Refugee Health Ed Conference - Tricia Ryan and Julie Rosenberg
April 14, 2021ID6442
To CiteDCA Citation Guide
- 00:00Today will be speaking a little bit
- 00:02about an initiative that we're doing
- 00:04here related to mental health for
- 00:05the pediatric refugee population
- 00:07in the time of covid and beyond.
- 00:09With a program called Empower,
- 00:10My name is Julia Rosenberg.
- 00:12I'll be speaking with one
- 00:13of my Co investigators,
- 00:15Doctor Mcdonna Ryan and with big thanks
- 00:17to Caroline O'Brien and Fresh take
- 00:20on Java who are both Co investigators
- 00:22and part of this program as well.
- 00:24I'm So what will speak about just here.
- 00:27Have a road map in mind.
- 00:30Are the mental health risks and barriers
- 00:32to care for refugee children that had
- 00:35already existed an then exacerbated
- 00:37as we've just heard with COVID-19.
- 00:39And then we'll speak about
- 00:41our pilot intervention,
- 00:43empower its education as
- 00:44prevention and intervention,
- 00:45and then opportunities for
- 00:47ongoing collaboration,
- 00:48exactly as everyone has just
- 00:50been mentioning the importance
- 00:52of community and collaboration.
- 00:54To begin with,
- 00:55we know that children in refugee
- 00:57families face unique stressors that
- 00:59place them at higher risk for mental
- 01:01and behavioral health problems.
- 01:03Long before Covid there are pre
- 01:05migration stressors in their home country.
- 01:07Maybe exposure to war, violence,
- 01:08migration,
- 01:09stress stressors on the journey
- 01:11and sadly as many of us see post
- 01:14migration migration stressors upon
- 01:15arrival to the United States.
- 01:17And then with these risks,
- 01:19there are still barriers when
- 01:21it comes to accessing care.
- 01:23As we all know, there are language barriers,
- 01:26challenges with parental literacy,
- 01:27difficulty finding culturally
- 01:28concordant providers,
- 01:29a constantly changing political landscape,
- 01:31difficulty finding providers
- 01:32that they may trust these unique
- 01:34stressors that all add together.
- 01:36And then our challenges of finding
- 01:38culturally sensitive screeners that
- 01:40are appropriate to detect mental
- 01:41and behavioral health problems
- 01:43in refugee children.
- 01:44When it comes to thinking about
- 01:46supporting refugee children,
- 01:47it's helpful to take a
- 01:49framework specifically here,
- 01:50the Bronfenbrenner and Bent
- 01:51Brenner ecological systems theory,
- 01:53and in this theory the child
- 01:55is at the center.
- 01:56The individuals at the center and
- 01:58around them are many systems,
- 02:00starting with the most immediate system,
- 02:02so the micro system of the immediate
- 02:04family and the classroom that they go to
- 02:07and then going out towards the MISO system,
- 02:09the ecosystem,
- 02:10the macro system,
- 02:11so home,
- 02:12schools and neighborhoods,
- 02:13things like more institutions like
- 02:15hospitals and refugee resettlement
- 02:16agencies and then macro systems
- 02:18thinking about widely shared values.
- 02:19Laws and safety and we had done
- 02:21some preliminary work that was
- 02:23incredibly helpful to be partnering
- 02:25with many community organizations,
- 02:27like with Iris.
- 02:28Like with Elena's light which supports
- 02:30Afghan refugees in the New Haven community.
- 02:32To find out where there are
- 02:34opportunities to provide additional
- 02:36support at each of these systems.
- 02:38And we were working towards that one.
- 02:40Of course along came Covid,
- 02:42which we're all unfortunately
- 02:43very familiar with,
- 02:44and it exacerbated many of these
- 02:46essentially opportunities,
- 02:47but gaps in care that we could.
- 02:50And opportunities to help support children.
- 02:52At each of these levels.
- 02:53So with that with our partnership in mind,
- 02:56we transition towards creating
- 02:57a program called Empower,
- 02:58which we'll talk about now.
