Voices and Views of Congolese Refugee Women: A Qualitative Exploration to Inform Health Promotion and Reduce Inequities

Photovoice for leveraging traditional, complementary, and integrative medicine amongst black adults to improve sleep health and overall health

Introduction

Average adults are recommended to have 7-8 h of sleep. However insufficient sleep (IS defined as <7 h/nightly) is associated with increased risk of chronic diseases such as cardiovascular disease (CVD) and type 2 diabetes mellitus (T2DM). Traditional, complementary, and integrative medicine (TCIM), a burgeoning area of research and practice, leverages both modern and traditional approaches to improve health. Despite TCIM's recognition as a tool to improve sleep and related outcomes, there is a gap in literature in addressing its impact among black individuals, who experience a disproportionate burden of IS and chronic disease. This qualitative study aimed to increase understanding of TCIM practices to overcome IS and overall health in black communities.

Methods

Using photovoice methodology, a qualitative tool which applies community-engaged principles to produce culturally informed results through interviews and digital media, consented participants were recruited from Miami, Florida and (1) instructed to capture images over one week that communicated their TCIM to improve sleep and overall health on their mobile device; (2) interviewed using individual, semi-structured procedures to add "voice" to the "photos" they captured for ~20 min; and (3) invited to participate in follow-up focus groups for refined discussion and data triangulation for ~1.5 h. Both individual and focus group interviews were conducted over Zoom with recordings transcribed for formal content analysis using Nvivo software.

Results

The sample included N = 25 diverse US black individuals (M = 37, SD = 13, range 21-57). Approximately a quarter of the sample were unemployed (N = 7) and majority were women (N = 21). Results highlighted five themes including: (1) natural wellness (sleep supplements, comfort beverages, aromatherapy, herbalism, outdoors); (2) self-care (self-maintenance, physical activity, spatial comfort); (3) leisure (pet support, play); (4) mental stimulation (mindfulness, reading); and (5) spiritual wellness (faith-based practices). Study results elucidate the heterogeneity of diverse US black individuals regarding sociocultural knowledge, beliefs, and behaviors.

Conclusion

Addressing IS in black communities requires a comprehensive strategy that integrates cultural sensitivity, family and community dynamics, education, mental health support, and informed policymaking. Future studies should consider how sleep health literacy, stress appraisal, and coping strategies may vary by race/ethnicity for tailored intervention.

Qualitative Systematic Literature Review: Participatory Visual Methods in Community Health Interventions With Migrants

This systematic review investigates how participatory visual methods (PVMs) (1) are applied in community health interventions (CHIs) with adult migrant populations and (2) identify potentials for participation. The search was performed in PubMed in 2021 and 2023. Eighteen articles fulfilled inclusion criteria as they investigated a CHI targeting migrants and used a visual method. We excluded articles that used quantitative methods, articles written in languages other than English, Danish, Swedish, or Norwegian, and the formats reviews, protocols, and theoretical articles. As a framework to graduate the degree of participation, we applied Arnstein's 'A Ladder of Citizen Participation'. Most of the studies took place in the United States, and the most frequent method used was photovoice. We categorize an equal number of articles as 'degrees of citizen power' or 'degrees of tokenism'. We identify the capacity to accommodate the needs of specific target groups to be a strength in PVMs, which has potential to engage migrants in several parts of the research process. Additionally, PVMs can be used to support a change in the participants' lives by facilitating a reflexive process concerning their life situation. However, utilization of PVMs also include a risk of tensions, they can be resource-demanding and potentially exclude certain groups.

Participatory approaches and methods in gender equality and gender-based violence research with refugees and internally displaced populations: a scoping review

Using participatory approaches or methods are often positioned as a strategy to tackle power hierarchies in research. Despite momentum on decolonising aid, humanitarian actors have struggled to describe what 'participation' of refugees and internally displaced persons (IDPs) means in practice. Efforts to promote refugee and IDP participation can be tokenistic. However, it is not clear if and how these critiques apply to gender-based violence (GBV) and gender equality-topics that often innately include power analysis and seek to tackle inequalities. This scoping review sought to explore how refugee and IDP participation is conceptualised within research on GBV and gender equality. We found that participatory methods and approaches are not always clearly described. We suggest that future research should articulate more clearly what constitutes participation, consider incorporating feminist research methods which have been used outside humanitarian settings, take more intentional steps to engage refugees and IDPs, ensure compensation for their participation, and include more explicit reflection and strategies to address power imbalances.

