Hyojin Im

Background and Objective: Bhutanese refugees in the United States face intersecting health disparities shaped by trauma, cultural disruption, and systemic barriers. Despite growing attention to refugee health, little is known about how this community defines and practices healthy living post-resettlement. This study explores Bhutanese refugees' lived experiences of health using participatory, culturally grounded methods. Methods: Using photovoice within a community-based participatory research framework, 24 Bhutanese participants and 6 peer facilitators engaged in photodocumentation and community wellness workshops. Participants captured images related to healthy living and discussed their meanings in collective sessions. Thematic analysis of photonarratives was codeveloped with community members. Results: Four themes emerged: (1) Land as memory and identity, where loss of agrarian life symbolized disconnection from health and culture; (2) Food as cultural survival, as traditional eating practices supported well-being and adaptation; (3) Health navigation in a system not built for us, showing how chronic illness and healthcare inaccessibility were mitigated by community-led support; and (4) Spiritual continuity as healing, where faith, ritual, and language sustained emotional and cultural resilience. Conclusion: Health among Bhutanese refugees is relational, culturally embedded, and shaped by collective resilience. Effective interventions must integrate cultural continuity, peer leadership, and place-based strategies.

And relational practices, its growing institutional adoption risks obscuring the structural and political conditions that continue to re-traumatize refugees and (im)migrant populations [5,6].TIC has largely been practiced within clinical and interpersonal frameworks, limiting its capacity to address the structural conditions that shape trauma in refugee contexts. In health systems, trauma-informed practice is operationalized as a set of provider competencies, communication strategies, or screening tools designed to reduce re-traumatization and improve patient engagement [1,7]. For refugees and asylum seekers, however, trauma is rarely confined to the past, and experiences of forced migration are frequently followed by prolonged asylum procedures, temporary or uncertain legal status, documentation instability, and barriers to employment, housing, transportation and health care. These conditions create persistent uncertainty and insecurity long after arrival in receiving countries [8]. As a result, trauma in refugee and (im)migrant contexts is not only a past exposure or individual clinical history; it can also be sustained when receiving-country systems repeatedly expose people to uncertainty, loss of control, conditional access to resources, and prolonged waiting. Health systems serving displaced populations operate at the intersection of clinical care and multiple bureaucratic regimes, including immigration adjudication, housing systems, and public benefits programs.Administrative delays, repeated eligibility verification, documentation requirements, and health coverage transitions can therefore sustain chronic stress and undermine recovery [9]. In this context, TIC cannot be meaningfully confined to interpersonal clinical practice. The central challenge is not simply a deficit of compassion or commitment among providers, but a structural misalignment between clinical care models and the policy environments that reproduce instability, bureaucratic friction, and administrative lag, generating chronic uncertainty. This paper argues that TIC, as currently operationalized, remains insufficient for refugeeserving systems because it is overly confined to interpersonal and clinical domains. We propose a reconceptualization of TIC as a structurally embedded, system-level approach that integrates administrative, legal, and policy conditions as core determinants of trauma and healing.Although these structural mechanisms are relevant across many Western resettlement contexts, this paper draws primarily on the United States health and social service system. U.S.-based examples are used to illustrate broader patterns of administrative burden and structural misalignment, while recognizing that these processes vary across welfare regimes, migration policies, language access systems, and institutional contexts.For refugees and asylum seekers, trauma cannot be understood as an individual condition alone. It is also shaped by the legal, administrative, and policy environments through which displaced people are required to seek safety, care, and belonging. Legal precarity, bureaucratic uncertainty, and exclusionary policy regimes can generate cumulative psychological harm by repeatedly constraining access to stability, resources, and social participation [10]. For example, temporary or unresolved immigration status constrains access to employment, housing, and public benefits while prolonging uncertainty regarding long-term stability. Prolonged asylum processes have been consistently associated with elevated rates of depression, anxiety, and posttraumatic stress symptoms [11,12]. These harms are not merely downstream effects of displacement. They are ongoing conditions through which distress is organized and sustained.Administrative burden is one key mechanism through which institutions produce distress.Refugees and asylum seekers often navigate repeated documentation requirements, eligibility verification, delays, and discretionary gatekeeping across health care, immigration, housing, and public benefit systems [13,14]. Medicaid interruptions after status transitions, disability benefit denials despite documented impairment, repeated requests for records already submitted, and prolonged case backlogs can suspend access to treatment, housing, or family reunification [15,16]. These processes impose cumulative cognitive and emotional demands under conditions of uncertainty and limited control. In this sense, administrative systems do not merely mediate access to care. They actively participate in the production of distress, which creates a fundamental tension. TIC is implemented within systems that simultaneously generate the instability it seeks to mitigate. While providers are tasked with fostering safety, trust, and continuity, institutional processes routinely introduce disruption, unpredictability, and exclusion.The result is not simply a gap in implementation, but a structural misalignment between the goals of care and the conditions under which care is delivered. The problem is not merely inadequate implementation of TIC, but the assumption that trauma can be addressed primarily through interpersonal intervention while structural conditions remain unchanged. This conceptual narrowing has organizational consequences. When refugee trauma is framed primarily through individual psychiatric categories, particularly PTSD, organizations may focus on screening, referral, and symptom management while treating legal, administrative, and socioeconomic conditions as external context. This disconnect becomes visible at the level of organizational implementation. Although trauma-informed principles are widely endorsed, their translation into practice remains uneven and often superficial. Many TIC models remain anchored in Western psychiatric frameworks, particularly PTSD as the dominant lens for understanding refugee distress [6,17]. While clinically useful in some contexts, this framing can narrow attention...