- 03:05So together a multidisciplinary
- 03:08team developed a health program
- 03:11through a collection of lenses and
- 03:14a convergence of lenses and looked
- 03:17at program development with a nuro
- 03:21psychosocial systems framework
- 03:22coupled with cultural integrity.
- 03:25In an integration,
- 03:27recognizing barriers and systemic inequity.
- 03:29To access to care and implementing
- 03:33something in the context of COVID-19.
- 03:37With these factors in mind,
- 03:40we created an empower.
- 03:42An empower stands for emotion.
- 03:49The clinic with a Wellness
- 03:52education for refugees.
- 03:54So you'll see here on our left
- 03:57is our selfie of our team and a
- 03:59list of all of our partnerships.
- 04:02And so to address the systemic inequities
- 04:05and Keran improve access to care,
- 04:07we develop multiple partnerships.
- 04:08The key was with a local
- 04:10refugee resettlement nonprofit,
- 04:12alina's light and you'll see
- 04:13Fresh Day who is the leader and
- 04:16founder of Elaine's late there,
- 04:18who's a refugee herself at
- 04:20the bottom of the screen,
- 04:22taking the selfie and her.
- 04:24Wonderful Assistant who was
- 04:26an interpreter for our program
- 04:28and helped us with all our
- 04:30recruitment of our families.
- 04:32But we as you can see we we partnered
- 04:34with multiple organizations for
- 04:36everything from donations to partnering
- 04:39on actually implementing the program and
- 04:42helping families get to the program.
- 04:46As a neuropsychologist,
- 04:47I look at program development in mental
- 04:51and behavioral health and refugees through
- 04:53a nuro psychosocial in a systems lens.
- 04:56Taking into consideration the
- 04:58implications of adverse experiences on
- 05:01the neural circuits, the underpinnings,
- 05:03particularly for executive functioning
- 05:06and the frontal striatal circuits that
- 05:09make these kiddos vulnerable to the
- 05:12effects of how the integrity of this
- 05:15system based on the trauma they've
- 05:17experienced as a individual child,
- 05:20an as the traumas imposed on a family
- 05:23system and the interplay between those two.
- 05:27A lack of exposure throughout the
- 05:30migration journey and interruptions to
- 05:33their development as well as many of our
- 05:36kiddos are exposed to neurotoxins either
- 05:38in utero or early in childhood that
- 05:41all make their this system vulnerable.
- 05:43When you take those experiences and
- 05:46in the implications and you look
- 05:48at that in with the convergence of
- 05:51research of the benefits of social,
- 05:53emotional learning,
- 05:54executive functioning rehabilitation
- 05:55and remediation, and research into.
- 05:58Family system interventions
- 05:59with medical populations.
- 06:00This helped us create a framework for the
- 06:04foundation of our social emotional learning.
- 06:10Next, we in partnership
- 06:12with our cultural experts.
- 06:14Our goal was to create a program of
- 06:18cultural integration and integrity,
- 06:20taking stock of cultural traditions,
- 06:22language, the family system,
- 06:24and perceptions of mental and
- 06:27physical health that families have
- 06:29experienced across their journey,
- 06:32from pre migration and their their host
- 06:35country to what they were experiencing.
- 06:38Post migration and resettlement.
- 06:44Last was looking at a lens
- 06:47through the implement.
- 06:48The implications of COVID-19 and how to
- 06:52deliver a program within the confines of
- 06:55COVID-19 where families were experiencing.
- 06:58As Jen just pointed out from Irish
- 07:02significant fear misinformation,
- 07:03tremendous isolation,
- 07:04rapid changes in their financial situations,
- 07:08and feelings of financial
- 07:10stress and survival.
- 07:11Stress impairment parents.
- 07:13And then abrupt disconnection
- 07:14with cognitive and social
- 07:16stimulation and New Haven,
- 07:18the kiddos at the time we ran our
- 07:21program had been out of school for
- 07:24a solid four months and pretty
- 07:26much kept inside that whole time.
- 07:32So together in this this through
- 07:34these lenses we created emotions
- 07:36program outside the clinic with
- 07:39Wellness education for refugees.
