed them opportunities to
come together with each other and with the local community to communicate about everyday issues,
so learning takes place on multiple fronts—with the refugees, the community, and the research team.
Finally, the Healing Transitions team hopes to develop a website that will house training modules
and links to informational sites for the community. Long term, the project hopes to better understand
the complete migration experience from pre-flight through resettlement.