Bridge to care for refugee health: Lessons from an interprofessional collaboration in the Midwest

Abstract

The United States resettles tens of thousands of refugees annually, with hundreds placed in mid-sized Midwestern cities such as Omaha, Nebraska. Prior to resettlement, refugees have limited access to health services and arrive with inadequate knowledge on basic hygiene practices, general healthcare issues, and minimal understanding of the American healthcare system. Additionally, current training for healthcare practitioners in the United States on issues related to refugee populations and their unique health needs is insufficient. The enormous need coupled with inadequate preparation, poses great challenges for both newly resettled refugees and health professionals, and provides opportunities for improvement with creative initiatives. The Bridge to Care (BTC) project is a unique partnership between health professions students, leaders from city and state refugee service organizations, and refugee leaders. It is a student-led/community-engaged organization overseen by the Service Learning Academy (SLA) in the College of Public Health at the University of Nebraska Medical Center. The SLA facilitates campus wide interprofessional community-based experiences like Bridge to Care. Through BTC, students take the forefront in communicating directly with leaders from community organizations and engaging with refugee leaders to determine all relevant service activities. Bridge to Care provides opportunities for students to engage in experiences that are not otherwise available in their standard curriculum. While providing essential services, students are able to enhance cultural and communication skills and gain experience working with an interprofessional team, building an understanding of the vital role each profession plays within the full spectrum of care for patients and communities.

Full text

Int Public Health J 2015;7(1):163-171 ISSN: 1947-4989
© 2015 Nova Science Publishers, Inc.
Bridge to care for refugee health: Lessons from an
interprofessional collaboration in the Midwest
Ruth Margalit, MD,1, Laura Vinson, MPH1,
Christine Ngaruiya, MD2,
Kara Gehring, MPH3, Pam Franks, BSN4,
Caci Schulte5, Andrew Lemke, BA5,
Joshua Blood 5, Tyler Irvine, BAS1,
Chelsea Souder, BS1, Deeko Hassan, BS5,
Andrea Langeveld, BS6, Carolyn Corn, BS5,
Thu Hong Bui, PharmD5, and
Ann Marie Kudlacz, BSA7
1Inter-Professional Service Learning Academy, College
of Public Health, University of Nebraska Medical
Center (UNMC), Omaha, Nebraska USA
2Department of Emergency Medicine, Yale New Haven
Hospitals, New Haven, Connecticut USA
3Public Health Project Coordinator, CityMatCH, Omaha,
Nebraska USA
4Embrace the Nations, Omaha, Nebraska USA
5College of Pharmacy, UNMC, Omaha, Nebraska USA
6College of Medicine, UNMC, Omaha, Nebraska USA
7Southern Sudan Community Association, Omaha,
Nebraska, USA
 Ruth Margalit MD; Associate Professor and Director, Inter-
Professional Service Learning Academy, Maurer Center
for Public Health, Rm 2038; College of Public Health,
Health Promotion, Social and Behavioral Health,
University of Nebraska Medical Center, 986075 Nebraska
Medical Center, Omaha NE 68198-4375, United States.
E-mail: rmargalit@unmc.edu
Abstract
The United States resettles tens of thousands of refugees
annually, with hundreds placed in mid-sized Midwestern
cities such as Omaha, Nebraska. Prior to resettlement,
refugees have limited access to health services and arrive
with inadequate knowledge on basic hygiene practices,
general healthcare issues, and minimal understanding of the
American healthcare system. Additionally, current training
for healthcare practitioners in the United States on issues
related to refugee populations and their unique health needs
is insufficient. The enormous need coupled with inadequate
preparation, poses great challenges for both newly resettled
refugees and health professionals, and provides
opportunities for improvement with creative initiatives. The
Bridge to Care (BTC) project is a unique partnership
between health professions students, leaders from city and
state refugee service organizations, and refugee leaders. It is
a student-led/community-engaged organization overseen by
the Service Learning Academy (SLA) in the College of
Public Health at the University of Nebraska Medical
Center. The SLA facilitates campus wide interprofessional
community-based experiences like Bridge to Care. Through
BTC, students take the forefront in communicating directly
with leaders from community organizations and engaging
with refugee leaders to determine all relevant service
activities. Bridge to Care provides opportunities for
students to engage in experiences that are not otherwise
available in their standard curriculum. While providing
essential services, students are able to enhance cultural and
communication skills and gain experience working with an
interprofessional team, building an understanding of the
vital role each profession plays within the full spectrum of
care for patients and communities.
