Refugee Health Ed Conference - Tricia Ryan and Julie Rosenberg

April 14, 2021

ID6442

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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.