Health Experiences of Women University Students of Color and Women International Students in the United States During the First Year of the COVID-19 Pandemic: Findings From a Transnational, Virtual Photovoice Study

Women university students in the United States who are students of color and international students consistently experience health disparities. These were exacerbated due to the COVID-19 pandemic and racial upheaval following the murder of George Floyd. Within that context, this study aimed to explore the health and well-being experiences of women students of color and international women students at a university in the Midwestern United States in 2020-2021. This participatory, transnational study utilized a virtual adaptation of Photovoice with 14 participants who joined the study from five different countries. Participatory elements included participant co-researchers co-leading development of the photo "mission," icebreakers, naming of the project, design of the project logo, choosing photos for discussion and exhibits, initial analysis of emergent themes, and approval and editing of photos for exhibit. Inductive thematic analysis revealed three themes: (1) grief and loss, (2) barriers and facilitators to social health, and (3) fear and stress from simultaneous social stressors. Data was not mutually exclusive with some photos and narratives illustrating more than one theme. The women experienced grief and loss while negotiating effects of social isolation and adapting to maintain social health. Negative mental and emotional health experiences were amplified as the social context of police brutality and anti-immigrant sentiments overlaid the stress of the pandemic. Study results demonstrate need for increased and tailored health and social service support for women students of color and international women university students.

Health Literacy of Healthcare Providers and Mental Health Needs of Immigrant Perinatal Women in British Columbia: A Critical Ethnography

AIMS

This research explores how health care providers determine the mental health needs of immigrant women in the perinatal phase of childbirth. The contextual factors that affect the mental health of these women and influence their engagement with the British Columbian communities in which they reside are investigated.

METHOD

Using a critical ethnographic approach, eight health care providers were interviewed to gain insight into health care provider's health literacy and immigrant perinatal women's mental health. Each participant was interviewed for 45-60 min in the period from January to February 2021 to obtain relevant data.

RESULTS

Three themes emerged from the data analysis: the health care provider's role and his/her health literacy, the health literacy of the participant, and the impact of the ongoing COVID-19 pandemic on the participant's situation.

CONCLUSIONS

The findings indicate that a healthy working relationship between the health care provider and an immigrant woman in the perinatal phase of childbirth is essential to facilitate an effective interchange of health information.

Mixed messages and COVID-19 prevention: Why information isn't always enough to protect meat processing workers

Introduction

The objective of this project was to investigate U.S. meat and poultry processing workers' knowledge of COVID-19, perceived ability to protect themselves from infection, and perspectives on COVID-19 vaccines to inform COVID-19 prevention efforts within this linguistically, racially, and ethnically diverse workforce.

Methods

Qualitative semi-structured in-depth interviews were conducted with Mexican, Central American, Congolese refugee, and Black or African American meat/poultry processing workers from Mississippi, Minnesota, Virginia, and Kentucky (N=40). Data were collected from December 5, 2020, to January 28, 2021. Interview audio was transcribed, and rapid qualitative data analysis was used to analyze transcripts.

Results

Most participants expressed receiving mixed messages about COVID-19 protection measures: they were told how to protect themselves (n=38), but workplace policies (such as lack of paid sick leave) often undermined their efforts. Participants who were asked about COVID-19 vaccines (n=31) were aware there were one or more vaccines available to protect them from COVID-19; one-third were eager to get vaccinated.

Conclusions

Community-based efforts may consider supplementing large scale unified information campaigns in order to prevent mixed messages, address worker needs to accurately gauge the threat of illness to their families and communities and empower them to prevent infection.