Keywords: Interprofessional education, refugees, health,
community engagement

Ruth Margalit, Laura Vinson, Christine Ngaruiya et al.
164
Introduction
According to the United Nations High Commissioner
for Refugees (UNHCR), a refugee is defined as
someone who “owing to a well-founded fear of being
persecuted for reasons of race, religion, nationality,
membership of a particular social group or political
opinion, is outside the country of his nationality, and
is unable to, or owing to such fear, is unwilling to
avail himself to the protection of that country” (1).
“Secondary Migrants” are those refugees who have
originally resettled in one part of the country and have
subsequently moved to another location. There are
approximately 15 million refugees around the world
(1).
Refugees begin the process of seeking
resettlement after fleeing their home countries to seek
safety in neighboring nations. When refugees arrive at
the nation providing asylum or temporary residence,
they face three possible endpoints, one of which is
resettlement in a third country such as the United
States (1). This process often times takes more than 5
years while refugees live in harsh conditions within
the refugee camps (1). The President of the United
States sets the ceiling for refugee admission to the
United States (U.S.) each fiscal year (2), for which the
U.S. averages more than 50,000 refugee resettlements
per year (1). Many of these refugees choose to resettle
in mid-sized Midwestern cities given low costs of
living and low rates of unemployment (2). Refugees
are also placed in locations where existing family ties
are already established (2).
Refugee resettlement in Nebraska
Currently, there are an estimated 25,000 refugees in
Nebraska, with 15,000 in Omaha alone, according to
Omaha resettlement agencies (personal communica-
tions) and federal resettlement reports (2, 3). In fiscal
year 2013, there was a record high of 1,006 refugees
resettled, and the number is expected to increase in
2014 (4). Over the years, refugees from Sudan,
Somalia, Burma, Bhutan, Nepal, Iraq, Afghanistan,
Ethiopia, Liberia, Congo, and Burundi have been
resettled in Nebraska. As of 2006, it is estimated that
over 50% of the Sudanese population in the U.S.
settled in Nebraska (5, 6). In more recent years, the
majority of resettled refugees are those who have fled
to camps in Thailand from nearby Burma (Myanmar)
(7).
The three primary refugee resettlement agencies
that provide services to these refugees in Nebraska are
Lutheran Family Services (LFS), Southern Sudan
Community Association (SSCA), and Catholic
Charities (4). The agencies provide various services
such as: English classes, cultural orientation,
employment assistance, fair housing education,
financial literacy and household budgeting, as well as
training programs for churches and civic
organizations that wish to sponsor refugees and
immigration legal assistance. Agencies also help
coordinate access to healthcare services while in the
U.S (8).
Refugee health issues
Prior to arrival in the U.S., the refugee receives
inadequate preparation regarding health and health-
related issues (3). Refugees also lack basic
understanding about navigating the healthcare system,
Western hygiene practices, preventive practices, and
Western disease management (9). As a result of their
circumstances, it is not unusual to find individuals
with complicated health issues upon arrival and for
years following resettlement. Past history of poor
nutrition, poor sanitation, exposure to on-going
violence and lack of adequate medical care also
contribute to poor health (1).
One particular area of concern is the high rates of
undiagnosed infectious conditions such as
tuberculosis, malaria, hepatitis C, Human Immuno-
deficiency Virus (HIV), as well as skin and intestinal
parasites (9-11). Mental health disorders also affect a
large portion of the population including a high
prevalence of depression, drug and alcohol abuse (7,
11). Individuals who experienced persecution,
terrorization by violent groups, imprison-ment, and
torture, may suffer from somatization disorders,
psychosocial distress, post-traumatic stress disorder,
anxiety and depression (1,9-11). Another source of
health concern is injury at the workplace (4). The
majority of refugees in Omaha, Nebraska work in
meat packing plants performing physically demanding
jobs which puts them at high risk for injury (8).

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165
Lastly, cultural differences distinguish America
from many of the countries from which refugees
originate, and these differences extend to healthcare
(12). For example, in Somalia, only 2% of births take
place in a health facility whereas in America, women
are expected to deliver in the hospital. In addition,
numerous Somali women have undergone female
circumcision, which can make birthing more
complicated (12).
