Culturally-Appropriate Orientation Increases the Effectiveness of Mental Health First Aid Training for Bhutanese Refugees: Results from a Multi-state Program Evaluation

Abstract

Poor mental health remains a significant source of morbidity and mortality in the Bhutanese refugee community. Mental Health First Aid (MHFA) is a promising intervention that has been used in other immigrant communities to prepare individuals to recognize and respond to mental health warning signs. This was a non-randomized program evaluation. Using pre- and post-training questionnaires developed for prior evaluations of MHFA, we examined the effectiveness of training offered with and without culturally-appropriate orientation to mental health terminology and concepts (N = 458). Pre- to post-training improvement in ability to recognize schizophrenia, ability to respond to schizophrenia and depression, and the overall mental health literacy was greater for Bhutanese refugees who attended orientation relative to other participants (P < 0.05). In scaling up MHFA training for other immigrant communities, we recommend developing and systematically evaluating culturally-appropriate orientation materials that introduce mental health vocabulary and contextualize mental health concepts.

Full text

Vol.:(0123456789)
1 3
Journal of Immigrant and Minority Health
https://doi.org/10.1007/s10903-020-00986-8
ORIGINAL PAPER
Culturally‑Appropriate Orientation Increases theEectiveness
ofMental Health First Aid Training forBhutanese Refugees: Results
fromaMulti‑state Program Evaluation
AshokGurung1· ParangkushSubedi2· MengxiZhang3· ChangweiLi4· TimothyKelly2· CuriKim2· KatherineYun5,6
© Springer Science+Business Media, LLC, part of Springer Nature 2020
Abstract
Poor mental health remains a significant source of morbidity and mortality in the Bhutanese refugee community. Mental
Health First Aid (MHFA) is a promising intervention that has been used in other immigrant communities to prepare indi-
viduals to recognize and respond to mental health warning signs. This was a non-randomized program evaluation. Using
pre- and post-training questionnaires developed for prior evaluations of MHFA, we examined the effectiveness of training
offered with and without culturally-appropriate orientation to mental health terminology and concepts (N = 458). Pre- to
post-training improvement in ability to recognize schizophrenia, ability to respond to schizophrenia and depression, and
the overall mental health literacy was greater for Bhutanese refugees who attended orientation relative to other participants
(P < 0.05). In scaling up MHFA training for other immigrant communities, we recommend developing and systematically
evaluating culturally-appropriate orientation materials that introduce mental health vocabulary and contextualize mental
health concepts.
Keywords Bhutanese refugees· Cultural perspectives· Mental health terminology· Stigma
Introduction
Mental health is a pressing concern for the world’s 25.4 mil-
lion refugees, people who have fled from their home coun-
tries due to a well-founded fear of persecution based on race,
religion, nationality, political opinion, or membership in a
particular social group [1]. A history of trauma and uncer-
tainty about the future contribute to refugees’ heighted risk
of depression, post-traumatic stress disorder [2], anxiety,
and emotional distress [3]. For many refugees, poor mental
health may persist following resettlement and may even be
exacerbated by post-resettlement stressors [4–7].
Bhutanese refugees are a Nepali-speaking ethnic minority
who were expelled from Bhutan in the early 1990s amidst
political violence and then restricted to refugee camps in
rural Nepal before third-country resettlement became an
option in 2007. More than 96,000 Bhutanese refugees have
resettled in the United States since 2008 [8]. Despite relative
safety following resettlement, a large cross-sectional sur-
vey of randomly-selected Bhutanese refugee adults in seven
U.S. cities found that 21% screened positive for depression,
19% for anxiety, and 4.5% for PTSD [2]. In 2012, the U.S.
Centers for Disease Control and Prevention reported that the
Electronic supplementary material The online version of this
article (https ://doi.org/10.1007/s1090 3-020-00986 -8) contains
supplementary material, which is available to authorized users.