- 07:41This is a culturally informed
- 07:43innovative health education and
- 07:45prevention program that was done
- 07:47in collaboration with our partners
- 07:49using evidence based program
- 07:51components and adaptations of these
- 07:54components to provide covid education.
- 07:56Social, emotional learning
- 07:58and Wellness hygiene.
- 08:00We developed and piloted this
- 08:02program last summer in 2020
- 08:04with our community partners.
- 08:10Our program had multiple goals.
- 08:12First in the short term and and really
- 08:14are the foundation was to develop a
- 08:18program and relationships of trust
- 08:20and to assess the feasibility of our
- 08:23program in terms of the ability to
- 08:25deliver it and for it to be accepted to
- 08:29introduce social emotional language,
- 08:31which is just one component
- 08:33of social emotional learning.
- 08:35So language in Wellness tools to provide
- 08:38a safe outlet for kids to get to school.
- 08:41To get outside, I'm sorry because
- 08:43they haven't been in school and too.
- 08:50Routine where they have not had not
- 08:52had any routine because school had
- 08:54been closed and they were not getting
- 08:56outside in their days did not have
- 08:58any sense of rhythm in the long term.
- 09:00Though ultimately our goal through
- 09:02this pilot program in our steps
- 09:04going forward is to build community
- 09:05and overcome barriers to access
- 09:07to care and improve emotional,
- 09:08social, emotional well being mental
- 09:10and physical health.
- 09:11Our Empower participants included families
- 09:14units from Afghanistan that, on average,
- 09:16had been resettled for about five years.
- 09:19Our participants were family units with
- 09:22our direct participants being kiddos
- 09:24from 5 to 14 years old and indirectly,
- 09:27though we were really affecting
- 09:29the whole family system because
- 09:31parents were there bringing younger,
- 09:33younger and older children as well as
- 09:37we had children who were not purchased
- 09:40in our program who came to watch.
- 09:43Our our program was delivered in
- 09:45person four or five in person
- 09:48sessions for each family,
- 09:49as well as four to six sessions by zoom.
- 09:55And one of the ways to address the
- 09:58barriers of access to care was we went
- 10:01directly to the family neighborhoods.
- 10:04So with the help of Elena's
- 10:06light and Neighborworks,
- 10:07we identified two outdoor locations
- 10:09where we could gather families safely,
- 10:12and so you'll see here,
- 10:14we literally dropped ourselves down
- 10:16into these family into center location
- 10:19where these families could actually
- 10:21walk to us or easily get to us.
- 10:24So this would help.
- 10:26Allow for attending and reducing
- 10:29any barriers related to location.
- 10:36So our first component to begin was
- 10:38we had to address COVID-19 and make
- 10:41families feel like they were safe,
- 10:43and so we set up a system
- 10:46where the families would come.
- 10:48They check in as you see at a table they
- 10:51were checked for all covid symptoms.
- 10:54They were then set over to a group of
- 10:57yoga mats that each child was presented
- 11:00in an provided with their own Matt
- 11:02set up by Family unit in each unit was
- 11:05given 11 facilitator worked for unit.
- 11:08And we're trying to demonstrate social
- 11:11distancing and and demonstrating
- 11:14the use of PPE materials,
- 11:16and we provided all families with PPE.
- 11:21Tools and safety equipment.
- 11:26Part of our COVID-19 curriculum included
- 11:29materials that were multilingual and
- 11:31these were provided through handouts
- 11:33as well as we did daily drills
- 11:35with the kids with role playing
- 11:37and quizzing them on what are the
- 11:40symptoms and how do you prevent covid?
- 11:43And we're trying to get them to habituate
- 11:45to the information an it happened quickly.
- 11:49We could quiz them and they could
- 11:51answer us very quickly as Doctor
- 11:54Camille Brown came one day as a guest.
- 11:57And we put, she put the kids on the spot
- 11:59and quickly they were able to give all
- 12:01the answers that she was looking for.
- 12:06Our social, emotional language and
- 12:08self-awareness component was developed
- 12:09by gaming and through artworks.