Barriers adult refugees face to community health and patient engagement: a systematic review

Meeting the health needs of refugee populations and increasing access to healthcare remains a challenge for healthcare systems globally. As such, community health and patient engagement are increasingly recommended strategies to address health-related issues among refugees. This systematic review aims to identify the reported barriers that adult refugees encounter with community health and patient engagement. Data sources included MEDLINE, Embase, APA PsycINFO, CINAHL, and Core Collection (Web of Science), yielding 1156 records. After removing duplicates and two levels of screening, 18 studies were selected for qualitative analysis. The barriers were conceptualised as cultural norms, pre-departure history, education, language proficiency, stigma, racism, social support, and multi-factorial barriers. These barriers can be addressed to improve rapport with refugees and the quality of community health and patient engagement initiatives.

Research Engagement in a Virtual World: Strategies for Maintaining the Power and Impact of Photovoice Research Online

When our photovoice research intersected with the COVID-19 pandemic, we were thrust into a new world of adapting the method in the virtual environment. Between both authors, we had over two decades of experience implementing photovoice. However, that involved tried and true methods of working face to face and side by side with people in community-based settings. This article describes lessons learned from two virtual photovoice projects. One involved pivoting from a project already well underway in person to online and the other was designed for virtual implementation since that was the only option available. Key considerations discussed are navigating our institutional review boards, adapting project management, building community online, and sharing results and advocacy for social change. Dilemmas and key decisions in each of these areas are described for practitioners and community-based researchers who need or seek to transition their photovoice research to the virtual environment. Practical tips and strategies for implementation are described and offered to photovoice researchers.

Recognizing and Breaking the Cycle of Trauma and Violence Among Resettled Refugees

Purpose of Review

The number of refugees across the globe continues to grow, leaving a large proportion of the global population in a vulnerable state of health. However, the number of robust clinical interventions has not kept apace. This paper provides a general review of literature on the trauma and violence that refugees face, the impact on health outcomes, and some of the promising models for clinical intervention.

Recent Findings

Refugees experience a cycle of trauma, violence, and distress that begins before migration and continues during migration and after resettlement. It has been challenging to develop robust clinical interventions due to the cumulative and cyclic effects of trauma, as well as the unique experiences of trauma that each refugee community and each refugee individual faces.

Summary

Trauma-informed care is a critical component of health care. Developing stronger guidelines for trauma-informed care will help clinicians better provide inclusive and equitable care for refugee patients.

Health promotion focusing on migrant women through a community based participatory research approach

Background

Migrants are often more vulnerable to health issues compared to host populations, and particularly the women. Therefore, migrant women’s health is important in promoting health equity in society. Participation and empowerment are central concepts in health promotion and in community-based participatory research aimed at enhancing health. The aim of this study was to identify conditions for health promotion together with women migrants through a community-based participatory research approach.

Methods

A community-based participatory research approach was applied in the programme Collaborative Innovations for Health Promotion in a socially disadvantaged area in Malmö, Sweden, where this study was conducted. Residents in the area were invited to participate in the research process on health promotion. Health promoters were recruited to the programme to encourage participation and a group of 21 migrant women participating in the programme were included in this study. A qualitative method was used for the data collection, namely, the story-dialogue method, where a process involving issue, reflections and actions guided the dialogues. The material was partly analysed together with the women, inspired by the second-level synthesis.

Results

Two main health issues, mental health and long-term pain, were reflected upon during the dialogues, and two main themes were elaborated in the process of analysis: Prioritising spare time to promote mental health and Collaboration to address healthcare dissatisfaction related to long-term pain. The women shared that they wanted to learn more about the healthcare system, and how to complain about it, and they also saw the togetherness as a strategy along the way. A decision was made to start a health circle in the community to continue collaboration on health promotion.

Conclusions

The community-based participatory research approach and the story dialogues constituted an essential foundation for the empowerment process. The health circle provides a forum for further work on conditions for health promotion, as a tool to support migrant women’s health.