* Ashok Gurung
asg62@pitt.edu
1 University ofPittsburgh, 4200 Fifth Ave, Pittsburgh,
PA15260, USA
2 Division ofRefugee Health, Department ofHealth
andHuman Service, Office ofRefugee Resettlement,
Administration forChildren andFamilies, 330 C Street, SW,
Washington, DC20201, USA
3 Department ofNutrition andHealth Science, College
ofHealth Science, Ball State University, 2000 W. University
Ave., Muncie, IN47306, USA
4 Department ofEpidemiology & Biostatistics, University
ofGeorgia, 120 B.S. Miller Hall, Health Sciences Campus,
101 Buck Road, 30602Athens, GA, USA
5 Policy Lab, Children’s Hospital ofPhiladelphia, 3401 Civic
Center Blvd., Philadelphia, PA19104, USA
6 Division ofGeneral Pediatrics, Children’s Hospital
ofPhiladelphia & University ofPennsylvania Perelman
School ofMedicine Philadelphia, 3400 Civic Center
Boulevard, Philadelphia, PA19104, USA

Journal of Immigrant and Minority Health
1 3
annual suicide rate in this community was (21.5/100,000)
almost double the rate for the overall U.S. population at that
time [9]. Victims included both men and women, ranged
in age from 16 to 85years old, and in many cases suicide
was believed to be associated with integration, financial, and
family difficulties [10, 11].
Efforts to address mental health in the Bhutanese com-
munity have been multifaceted. Refugee-run nonprofit
organizations have sought to leverage resources within
the Bhutanese community—including cultural norms that
value mutual support and assistance—to help vulnerable
community members resolve integration-related challenges
[12]. The federal Office of Refugee Resettlement (ORR) has
collaborated with Bhutanese community leaders to develop
culturally-appropriate suicide prevention video messages
[13] and to offer Mental Health First Aid (MHFA) training.
MHFA teaches participants to recognize and respond to
mental health warning signs and symptoms in themselves
or their fellow community members. It has had promising
results with Vietnamese and Chinese immigrant communi-
ties in Australia [14, 15]. The 8-h course introduces risk
factors, warning signs, and symptoms of various mental ill-
nesses (depression, anxiety, trauma, psychosis, substance use
disorders, self-injury and suicidal behaviors). It examines
the impact of mental illness on a person’s life and reviews
common treatments [14]. Participants learn a five-step action
plan, which uses the acronym ALGEE, to help people who
present with signs and symptoms of mental illness or are
in crisis: (1) Assess the risk of suicide or harm, (2) Listen
nonjudgmentally, (3) Give reassurance and information, (4)
Encourage appropriate professional help, and (5) Encour-
age self-help and other support strategies [14, 15]. MHFA
training methods include didactic presentations, small group
activities, and role-playing, e.g., enacting the MHFA action
plan with someone experiencing a panic attack.
A prior evaluation of conventional MHFA training pre-
sented in English for 58 Bhutanese refugees found moder-
ate improvement in the recognition of symptoms of depres-
sion, improvement in applying ALGEE to assist a depressed
community member, and increased mental health literacy.
However, there was no change in negative, stigmatizing
beliefs about people with mental illness, and this evalu-
ation was limited to a small, predominantly male sample
[16]. The current program evaluation builds upon this work
by examining and comparing the effectiveness of bilingual
(English/Nepali) MHFA training offered with and without a
culturally-appropriate orientation to mental health terminol-
ogy and concepts used in conventional approaches to mental
health care in the United States.
Methods
The MHFA trainings included in this non-randomized
evaluation were conducted in 17 cities in eight states from
May 7, 2016, through June 22, 2018. Because our goal
was to improve program effectiveness for the Bhutanese
refugee community and inform ongoing program plan-
ning rather than contribute to generalized knowledge, this
project was found to be a program evaluation rather than
human subjects research by staff in the Human Research
Protection Office at the University of Pittsburgh.