Bridge to Care (BTC) was founded on principles
of community-based participatory research (CBPR)
and service learning after identifying a gap in refugee
health and healthcare needs. In addition to the
language barrier, numerous refugees lack the cultural
constructs to understand life in this country. Timely,
appropriate healthcare acculturation is frequently
unmet and much needed (9, 10). Refugees receive
inadequate preparation prior to resettlement regarding
fundamentals such as running a ‘Western home’,
family roles, job distribution, the legal system, and
navigating the education system (2).
The program is designed to prioritize the vast
needs of the refugee populations, link refugees to
existing services, and increase provider competence
for refugee care. When working with refugees, BTC
refers to health as “a state of complete physical,
mental and social well-being and not merely the
absence of disease or infirmity” (13). Few other
programs have been set up to address refugee health
issues through collaboration with community
organizations.
The purpose of the work described in this
manuscript is to illustrate the unique setup between
community, interprofessional health professions
students and refugee leaders to enhance refugee health
in Omaha and surrounding communities. With the
number of interactions through BTC currently
approaching 4,000 and continuing to grow, the
organizational leaders seek to share this novel
initiative to impact other communities that interact
with refugee populations. The Institutional Review
Board of the University of Nebraska Medical Center
approved parts of this project that involve research,
such as implementation of surveys for the health
education sessions.
Methods
Bridge to Care (BTC) was established in April 2010
as an interprofessional organization supported by the
interprofessional Service Learning Academy (SLA),
College of Public Health at the University of
Nebraska Medical Center (UNMC). It is a partnership
involving students from the colleges of medicine,
nursing, pharmacy, public health, and allied health,
faculty, healthcare providers and community refugee
service agencies. The goal is to facilitate positive
healthcare outcomes for refugees by teaching them
how to navigate the healthcare system, enhancing
knowledge and cultural skills necessary for successful
assimilation, and developing strong relationships with
their communities.
This is achieved by: discerning group specific
health needs from each refugee community; providing
health education, linkage to healthcare and services;
and improving cultural awareness and knowledge
regarding resettled refugees among healthcare
providers
BTC has three initiatives to accomplish this
mission; monthly health education sessions, monthly
mentoring sessions, and health fairs/ linkage to care
events. Each of these initiatives requires collaboration
with the community. Table 1 lists the partners of this
project.
Health education sessions
Health education sessions are developed with each
refugee community (Sudanese, Somali, Burmese
/Karen, and Bhutanese) for a period of three
consecutive months. Health professions student
leaders with respective refugee community leaders,
work on building relationships, identifying health
needs, planning the education opportunities in
community settings and linking the refugee
community to appropriate health services. Typically
15-40 participants attend each session.
Health education session topics have included
pain management, hypertension, stroke, addiction,
mental health, suicide prevention, immunizations,
autism, healthy eating, using over the counter
medications, and navigation of the U.S. healthcare
system.

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166
Table 1. Bridge to Care Partners
BTC Partners Role
University of Nebraska Medical Center, College
of Public Health, Service Learning Academy Oversees the Bridge to Care program and assists in sustaining and
expanding the program; Provides evidenced-based models of theory
and community development, research methods for tracking and
identifying evaluation process and outcomes
Southern Sudan Community Association (SSCA) Resettlement Agency
Lutheran Family Services (LFS) Resettlement Agency
Embrace the Nations Faith-based organization providing cultural awareness training to
Bridge to Care volunteers; Assists refugees in multiple areas of need
and assists the public in better understanding and interacting with
refugee populations
Omaha Public Schools, ESL Program Partners for the mentoring program offered to refugee youth grades 5-
12
Nebraska Department of Health and Human
Services Responsible for coordinating and administering the Refugee
Resettlement Program on the state level
Alegent-Creighton Florence Clinic Federally designated clinic assigned to provide initial health
screenings/healthcare services to refugees; participates in annual health
fair and various educational sessions, while linking refugees to long
term healthcare
One World Community Health Center Provides clinical supplies for health fairs and flu shots for multiple ‘Flu
Shot Clinics’
Douglas County Health Department Providing health education resources and support
Walgreens Pharmacy Provides clinical supplies and personnel for health fairs and flu shots
for multiple ‘Flu Shot Clinics’
When health needs are selected, refugee community
leaders play an important role in identifying an
appropriate session format (presentation by students
or experts versus discussion groups), venue (faith
gathering place – Church/mosque, community center,
the familiar resettlement organization office), and
time/day for the session, recruitment of interpreters,
as well as recruitment of refugee community members
to attend. The health education sessions occur once
every 2-4 weeks in the community.