Evidence from a Longitudinal Photovoice and Interview Assessment with Congolese Refugee Women in the Midwestern United States

Purpose: Refugees from the Democratic Republic of Congo have rapidly increased since 2016 and are growing to represent one of the top refugee groups in the United States. They are at high risk for health inequities, yet, there is limited qualitative research exploring the health needs, assets, and experiences of this group and even less longitudinal research. In addition, women refugees are understudied across all global contexts. Therefore, the purpose of this study was to conduct longitudinal qualitative research to provide rich contextual data on health and integration experiences of Congolese refugee women when they were newly resettled in 2016 and 3 years later in 2019. Methods: We conducted photovoice and interviews with 16 women in March through May of 2016 and 10 of the same women in March and April of 2019. Results: Women chose and discussed photos revealing a multitude of assets and needs spanning 2016 and 2019. Experiences with nutrition and food security were illuminated and are the focus of this article. Two major themes were access to food in contrast with availability of abundance of food in the United States and concern about what constitutes healthy food in the United States contrasted with accessing healthy and culturally appropriate food in the United States. Findings highlight strength bases of nutritional knowledge, attitudes, and skills as well as a strong social network aiding food security demonstrated by the Congolese refugee women in the study, offering an opportunity to shift to an assets and strength-based approach. Findings also note risk of food insecurity linked to barriers to employment and sociohistorical reflection on living with food shortages before migration to the United States that should be considered as providers strive to provide culturally relevant care. Conclusion: Findings offer contextual data for health care providers and public health professionals to improve nutritional health promotion and food security support for this population. Overlooking nuanced structural barriers may lead to providers perpetuating health inequities for this population.

A Photovoice Inquiry Into the Impacts of a Subsidized CSA Program on Participants' Health

Although consumption of fruits and vegetables is associated with reduced risk of disease, many Americans do not eat the recommended quantity or variety. This is especially true for low-income populations, who may face significant barriers to accessing fresh produce, including cost. Community-supported agriculture (CSA) Partnerships for Health is a subsidized community-supported agriculture program designed to reduce barriers to accessing fresh produce in a low-income population. This Photovoice study gave participants (n = 28) an opportunity to take photos representing how the program affects their lives. The aim was to understand the program's impact from the perspective of CSA members. Participants had 2 to 4 weeks to take photographs, and then selected a few to discuss during a subsequent focus group. Through this discussion, we learned that participants see the program as (a) supporting positive changes to their physical and social health and (b) facilitating learning about new foods, cooking, and agriculture. The study suggests that a reduced-cost CSA membership that incorporates cooking education supports participants' ability to try new foods, build skills, and improve health outcomes.

Promoting the health of refugee women: a scoping literature review incorporating the social ecological model

The health of refugee women after settlement in a new country, can be adversely or positively affected by individual, interpersonal, community, and organizational factors. While much of the previous literature highlights these factors individually, there is a lack of comprehensive synthesis regarding how the factors interact to influence the health of refugee women. We conducted a thematic analysis in our literature review to elucidate how providers can work with refugee women to prevent adverse health outcomes and intervene at multiple levels to improve their health outcomes after resettlement. We reviewed peer-reviewed literature from 2009 to 2019 from Google Scholar, JSTOR, Global Health, PubMed, CINAHL, Sociological Abstracts, and Social Service Abstracts, and also used citation chaining, to identify relevant information pertaining to refugee women's health. The key terms used for our literature review were, health care, violence, social support, and mental health. In total, we included 52 articles, 3 books, and 8 other sources. We found that refugee women are vulnerable to violence during migration and typically have high rates of post-traumatic stress disorder. There were also concerns of secondary victimization by providers after resettlement. We also found that social support is an important factor for reducing isolation, and improving access to health care, as well as improving mental health outcomes. However, social support was often difficult to maintain, and was moderated by factors such as English language fluency. Health care was influenced by health literacy, cultural difference, communication concerns, and access issues. The findings suggest that at the individual and interpersonal levels there is a need to address language barriers, improve provider-patient communication, and provide appropriate medical and mental health screenings. At the organizational level, inter-organizational communication and awareness are vital. At the community level, providers can work with community leaders, to educate, create dialogue and collaboration, to help facilitate understanding and bolster community social support. Improved communication and knowledge about the unique needs and concerns of refugee women through an integrated, multi-system approach is necessary to improve their health outcomes.