The same pair of bilingual, bicultural Bhutanese MHFA
trainers, who were former refugees themselves, led each
training using an 8-h standardized MHFA curriculum
offered in a mix of English and Nepali. As described in
the Introduction, the curriculum included group exercises,
videos, and role-playing to recognize and respond to warn-
ing signs and symptoms of mental distress.
A 40-min, Nepali-language orientation had been devel-
oped by the Bhutanese MHFA trainers (and co-authors),
who believed that culturally-informed orientation would
enhance the effectiveness of the standard MHFA curric-
ulum for this population. The orientation included four
components described in detail in the Appendix: “Stories
of Hope from Bhutanese Refugees,” mental health termi-
nology, discussion of migration-related social pressures
associated with increased suicide risk, and discussion of
two case vignettes in which MHFA-trained Bhutanese
community leaders intervene to help an individual expe-
riencing a mental health crisis. Mental health terminol-
ogy was included because many English-language terms
(e.g., “schizophrenia”) do not have a direct translation
in Nepali, so the trainers felt that establishing a shared
vocabulary was important. Orientation training methods
included didactic presentations and small group discus-
sions in English and Nepali.
Participants
In each city, local Bhutanese community leaders were
asked to invite other Bhutanese adults (≥18years), espe-
cially community leaders and those associated with social
service, health care, or community volunteer experience,
to participate in MHFA training. Outreach modalities
included fliers, emails, phone calls, and announcements
at community gatherings. Any interested adult in the Bhu-
tanese refugee community was eligible to participate. We
do not have information about those who opted out.
Local Bhutanese community leaders were also asked to
invite approximately half of the registered trainees to par-
ticipate in the Nepali-language orientation offered in the

Journal of Immigrant and Minority Health
1 3
morning prior to each MHFA training (Fig.1). Thus, the
individuals participating in the orientation were an oppor-
tunistic sample of community members who were easy to
contact—generally friends, relatives, or acquaintances of
local Bhutanese community leaders—or who lived near
the training venue. Those who were not invited to the ori-
entation or who opted not to participate were simply given
breakfast at the training venue.
Survey Instruments
MHFA training participants were invited by the local organ-
izers to complete brief, anonymous, self-administered, pre-
and post-training questionnaires offered in both English and
Nepali. The trainers informed participants verbally and in
writing that completing the questionnaires was voluntary
and information would remain confidential and be used to
calculate summary statistics. Participant identification num-
bers linked pre- and post-responses but were not linked back
to any personal identifiers. Pre- and post-training question-
naires were adapted from an instrument originally developed
for MHFA evaluations in Australia [17, 18] and translated by
a team of three bilingual Bhutanese former refugees (includ-
ing two of the authors) using a group consensus process.
In addition to capturing sociodemographic characteris-
tics (pre-test only), the questionnaires assessed participants’
recognition of mental health symptoms, MHFA response,
self-reported confidence helping someone with mental
health symptoms, attitudes towards people with mental ill-
ness (stigma), and mental health literacy.
Each questionnaire was scored by a trained team mem-
ber who was blinded to whether the questionnaire had been
administered before or after MHFA training and whether the
respondent had or had not participated in orientation.
To assess mental health symptom recognition, partici-
pants were asked to read two case vignettes—one about
depression and the other about schizophrenia—developed
for prior MHFA evaluations and then adapted to better
reflect Bhutanese refugee experiences in the United States
(Table1). After reading each case vignette, respondents
were asked the following open-ended question, “What, if
anything, do you think is wrong with [Rukmini/Karma]?”
with responses scored 0 (incorrect) or 1 (correct).