- 12:11So you'll see here that this is just an
- 12:14example of games we played with them
- 12:16and materials on how are you feeling
- 12:18and using pictures in words in English
- 12:21as well as in their language as well
- 12:24as cards that you see on the right.
- 12:26We gave them these key rings and they
- 12:29would take the cards out and they
- 12:31would match the cards to the the main
- 12:34paper and we play different games with
- 12:37them to get them used to the language.
- 12:40Used to talking about I feel statements,
- 12:43ideas for coping,
- 12:44and it was all again this whole idea of
- 12:48routine and habituation to language,
- 12:51and doing this pretty much on
- 12:53a suit shoestring budget.
- 12:55We also introduce them to
- 12:58exercise through yoga.
- 12:59We provided a farmers market with each
- 13:02group and talked about nutrition,
- 13:04sleep, hygiene, electronic hygiene.
- 13:10And we also were able to do an evaluation
- 13:13with this put together so quickly.
- 13:15This is a post evaluation,
- 13:17and so we wanted to share a little bit
- 13:19about what we found and some of the
- 13:22next steps in terms of feasibility.
- 13:24One of our main outcomes,
- 13:26the parents that we ask,
- 13:27the 13 parents who participated and
- 13:29attended with their with their children.
- 13:31None of them reported problems with
- 13:33understanding travel or timing.
- 13:35There were some difficulties with zoom,
- 13:37mostly related to storms that
- 13:39happened during the summer.
- 13:40Of all the questions we ask
- 13:42related to satisfaction,
- 13:43we had 100% satisfied when we asked about
- 13:45continuing these program components at home.
- 13:47Yoga was continued at home by most children
- 13:50and a lot of parents joined into as well.
- 13:53Additionally,
- 13:53very interesting Lee related to
- 13:55some of the COVID-19 knowledge.
- 13:56When we ask parents in terms
- 13:58of personal history,
- 13:59we're very thankful to see that it was
- 14:02very few who had any family members
- 14:04who had been exposed to kovid when
- 14:06it came to spontaneous recall of the
- 14:09things that we had talked about each class.
- 14:11Most parents were able to correctly
- 14:13recall at least I as a median 5 symptoms
- 14:16correctly and for protective measures
- 14:17with all of them remembering masks and
- 14:20most remembering things like hand washing,
- 14:22social distancing and other measures.
- 14:23And none of them said that
- 14:25they thought it was a hoax.
- 14:27Additionally,
- 14:27we have some qualitative
- 14:29data we wanted to highlight.
- 14:30Some of that when parents talked about
- 14:32learning through the eyes of their children.
- 14:34I learned through my kids another
- 14:36said before the kids were at
- 14:38home with no physical activity.
- 14:40Now they're active and inspired.
- 14:41Us to be active too.
- 14:43I was not involved directly in the class.
- 14:45I had two jobs but when I came back
- 14:47I saw they were playing at home.
- 14:49So this is an indirect indirect
- 14:50participant benefit from a class.
- 14:52Another said before my wife and I were
- 14:54thinking just take the kids outside,
- 14:55take them to the mall,
- 14:57bring them home as an activity,
- 14:58but that's not a real activity.
- 15:00After we've seen several activities
- 15:01and games you do with the kids.
- 15:03Now we know if we sit with them
- 15:05and do a real activity,
- 15:06do painting and requesting things
- 15:08to do that will be more helpful
- 15:09than just taking them outside
- 15:11and then bringing them home.
- 15:12We have to be more meaningful with
- 15:14what we what we're doing with them.
- 15:16They can learn something from us
- 15:18that was really good outcome for
- 15:20this program for me and my wife.
- 15:22In terms of next steps,
- 15:23so we've developed a program manual.
- 15:26We've established feasibility,
- 15:27trust, and community.
- 15:28Partnerships remain central for this.
- 15:29I'm going and we're currently planning
- 15:31in 2021 with more children and family
- 15:34systems with ongoing collaborations,
- 15:35and also thinking about
- 15:37including community champions,
- 15:38so even teenagers from these refugee
- 15:40communities as facilitators as well,
- 15:42we have a lot of people to think it really
- 15:45does take a community to
- 15:47make all of these have.