Food insecurity among immigrants and refugees of diverse origins living in metropolitan Atlanta: the roles of acculturation and social connectedness

Little is known about the prevalence and correlates of food insecurity among immigrants and refugees. Acculturation and social connectedness may influence food insecurity (lack of access at all times to enough food for an active, healthy life) by affecting a person's ability to access and use governmental and charitable food assistance programs, as well as other community-based or informal food-related resources. We explored associations of acculturation and social connectedness with food insecurity among diverse immigrants and refugees living in metropolitan Atlanta, a major destination for these populations in recent years. From 2017 to 2018, we surveyed 162 adults attending health fairs or programs hosted by two community-based organizations serving immigrants and refugees. Food insecurity within the past year was assessed using the American Academy of Pediatrics' two-item questionnaire. Acculturation indicators included heritage culture and American acculturation scores (Vancouver Acculturation Index), English fluency, heritage language fluency, and percentage of lifetime in the USA. Social connectedness was operationalized using measures of religious attendance and social isolation. We conducted a multivariable logistic regression controlling for age, sex, education, household income, employment status, and household size. In the sample, 51.9% identified as Vietnamese, 16.0% Hispanic, 15.4% Burmese, 14.8% Bhutanese or Nepali, and 1.8% other. The average age was 39.10 (standard deviation [SD] =13.83), 34.0% were male, 73.8% had below a Bachelor's degree, and 49.7% were unemployed. Average scores for American acculturation (mean [M] = 3.26, SD = 1.05, range 1-5) were lower than heritage acculturation (M = 4.34, SD = 0.68, range 1-5). Additionally, 43.4% were fluent in English. Average percentage of life in the USA was 40.59% (SD = 33.48). Regarding social connectedness, 55.9% regularly attended religious services. Average social isolation scores were 3.93 (SD = 1.34, range 3-9). Overall, past-year food insecurity was reported by 17.3% (34.6% in Hispanics, 24.0% in Burmese, 13.1% in Vietnamese, and 8.3% in Bhutanese or Nepali). In adjusted models, food insecurity was associated with English fluency (adjusted odds ratio [aOR] = 0.36, p = .03) and social isolation (aOR = 2.29, p < .001) but not other measures of acculturation or religious attendance. Limited English proficiency may make it more difficult to navigate or use governmental and charitable food assistance programs. Social isolation may hinder individuals from obtaining information about food assistance programs, receiving aid for services navigation, and sharing or borrowing food from family, friends, and neighbors. Interventions should seek to improve access to English language and literacy services, enhance the linguistic and cultural competency of service providers, and build social connectedness among immigrants and refugees.

"In Africa, There Was No Family Planning. Every Year You Just Give Birth": Family Planning Knowledge, Attitudes, and Practices Among Somali and Congolese Refugee Women After Resettlement to the United States

It is crucial for refugee service providers to understand the family planning knowledge, attitudes, and practices of refugee women following third country resettlement. Using an ethnographic approach rooted in Reproductive Justice, we conducted six focus groups that included 66 resettled Somali and Congolese women in a western United States (US) metropolitan area. We analyzed data using modified grounded theory. Three themes emerged within the family planning domain: (a) concepts of family, (b) fertility management, and (c) unintended pregnancy. We contextualized these themes within existing frameworks for refugee cultural transition under the analytic paradigms of "pronatalism and stable versus evolving family structure" and "active versus passive engagement with family planning." Provision of just and equitable family planning care to resettled refugee women requires understanding cultural relativism, social determinants of health, and how lived experiences influence family planning conceptualization. We suggest a counseling approach and provider practice recommendations based on our study findings.