To assess their MHFA response, participants were asked
the following open-ended question after each case vignette:
“Imagine [Rukmini/Karma] is a person you know. You want
to help her/him. What should you do?” Written responses
were evaluated for inclusion of each of the five potential
ALGEE actions. Each ALGEE action was scored 0 if there
was no mention or inadequate response, 1 if there was a
superficial response, and 2 if specific details were provided
for a maximum score of 10. Respondents were also asked to
rate their confidence in helping the person featured in each
case vignette (1 = “not at all” to 5 = “extremely”).
To measure personal stigma, meaning the degree to which
the survey respondent holds negative beliefs about individu-
als with mental illness, respondents were asked to rate seven
statements following each case vignette using a five-point
Likert scale (1 = “strongly agree” to 5 = “strongly disagree”).
Scores were summed such that higher scores reflect less stig-
matizing attitudes.
Overall mental health literacy was assessed using a
21-item instrument developed for prior MHFA evaluations.
Each of the close-ended mental health literacy questions had
three possible answers: “Agree,” “Disagree,” and “Don’t
Know.” Each item received a score of 1 if correct; otherwise,
the score was 0. Higher scores reflect mental health knowl-
edge concordant with those of mental health professionals.
Statistical Analyses
We described sociodemographic characteristics for all par-
ticipants and then compared characteristics of those who
attended the orientation and those who did not, applying chi-
square tests for categorical variables and t-tests for continu-
ous variables. To measure the effect of the orientation, we
compared the average pre- to post-training change in each
outcome measure for respondents who attended the orienta-
tion to the average pre- to post-training change for respond-
ents who did not attend orientation. Next, we measured the
Parcipated in culturally-
appropriate orientaon
(N=226)
Did not parcipate in
culturally-appropriate
orientaon (N=232)
Trained from May 2016 toJune 2018 (N=519)
Completed pre- and post-training surveys
(N=459)
Included in the analysis (N=458) *
Fig. 1 Description of the analytic sample: Bhutanese participating in
MHFA. *One participant was excluded from the analysis due to miss-
ing information

Journal of Immigrant and Minority Health
1 3
interaction effect between attending orientation and a time
dummy for pre-/post-test, applying random effects linear
regression models for continuous outcomes and random
effects logistic regression models for categorical outcomes.
The interaction term allowed us to model the difference
between respondents who attended orientation and respond-
ents who did not attend orientation with regards to changes
in their pre- and post-training scores. Random effects models
account for the correlation of different measures of the same
individual over time. Stata/SE, version 14.2, was used for
the analysis.
Results
Social and demographic information for the 458 individu-
als with evaluable data is presented in Table2. Just under
half of the participants were women (44.8%). The majority
had an associate degree or higher. Some participants had
attended prior mental health training (11.6%) or had a fam-
ily member who had experienced mental health problems
(16.8%). Among all 458 individuals with evaluable data,
226 attended the orientation and 232 did not. The social
and demographic characteristics of individuals who attended
orientation were comparable to those who did not, with the
exception of current immigration status. More individuals
in the non-orientation group were still refugees (11.2% ver-
sus 4.9%), meaning they had not yet applied for permanent
residency or naturalized citizenship.
Table3 shows baseline (pre-MHFA training) and post-
training survey responses for individuals who attended
the orientation and those who did not. The baseline sur-
vey responses were very similar for the orientation and
non-orientation groups. For most outcomes, Bhutanese
refugees who attended orientation had a greater change
in pre- to post-training scores than refugees who did not
attend orientation: They had greater changes in recognition
of schizophrenia symptoms (72.4% versus 52.5%), recogni-
tion of depression symptoms (52.7% versus 47.6%), MHFA
response for schizophrenia (4.8 vs. 3.4), MHFA response for
depression (4.7 versus 3.5), and overall mental health liter-
acy (6.8 versus 4.7). The exceptions were confidence helping
someone with symptoms of depression (2.6 versus 2.7), con-
fidence helping someone with symptoms of schizophrenia
(2.6 versus 2.6), stigma towards people with schizophrenia
(10.6 versus 9.6), and stigma towards people with depression
(10.0 versus 9.3), for which there were minimal or no differ-
ences between the orientation and non-orientation groups.