BTC leadership recruits health profession
students to participate in the sessions.
The majority of students participating in health
education sessions have no previous experience with
refugees prior to their involvement with BTC. Hence,
increasing the foundation of knowledge is important
to foster appropriate interactions with and
understanding of the populations being served. As an
introduction, at every health education session prior to
the arrival of the refugees, student and faculty
volunteers are required to participate in cultural
awareness training about refugees and their health
needs. The training is designed to enhance cultural
sensitivity, increase knowledge and ensure that
participants are better equipped to effectively interact
with the refugees. The training covers topics such as:
the unique characteristics of the various refugee
groups arriving in the U.S. and Omaha; the specific
health needs of refugees; the importance of and tips
on communicating effectively with various cultures
regardless of race, ethnicity, culture or language
proficiency.
Health-fairs/Linkage-to-care
In addition to health education and focused services
(like flu-shot clinics for specific refugee
communities), two major health fairs/linkage to care
events are organized each year in response to the
needs of the refugee community. These large events
(up to 500 participants) offer a wide range of
education opportunities, offering over 35 different
resource booths in 2013, including information

Refugee health
167
relating to proper hygiene, nutrition, immunizations,
chronic disease management, and child health.
Prescription and over the counter medication
counseling is also available. Free preventative
services like flu shots, screening for hypertension,
diabetes, obesity, vision and dental services are also
provided.
Mentoring program
In 2012, BTC expanded its engagement by adding the
BTC Mentoring Program, partnering with Omaha
Public School's English as a Second Language (ESL)
program for refugee students. Younger, school-aged
children often find it easier to acculturate into the
American lifestyle and can act as a great resource for
their families. Health professions students can become
mentors following successful completion of a
background check and training. Mentors are randomly
assigned mentees and engage with them on selected
Saturdays throughout the academic year, at least 12
times, covering topics concerning wellness and
health. BTC has identified this venue as another way
to improve communication with refugees. In Fall
2013, 352 refugee students participated with 20 health
profession student mentors.
Results
Since the inception of BTC (April 2010), over 700
students and over 4,000 refugees engaged together to
address health needs.
Unlike other venues for volunteering, Bridge to
Care is a relatively new model of healthcare outreach
in the community. The track record, albeit short, has
been consistent and positive. Different refugee groups
throughout the city have benefitted from relevant
education sessions and services. While progressing
through their rigorous programs of excellence,
students acquire skills and knowledge that will help
them excel in their field. Such skills as compassionate
care, cross cultural communication and multi-cultural
care, can impact their future patients who are likely to
come from various cultural backgrounds. These skills
are best learned through experiential real-life learning,
and the unique setting provided by BTC undoubtedly
forges the place for the learning while facilitating
potential better care for refugee populations in the
future. Table 2 presents qualitative data illustrating
community partners, refugees and students’
perspectives.
In addition to asking refugees about relevant
health topics and appropriate logistics to facilitate
BTC programming, refugees are all asked to provide
feedback through systematic evaluations through all
three BTC programs; health education sessions,
mentoring sessions, and health fairs/linkage to care
events. For example, following each health fair,
refugees are asked to complete an oral evaluation. Of
the 350 refugees who attended the past Fair, 131
completed the survey of which 99% indicated that the
event was ‘most useful’ (rated 10 on a scale of 1-10
the usefulness of the health fair - 1 being least useful
and 10 being most useful), and that the information
was presented in a way that they could understand.
Additional responses from the refugees include the
desire to have more clinical services offered and an
indication of the variety of ‘favorite booths’ such as,
basic health screenings, nutrition, over-the-counter
medication, free vaccinations, dental care and vision
screening with eye glasses.
Student perspectives
With each health education session, students take part
in a pre/post assessment to determine knowledge,
skills, comfort, and beliefs of the student’s cultural
competency.
The aggregate analysis of the pre and post
assessments, administered to a total of 29 students
over three consecutive sessions in 2013 with the
Bhutanese population concluded the following in
regard to knowledge, skills and cross cultural
competence: following the cultural awareness
training, 80% of students reported an increase in
knowledge of cultural challenges that face refugees in
U.S. and an increase in skills with student’s ability to
communicate effectively with different cultures
regardless of race, ethnicity, culture or language
(increase from 2 to 4 on a Likert scale [1-least, 5-
most].