Background and Objectives: Older refugees in the United States face substantial healthcare access barriers shaped by displacement, trauma, and systemic challenges. Despite growing recognition of these barriers, research remains limited. This study examined multilevel predictors of healthcare access barriers among older refugees using the Older Adult Immigrant Adapted Model for Health Promotion, an ecological framework integrating individual, interpersonal, community, and structural factors. Research Design and Methods: Data were drawn from the Annual Survey of Refugees (2020–2022), yielding a nationally representative sample of 840 refugees aged 50 and older. Healthcare access barriers were measured as cumulative difficulties across cost, transportation, language, knowledge, and appointment access. Using Poisson regression with LASSO regularization and multiple imputation, we identified salient predictors across ecological levels while accounting for missing data and overfitting. Results: The final model explained 65 percent of variance in barrier counts. Structural and social conditions were dominant: cumulative resettlement challenges showed the strongest association with barriers (Incidence Rate Ratio [IRR] = 1.60, p < .001), followed by perceived discrimination (IRR = 1.49–1.52, p < .001) and neighborhood unsafety (IRR = 1.34, p < .01). Poorer physical health modestly increased barriers (IRR = 1.14, p < .05), while residing in the United States for 2–3 years was protective (IRR = 0.81, p < .05). The model demonstrated excellent classification performance (AUC = 0.858). Discussion and Implications: Healthcare access barriers among older refugees reflect structural adversity and social exclusion rather than individual characteristics alone. Findings support an ecological perspective that emphasizes multilevel determinants and suggest that interventions should address resettlement coordination, discrimination reduction, and community welcoming alongside healthcare system improvements to achieve equity for aging refugee populations.

Experiences with forced displacement are associated with poor mental health and psychosocial wellbeing for Somali refugee families. Current understanding of family distress experiences primarily revolves around individual-level behavioral, psychiatric, or psychodynamic characteristics, neglecting the potential impact of system-level traumatization on individuals and family units. This qualitative study explores Somali refugee parents’ experiences with familial distress, the strategies employed to augment negative displacement experiences, and the culturally-embedded re/productions of resilience to help limit distress in light of culture loss. Semi-structured interviews were conducted with 16 Somali refugee families living in a homeless shelter. Thematic analysis resulted in three main findings concerning family distress experiences: (1) transnational experiences with traumatic stress; (2) the deterioration of family units and structures; and (3) the emergence of chronic, collective-based cultural marginalization. The study’s results highlight how chronic marginalization and discrimination may help increase the risk for cross-generational distress for Somali refugee families. Findings provide important insights for understanding the capacity for previously neglected sources of distress in the displacement and resettlement process that may influence the cross-transmission of distress in refugee families.