Random effects linear regression models and random
effects logistic regression models without and with adjust-
ment for covariates are shown in Table4. Compared to
individuals who did not participate in orientation, the
adjusted pre- to post-training change in correct recogni-
tion of schizophrenia was greater for those who attended
orientation. There was no difference between groups
with regards to the magnitude of improvement in recog-
nition of depression. Compared to individuals who did
not participate in orientation, the adjusted pre- to post-
training change in appropriately responding to someone
with symptoms of schizophrenia and depression were
greater for those who attended orientation. There was no
Table 1 Culturally-adapted case vignettes in MHFA training
A-1. Original Version Jenny is a 15-year-old who has been feeling unusually sad and miserable for the last few weeks. She is tired all the time
and has trouble sleeping at night. Jenny doesn’t feel like eating and has lost weight. She can’t keep her mind on her studies and her marks have
dropped. She puts off making any decisions and even day-to-day tasks seem too much for her. Her parents and friends are very concerned
about her. Jenny feels she will never be happy again and believes her family would be better off without her. She has been so desperate, she has
been thinking of ways to end her life
A-2. Modified version, changes highlighted in bold Rukmini is a 22year old who has been feeling unusually sad and miserable for the last few
weeks. She is tired all the time and has trouble sleeping at night. Rukmini doesn’t feel like eating and has lost weight. She can’t keep her mind
on her work and her monthly income dropped. She puts off making any decisions and even day-to-day tasks seem too much for her. Her
husband, parents, and friends are very concerned about her. Rukmini feels she will never be happy again and believes her family would be
better off without her. She has been so desperate, she has been thinking of ways to end her life
B-1. Original Version John is a 15-year-old who lives at home with his parents. He has been attending school irregularly over the past year and
has recently stopped attending altogether. Over the past 6 months he has stopped seeing his friends and begun locking himself in his bedroom
and refusing to eat with the family or to have a bath. His parents also hear him walking about in his bedroom at night while they are in bed.
Even though they know he is alone, they have heard him shouting and arguing as if someone else is there. When they try to encourage him
to do more things, he whispers that he won’t leave home because he is being spied upon by the neighbor. They realize he is not taking drugs
because he never sees anyone or goes anywhere
B-2. Modified version, changes highlighted in bold Karma is a 25-year-old who lives at home with his parents. He has been attending com-
munity college irregularly over the past year and has recently stopped attending altogether. Over the past 6 months he has stopped seeing his
friends and begun locking himself in his bedroom and refusing to eat with the family or to have a bath. His parents also hear him walking about
in his bedroom at night while they are in bed. Even though they know he is alone, they have heard him shouting and arguing as if someone
else is there. When they try to encourage him to do more things, he whispers that he won’t leave home because he is being spied upon by the
neighbor. They realize he is not taking drugs because he never sees anyone or goes anywhere

Journal of Immigrant and Minority Health
1 3
difference between groups with regards to changes in self-
rated confidence helping someone with schizophrenia or
depression or in stigmatizing beliefs. Finally, the adjusted,
pre- to post-training improvement in mental health literacy
was greater for orientation participants compared to non-
orientation participants.