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168
Table 2. Perspectives of partners in the Bridge to Care Program
Community partner Refugees Student
Positive “Thank you for providing
information to a population that
may have otherwise not received
anything.”
“The partnership with the university
helps us dream big and involve
individuals that otherwise are not
interested in refugees in our city.”
“The program provides services that
we do not have resources for. At
the same time students get to learn
in a real-world setting. It’s a
win/win!”
“Innovative; sustainable program!”
“My favorite part of the Fair is
that my kids know more about
health and healthy food.”
“I will tell my people to come
and attend the next event.”
“The session helped me
understand why I may need to
have a flu-shot.”
“It's a really good experience for
me to get to know more about
health, improve my health.”
“I respect the students who care
about me.”
“It has really opened my eyes to
refugees in Omaha to better
understand the various challenges
they face.”
“The most important part was to
gain trust and build relationships
with strangers: refugees and other
health profession students.”
“I developed appreciation and
awareness to the notion that
nothing should be taken for
granted.”
“I learned how important is
cultural awareness and competent
cultural practice.”
Negative “Shorten refugee evaluations they
are hard to understand.”
“Make sure you use language that is
simple and clear.”
“They ran out of flu shots and I
didn’t get one!”
“I want them to offer more
dental care and glasses.”
“I need more cultural training to be
effective.”
“Needed interpreters, but lacked
sufficient funding.”
Students have also consistently reflected positively on
their experiences through BTC. For example,
following a Somali health education session, a student
stated, “It has really opened my eyes to the refugee
population in Omaha and the various challenges they
face.” Another student reflected “….It was a
rewarding experience and I felt like I was doing
something that really mattered for the community.
The Bridge to Care organization is a great way to
interact with the diverse community that lives within
Omaha. It was very beneficial to learn about a
different culture as well as use skills we have learned
from our time at UNMC towards those in need. I will
be able to use what I learned on Sunday for the rest of
my career. I would encourage anyone to help out with
a Bridge to Care event[s] because not only are you
helping others, you are also bettering yourself as a
person as well as a professional.”
Discussion
The work with refugees has been often challenging,
complex, and at the same time very rewarding. In
various listening sessions during the past 2 years,
refugees in Omaha identified the following needs:
housing, health, employment, education, transporta-
tion and public safety/community awareness. Bridge
to Care focused on healthcare issues, while taking into
consideration the host of challenges the community
face. The major lessons learned are listed below:
1. Understanding of US healthcare system - many
members of the American society struggle to fully

Refugee health
169
understand the ins and outs of the U.S. healthcare
system, especially at a time of major changes in
insurance coverage. Refugees have little foundational
understanding of this complex system and often fall
victims to misunderstandings and incur startling costs
for minor services obtained outside of insurance
coverage or in an inappropriate manner (for example -
use of ER for simple upper respiratory infection).
Refugees hold a unique understanding of health and
sickness, embracing a holistic approach to treatment
of diseases (American medicine is deeply embedded
upon scientific data and physical exam, when other
cultures look at the environment, cultural customs and
traditions, and rely heavily on healers for cures). The
BTC program has to be both efficient in assisting with
the understanding of the healthcare system while
maintaining sensitivity to the traditional approach
when presenting strategies for diagnosis and
management of diseases.
2. Understanding preventive care - Students
learned firsthand how individuals from diverse
populations, cultural practices and beliefs have very
different perceptions and understanding regarding
health. A striking example was preventive health
services, discussed at an education session as an
important part of maintaining good health. Yet,
‘preventive care’, regarding cancer in the Bhutanese
community, was found to be a new concept and a
problematic one: “if you talk about or schedule
screening for colon or cervical cancer you will bring it
upon yourself”. BTC has learned that more education
and time is needed for preventive practices to be
understood and embraced by refugees. This finding
was an important one shared with the practice clinical
community.
3. Refugee participation in sessions: Almost all
refugees, regardless of geographic location, tend to
avoid drawing attention to themselves. Asian
refugees, especially, tend to be quite reserved. This
means remaining silent rather than speaking up, not
asking questions, not asking for clarification and
essentially agreeing with whatever is said or done.
Because time is limited in the education sessions, it is
difficult to check for understanding, to assess how
much of the presented material is comprehended, and
how useful it was for the refugees. With consistent
repetition of health topics presented at health
education sessions, the hope is that the information
will eventually be absorbed.