Background: Depressive symptoms in displacement settings are often framed as consequences of refugee status, which can obscure the shared structural conditions emphasized in the Social Determinants of Health (SDoH) framework that shape mental health for refugees and host communities and limit the identification of practical intervention targets. This study examines the relative contribution of health, socioeconomic, protection, and contextual factors to depressive symptom severity among adults living in displacement-affected settings in South Sudan. Methods: We analyzed nationally representative data from 3,055 adults (2,066 refugees, mean displacement duration 11.15 years; 989 host community members) from the 2023 Forced Displacement Survey. Depressive symptom severity was measured using the PHQ-9. We compared Elastic Net regression, Random Forests, and Extreme Gradient Boosting (XGBoost) using 10 × 5 nested cross-validation. The best-performing model was interpreted using SHapley Additive exPlanations (SHAP) to estimate the marginal contribution of each predictor in PHQ units. Results: Mean depressive symptom severity was low to moderate overall ( M = 4.43, SD = 5.00) and did not differ by population type ( p = 0.783). XGBoost showed the highest predictive performance [Root Mean Squared Error (RMSE) = 4.47, R ² = 0.247], significantly outperforming Elastic Net regression ( p = 0.006). Model explanations identified self-rated health status as the dominant predictor (19.3% of total importance), followed by perceived community violence (11.1%), perceived poverty (9.6%). Age (9.3%), discrimination (9.2%), food insecurity (8.6%), and citizenship (8.2%, pooled model only) contributed at moderate levels, whereas social protection (3.4%) and remittances (0.7%) contributed minimally. Predictor profiles were broadly similar across refugee and host models, with differences primarily in magnitude rather than rank ordering. Conclusion: Depressive symptoms in South Sudan appear to be structured primarily by health, material hardship, and protection-related gradients rather than refugee status per se . Findings support integrated, area-based public health responses that link mental health support with primary health care access, poverty-oriented assistance, and protection and safety interventions rather than programming organized primarily around legal status distinctions.

The complexities of refugee resettlement in the U.S. require comprehensive mental health and psychosocial support (MHPSS) strategies, yet significant gaps persist due to resettlement policies prioritizing short-term self-sufficiency over long-term mental health and well-being. This study explores the shift from traditional "burden sharing" to "task sharing" models that emphasize community-initiated care (CIC). Using a two-phase qualitative method, 27 refugee leaders and bilingual service providers from 14 refugee communities, including Afghan, Bhutanese, Burmese, Congolese, Somali, and Sudanese communities, across four states participated in focus groups or key informant interviews. Thematic analysis revealed that peer support models play a critical role as bridges between cultures, service sectors, and formal and informal networks. However, peer support remains insufficient without structural reform, as refugees face barriers such as lack of professional development and power imbalances with professionals while managing their own life challenges. This study emphasizes formalizing CIC models that empower refugees to lead the sharing process in collaborative care. Intersectoral collaboration and supportive policy frameworks are necessary to sustain peer support and build long-term leadership capacity. The findings highlight the need for a system-level shift to ensure equitable responsibility for care, fostering sustainable, community-driven MHPSS solutions in refugee resettlement.

Refugee newcomers in the United States experience pronounced disparities in healthcare access, shaped not only by individual-level or material constraints

The global rise in aging populations intersects with increasing rates of forced displacement and chronic illness, prompting an urgent need to integrate older refugees into national healthcare systems. Health service use is a key means of decreasing health disparities and improving health equity, particularly among individuals with chronic illness. Yet little is known about the factors that shape healthcare use among older refugees in the US. This study uses nationally representative data to examine primary care visits among older refugees resettled between 2015 and 2019. Using data from the 2020 Annual Survey of Refugees, we applied Andersen's Modified Behavioral Model of Health Service Use to examine the association of migration-related predisposing, enabling, and need factors with having a routine physical exam during the past year. Migration-specific variables included post-migration stressors, ethnic density, and arrival cohort. We conducted hierarchical logistic regression to evaluate the relative influence of each factor category, entering predisposing factors first, followed by enabling and need factors. Primary care use was significantly associated with race, religion, insurance coverage, education, and English proficiency. Muslim identity was a strong predictor, and Asian and Black refugees were more likely than White refugees to have had a physical exam. Both higher education and lower English proficiency were linked to increased use of primary care. Findings highlight key determinants of healthcare utilization and suggest a need for targeted interventions to improve older refugees' use of health services. Notably, need-based health variables were not significantly linked to exam completion. Expanding insurance, education, culturally responsive care, and community-based interventions could enhance access. Future research should incorporate administrative health data and qualitative methods to address survey limitations and explore within-group differences in healthcare utilization.