Discussion
This is the largest evaluation of MHFA training for
Bhutanese refugees in the United States and the first
evaluation of MFHA augmented by a culturally-appro-
priate orientation session. The findings support using
Table 2 Social and demographic characteristics of Bhutanese MHFA trainees, by participation in culturally-appropriate orientation to mental
health terminology and concepts
Total (N = 458) Orientation (N = 226) No orientation
(N = 232)
p-value
Gender, male (%) 55.2 56.5 54.0 0.593
Age in years, mean (SD) 32.2 (8.9) 31.9 (9.4) 32.5 (8.5) 0.467
Educational attainment (%) 0.103
Grade 10 or less 3.3 1.8 4.7
Grade 11–12 14.0 15.5 12.5
Associate’s degree 35.7 38.9 32.8
Bachelor’s degree 21.0 21.7 20.3
Master’s degree or PhD 26.0 22.1 29.7
Current immigration status (%) 0.064
Refugee 8.1 4.9 11.2
Permanent resident 43.5 46.9 40.1
Naturalized US citizen 44.3 44.3 45.3
Other, e.g., asylee 3.5 4.0 3.0
Previous mental health training (%) 11.6 10.6 12.5 0.497
Personal experience with mental health problems (%) 10.5 9.3 11.6 0.396
Family experience with mental health problems (%) 16.8 18.1 15.5 0.465
Table 3 Pre- and post-training survey results for Bhutanese MHFA trainees, by participation in culturally-appropriate orientation to mental
health terminology and concepts
Correction recognition of schizophrenia and depression in case vignettes was scored 0 (incorrect) or 1 (correct). First aid response (ALGEE) was
scored 0–10 with higher scores corresponding to a more appropriate MHFA response to someone with symptoms of schizophrenia or depres-
sion. Confidence helping (self-reported) was scored 1–5, with 1 indicating “not at all” confident helping someone with symptoms of schizo-
phrenia or depression and 5 indicating “extremely” confident. Stigma was scored 7–35 with higher scores corresponding to less negative and
stigmatizing beliefs about individuals with symptoms of schizophrenia or depression. Mental health literacy was scored 0–21 with high scores
indicating greater familiarly with conventional US mental health diagnoses, concepts, and norms
Orientation No Orientation
Pre-test score Post-test score Change Pre-test score Post-test score Change
Schizophrenia
Correct recognition (%) 7.2 79.6 72.4 6.2 58.7 52.5
First aid response 1.1 5.8 4.8 1.1 4.5 3.4
Confidence helping 1.6 4.2 2.6 1.7 4.2 2.6
Stigma 19.0 29.6 10.6 18.9 28.5 9.6
Depression
Correct recognition (%) 37.7 90.3 52.7 32.3 79.9 47.6
First aid response 1.2 5.9 4.7 1.2 4.6 3.5
Confidence helping 1.9 4.5 2.6 1.8 4.5 2.7
Stigma 19.6 29.6 10.0 19.0 28.3 9.3
Mental health literacy 6.3 13.2 6.8 5.9 10.6 4.7

Journal of Immigrant and Minority Health
1 3
culturally-appropriate orientation to enhance the immedi-
ate impact of MHFA training for this population.
Contrary to the results of a prior exploratory evaluation
of English-language MHFA training for Bhutanese refu-
gees, we also found that bilingual MHFA training improved
(decreased) stigmatizing beliefs about individuals with
symptoms of depression or schizophrenia both for those who
participated the orientation session and those who did not.
Multiple studies have identified stigma as one of the primary
reasons refugees in the United States may not seek men-
tal health care [10, 12, 16]. It also discourages community
members from helping people with mental health problems
[19]. Hence, interventions that reduce mental health-related
stigma are believed to be of great importance for refugee
communities.
Orientation establishes a shared, Nepali-language vocab-
ulary for the mental health terminology used during MHFA
training. Additionally, it situates mental health symptoms
within the context of the community’s struggle to integrate
following resettlement in the United States. Thus, orienta-
tion may have enhanced the effectiveness of MHFA training
by ensuring that it was both comprehensible and relevant
to adult learners from the Bhutanese community, thereby
increasing engagement with the training material.
Orientation also had a greater impact on recognition of
schizophrenia and attitudes towards someone with symp-
toms of schizophrenia relative to depression. This may
reflect the fact that depression is more familiar to Bhuta-
nese refugees [20], many of whom have undergone educa-
tion about or screening for depression while overseas or
after arrival in the United States [9, 21]. In contrast, severe
psychosis and schizophrenia are rarely discussed in the Bhu-
tanese community [22], and individuals with these diagnoses
would generally be hidden from people outside the family.