4. Sensitive topics: Another challenge has been
the discussion of more sensitive topics such as
women’s health, torture and abuse, mental illness and
subjects related to sex (i.e. sexually transmitted
diseases). Generally speaking, these topics are
discussed very little in the community or in the home
and special measures must be taken in order to
successfully address them. Due to matters of
sensitivity and confidentiality, interpreters coming
from the community are especially unsuitable when
discussing these personal issues. The interpreters need
to correctly communicate the health needs of their
respective populations, and be of an appropriate age
with adequate knowledge. Medically-certified
interpreters are in very high demand, and as a result,
are quite expensive and often unavailable. Finding
competent medical interpreters was a challenge for
BTC as it was for the practice community, and many
of the sensitive topics could not be addressed. New
initiatives designed to address mental health and other
sensitive topics in group settings are currently being
developed.
5. Logistics of the program - The general logistics
for the BTC program have been a challenge and a
great lesson to all involved. Scheduling planning
meetings, session dates/times, session venues, refugee
recruitment and selecting appropriate food have all
required on-going open communication, flexibility,
leadership and good problem solving skills. Refugees
often work the first (7-4) and second (1-9) shifts 6-7
days a week, have limited access to transportation,
and prefer gatherings in places of worship or at the
housing complexes where most of the community
members live. Since weekends tend to work best for
the refugees, students, community organization
leaders and faculty extended their commitment to
meet these needs, scheduling most activities on the
weekends. Several sessions have been held following
the conclusion of an existing ESL class or after faith-
based activities to reach a larger number of refugees.
In addition, students from the various health
professions, have to coordinate between the various
professional curricula to ensure student participation
(avoiding dates prior to major exams etc.). In
addition, for each activity, interpreters need to be
recruited. They are expected to disseminate

Ruth Margalit, Laura Vinson, Christine Ngaruiya et al.
170
information about the activity, recruit individuals to
attend, and be present at the session. As stated earlier,
interpreters are in high demand and need to be
contacted long in advance.
Timely communication has also been an enduring
challenge; perhaps the different perception of ‘time,
the lack of access to electronic communication, or the
difference in norms and expectations for follow-up
and response. In any case, the expectation of prompt
reply to phone messages and emails is unrealistic and
adds another layer to coordination.
6. Funding and sustainability - Each of the BTC’s
activities, especially the bi-annual health fairs, require
resources (i.e.: medical supplies, transportation, food,
translated materials, and many other relevant items).
Funding for BTC activities has been secured through
an ongoing effort by the SLA, through applications to
local and national grants and for in kind contributions.
Since its inception in 2010, over $20,000 cash
funding were secured with over $100,000 in-kind
services. Although tedious and very time consuming,
through this process, BTC has formed numerous
partnerships with local businesses and service
providers.
New opportunities: The Refugee Health
Collaborative
As a direct result of the BTC program, the Nebraska
Refugee Health Collaborative (RHC) was formed,
with the goal to improve health of the refugees who
are a part of the fabric of the community. Twelve
organizations joined together: UNMC, College of
Public Health, (including the Service Learning
Academy and Bridge to Care), Southern Sudan
Community Association, Lutheran Family Services,
Embrace the Nations, Omaha Together One
Community, the Institute of Public Life, Nebraska
Department of Health and Human Services (Refugee
Coordinator and Refugee Health Coordinator),
Douglas County Health Department, Ready in Five,
Alegent-Creighton Florence Clinic, One World
Community Health Centers, Omaha Public Schools,
and to date, over 250 refugee leaders and key
community members have participated in the monthly
meetings.
Much like BTC, the larger RHC embraced the
following goals: to develop mutual understanding and
trust among the group, to determine major perceived
barriers to service (i.e. economic, cultural, language,
financial, organizational, navigation of the health
system, insurance), to identify culturally appropriate
methods of engagement and to determine priorities
and opportunities for action.