Health-Related Needs and Barriers for Forcibly Displaced Women: A Systematic Review

The number of forcibly displaced people has been steadily increasing over the last decades. Women represent a large proportion of this population. Due to gender roles, duties of care, educational and economic imbalances, their experiences during flight and relocation differ from those of men and children. The currently available information about their specific health-related needs and barriers to access is scarce. We sought to explore the specific needs of the female refugee population employing a user-centered perspective. Rather than focusing on provider-designed interventions, we aimed at defining what female refugees want and need and which priorities they define themselves.

We searched PubMed, Medline, EMBASE, Cochrane Library, and Scopus to identify publications that explored the unique experiences of female refugees between January 1, 2008 and June 30, 2018. Publications needed to address the health needs of refugees, asylum seekers, or displaced individuals, include at least 50% women in their study and employ a user-centered perspective. A framework of themes was identified and applied to all publications.

We identified 1945 publications of which 13 could be included in the present review. Twelve of these publications employed qualitative and/or innovative methodology. We identified 5 broad categories of health-related needs (immediate health care, communication, cultural/spiritual, social, and economic).

The identified publications described the need for complex, coordinated approaches. Concerted action providing information and culturally sensitive care, while supporting language acquisition and economic empowerment is essential to improve the health status of female refugees. Transformative interventions need to address multiple axes of unequal access for female refugees to improve their overall health.

Working Through Uncertainty: The Perils and Potential of Community-Engaged Research on Refugee Resettlement

What can be learned from the process of community-engaged research (CER) on refugee resettlement? In the following, we share experiences, reflections, and lessons from implementing such a project. We begin with background on refugee resettlement and recent resettlement dynamics in the United States and Wisconsin, as well as literature on the study of refugees and this type of research more generally. Results and discussion are presented though our understanding of, and involvement with, the process via a framework of CER desired process outcomes, which we both propose and utilize to encourage effective efforts with marginalized populations going forward. CER is challenging and must be undertaken thoughtfully. One of the paper’s primary contributions is to share successes and failures in a transparent and unvarnished fashion. In particular, researchers need to share power and listen deeply, actions that will reverberate throughout such a process. Doing so comes with certain risks, and may be tangled, but also has strong potential to produce useful data, deep learning for researchers and participants, as well as empowerment of marginalized populations and relationship building that can yield future collaboration towards resilience.

Using Photovoice to Document Living With Mental Illness on a College Campus

Almost one-fourth of college students are living with a mental illness. Although much discussion has taken place on the mental health of today’s students, information from the students living with mental illness is lacking. The purpose of this study was to allow college students living with mental illness to document and communicate their realities with peers and university stakeholders through the participatory action research methodology, Photovoice. Seventeen college students who were prescribed at least one medication used to treat mental illness were given disposable cameras and asked to take photographs reflecting their realities of living with mental illness. Students met individually with researchers for reflection and as a focus group with other participants to discuss their photographs. All meetings were audio recorded, transcribed and qualitatively analysed. An additional meeting was held to communicate the students’ realities with campus stakeholders. Main themes identified were: insights into campus services, increasing awareness and educating others, support, and barriers to getting better. Photovoice was an effective methodology to allow college students living with mental illness to communicate with campus stakeholders to increase awareness and education. Through the sharing of photographs and reflections, policies and practices affecting students living with mental illness are being examined.

The use of participatory visual methods with community health workers: A systematic scoping review of the literature

With the need to design and evaluate Community Health Worker (CHW) programmes from a more human-centred perspective, researchers and programme managers are exploring the role of participatory visual methodologies (PVMs). This review identifies, maps, and assesses the quality of current literature that describes the use of PVMs with CHWs. It includes material from the grey literature and 10 major databases between 1978-2018. A Critical Appraisal Skills Programme (CASP) Qualitative checklist was used to assess the overall quality of the included studies. 12 original studies met the inclusion criteria. The studies were located in North America (n = 9) or sub-Saharan Africa (n = 3), with photovoice (n = 6) and digital storytelling (n = 5) being the most commonly used forms of PVMs. The overall quality of the evidence described in these articles was high, but it was notable that seven studies did not fully report the ethical considerations of their work. The studies revealed that PVMs can help assist CHWs' reflective practice and understanding of complex health issues, as well as identifying key issues in the community to potentially leverage social action.