Therefore, orientation may have been particularly helpful
for establishing a shared vocabulary and understanding of
current Western concepts of psychosis and schizophrenia.
Limitations
The primary limitations of this evaluation are non-rand-
omized group assignment and lack of long-term follow up.
Opportunistic group assignment (rather than randomiza-
tion) was selected for pragmatic reasons due to resource
Table 4 The impact of culturally-appropriate orientation before MHFA training: applying random effects linear regression and random effects
logistic regression and models
Correction recognition of schizophrenia and depression in case vignettes was scored 0 (incorrect) or 1 (correct). First aid response (ALGEE) was
scored 0–10 with higher scores corresponding to a more appropriate MHFA response to someone with symptoms of schizophrenia or depres-
sion. Confidence helping (self-reported) was scored 1–5, with 1 indicating “not at all” confident helping someone with symptoms of schizo-
phrenia or depression and 5 indicating “extremely” confident. Stigma was scored 7–35 with higher scores corresponding to less negative and
stigmatizing beliefs about individuals with symptoms of schizophrenia or depression. Mental health literacy was scored 0–21 with high scores
indicating greater familiarly with conventional US mental health diagnoses, concepts, and norms
Covariates of the adjusted random effects models: time, gender, age, education, immigration status, previous training, personal experience of
mental health issues, family members’ experience of mental health issues
S.E. standard error
Significance: *p < 0.05, **p < 0.01, ***p < 0.001
Crude model Adjusted model
Coefficient S.E Coefficient S.E
Schizophrenia
First aid response (ALGEE) 1.35*** 0.31 1.34*** 0.31
Confidence helping 0.03 0.11 0.03 0.11
Stigma 0.92 0.66 1.06 0.66
Depression
First aid response (ALGEE) 1.27*** 0.28 1.27*** 0.28
Confidence helping − 0.12 0.11 − 0.13 0.11
Stigma 0.75 0.65 0.71 0.66
Mental health literacy 2.11*** 0.52 2.12*** 0.53
OR 95% CI OR 95% CI
Schizophrenia
Correct recognition 2.68* 0.98, 7.35 2.79** 1.01, 7.69
Depression
Correct recognition 2.18 0.93, 5.10 2.15 0.91, 5.03

Journal of Immigrant and Minority Health
1 3
limitations. However, this means that results may not be
generalizable to the larger Bhutanese refugee community in
the US, and the evaluation design cannot account for non-
program influences. While we note that the orientation and
non-orientation groups were relatively similar with regards
to measured sociodemographic characteristics and base-
line (pre-training) survey results, unmeasured differences
between groups may confound our results. While this evalu-
ation demonstrated meaningful improvement in training out-
comes immediately after bilingual MHFA training, it does
not speak to whether or not improvements were sustained
over time. Finally, we note that unintended crossover occa-
sionally occurred when participants belonging to the non-
orientation group nonetheless joined orientation sessions.
However, crossover would bias our results towards the null.
Conclusions
Our findings support the results from a prior evaluation
suggesting that MHFA training is a promising intervention
for improving knowledge and attitudes about mental health
among Bhutanese refugee in the US [16]. Ideally, ongoing
MHFA training for this community should be accompanied
by culturally-appropriate orientation materials that introduce
mental health vocabulary and contextualize mental health
concepts. In sum, our study offers a rationale and guidance
for scaling up MHFA training for Bhutanese refugees, espe-
cially when supplemented by culturally-tailored orientation.
Acknowledgements We thank Anthony Francis Jorm, and Tomas
Matza for their guidance, Keshav Acharya and Asmita Gurung for the
data entry, and Bhutanese community leaders in the US for outreach
and implementation of the survey. Dr. Yun was supported by NIH Grant
5K23HD082312. Mental Health First Aid training was supported by
the Office of Refugee Resettlement and their local partners.