The two sub-committees working under the RHC:
The first is the Engagement Team, which looks at
methods of engaging the refugee community in order
to build capacity, improve existing and develop new
services and empower the targeted populations to
improve their own health. The second is the Data
Team, which works a. to help clarify the number of
refugees and their respective culture groups living in
Omaha. Existing data sources were identified and will
be linked to create a usable database that will support
future activities including engagement and research;
b. Since major funding is needed to ensure the
sustainability of BTC and the RHC, the data team is
working on developing scientific research grant
applications. In addition, the RHC is diligently
working to develop a community health worker
program with the refugee communities. The RHC
encourages refugee involvement at all levels
including refugee leaders from all groups who are
represented in the city. This is not merely a project;
the RHC is committed to long-term goals and
implementation. With diverse team players from
academia, local refugee organizations and refugee
community leaders, the potential for successful
outcomes is promising.
As we identify and embrace the different refugee
groups in Omaha NE, we can better understand
health-related needs, develop effective interventions,
enhance cultural sensitivity and track outcomes. All
are bound to benefit from this endeavor.
Limitations
The limitations of this project center on the
assessment of its effectiveness. Currently, due to
language barriers, limited resources, slow
coordination among agencies, and limited data-
sharing agreements, we are unable to better track how
the program is making a difference in the community.

Refugee health
171
With a $50,000 grant recently obtained for linkage of
data and the development of a comprehensive data
system for the city, we hope to better capture the
impact on health and other related outcomes in the
near future.
Conclusion
The definition of Health as referred by the World
Health Organization (WHO) is especially important
when considering the refugee populations (13).
Started in 2010 from an initiative of a caring student
(author CN) the interprofessional student-
led/community-engaged Bridge to Care project
expanded its activities into 2014. It created great
ripples for further collaborative action and capacity
building to improve the health of the refugee
community. Students are rewarded with an
exceptional real-life community based experience,
while community needs are addressed, local capacity
is built, and sustainability is built.
Acknowledgments
We are deeply grateful for the work of all of the
Bridge to Care student leaders, the faculty volunteers
who supervise and mentor the students, refugee
community leaders; and to the refugee service
organizations leaders who trust and nurture this
partnership.
References
[1] UNHCR: The UN Refugee Agency. A pocket guide to
refugees 2008. URL: http://www.unhcr.org/pages/
49c3646c4b8.html
[2] US Office of Refugee Resettlement. Refugee arrival
data 2000-2012. URL: http://www.acf.hhs.gov/
programs/orr/resource/refugee-arrival-data
[3] US Department of State Refugee Resettlement in the
United States 2013. URL: http://www.state.gov/j/
prm/releases/factsheets/2013/203578.htm
[4] Department of Health and Human Services-Nebraska,
2012-2013 Minority Health Initiative Annual Report.
URL: http://dhhs.ne.gov/Pages/srd_srdindex.aspx
[5] Lainof CA, Elsea SJ. From Sudan to Omaha: how one
community is helping African refugees find a new
home. Am J Nurs 2004;104:58-61.
[6] Tompkins M, Smith L, Jones K, Swundell S. HIV-
education needs among Sudanese immigrants and
refugees in the midwestern United States. AIDS Behav
2006;10:319-23.
[7] Benner MT, Townsend J, Kaloi W, Htwe K,
Naranichakul N, Hunnangkul S, et al. Reproductive
health and quality of life of young Burmese refugees in
Thailand. Confl Health 2010;4:5.
[8] Campbell DS. Health hazards in the meatpacking
industry. Occup Med 1999;14(2):351-72.
[9] World Health Organization. Overcoming migrants’
barriers to health. URL: http://www.who.int/bulletin/
volumes/86/8/08-020808/en/
[10] Morris MD, Popper ST, Rodwell TC, Brodine SK,
Brouwer KC. Healthcare barriers of refugees post-
resettlement. J Commun Health 2009;34:529-38.
[11] Carswell K, Blackburn P, Barker C. The relationship
between trauma post-migration problems and the
psychological well-being of refugees and asylum
seekers. Int J Soc Psychiatry 2011;57:107-19.
[12] Herrel N, Olevitch L, Dubois DK, Terry P, Thorp D,
Kind E, el al. Somali refugee women speak out about
their needs for care during pregnancy and delivery. J
Midwifery Womens Health 2004;49:345-9.
[13] World Health Organization. Preamble to the
Constitution of the World Health Organization 1946.
URL: http://www.who.int/about/definition/en/print.html
[14] Israel BA, Schulz AJ, Parker EA, Becker AB. Review
of community-based research: assessing partnership
approaches to improve public health. Annu Rev Public
Health 1998;19:173-202.
Submitted: April 10, 2014. Revised: Maybe 29, 2014.
Accepted: June 05, 2014.