Compliance with Ethical Standards
Conflict of interest The authors report no conflict of interest, finance,
or otherwise.
Ethical Approval The intent of this project was to improve the effec-
tiveness of an ongoing program and inform decisions about future pro-
gram development, this project was found to be a program evaluation
rather than human subjects research. While a formal determination that
planned activities would not involve human subjects research was not
sought, categorization of this project as program evaluation was made
with guidance from staff in the Human Research Protection Office
(HRPO) at the University of Pittsburgh.
Research Involving Human Participants and/or Animals The intent of
our project is to improve program effectiveness and to inform decisions
about future program development using a questionnaire survey tool
to check new knowledge and skills learned. Therefore, this study does
not include humans’ or animals’ specimens for study.
Informed Consent All participants were informed verbally and in writ-
ing that completing the questionnaires was voluntary and the survey
would be used to calculate summary statistics. No identifying details
such as names, date of birth, or identity number were collected.
References
1. UNHCR, The UN Refugee Agency. Global Trends—Forced
displacement in 2017. 2018. https ://www.unhcr .org/figur es-at-a-
glanc e.html. Published June 19, 2018. Accessed 24 Oct 2018
2. Ao T, Shetty S, Sivilli T, etal. Suicidal ideation and mental health
of Bhutanese refugees in the United States. J Immigr Minor
Health. 2016;18(4):828–35.
3. Steel Z, Chey T, Silove D, etal. Association of torture and other
potentially traumatic events with mental health outcomes among
populations exposed to mass conflict and displacement: a system-
atic review and meta-analysis. JAMA. 2009;302(5):537–49.
4. Fazel M, Reed RV, Panter-Brick C, Stein A. Mental health of
displaced and refugee children resettled in high-income countries:
risk and protective factors. Lancet. 2012;379(9812):266–82.
5. Fazel M, Wheeler J, Danesh J. Prevalence of serious mental dis-
order in 7000 refugees resettled in western countries: a systematic
review. Lancet. 2005;365(9467):1309–14.
6. Li SS, Liddell BJ, Nickerson A. The relationship between post-
migration stress and psychological disorders in refugees and asy-
lum seekers. Curr Psychiatry Rep. 2016;18(9):82.
7. Porter M, Haslam N. Predisplacement and postdisplacement fac-
tors associated with mental health of refugees and internally dis-
placed persons: a meta-analysis. JAMA. 2005;294(5):602–12.
8. World Refugee Processing Center. Admission and arrivals. 2019.
https ://www.wraps net.org/admis sions -and-arriv als. Published
December 31, 2018. Accessed 6 Feb 2019.
9. Cochran J, Geltman PL, Ellis H, etal. Suicide and suicidal ideation
among Bhutanese refugees—United States, 2009–2012. MMWR.
Morbidity and mortality weekly report. (2013);62(26):533.
10. Ellis BH, Lankau EW, Ao T, etal. Understanding Bhutanese
refugee suicide through the interpersonal-psychological theory
of suicidal behavior. Am J Orthopsychiatry. 2015;85(1):43–55.
11. Hagaman AK, Sivilli TI, Ao T, etal. An investigation into suicides
among Bhutanese refugees resettled in the United States between
2008 and 2011. J Immigr Minor Health. 2016;18(4):819–27.
12. Yun K, Paul P, Subedi P, etal. Help-seeking behavior and health
care navigation by Bhutanese refugees. J Community Health.
2016;41(3):526–34.
13. Administration for Children & Families, Office of Refugee Reset-
tlement. 2015. Stories of Hope from Bhutanese refugees: mov-
ing from distress to wellness. 2016. https ://www.youtu be.com/
watch ?v=EYrXY YnUCJ I&t=529s. Published March 31, 2015.
Accessed 7 May 2016.
14. Lam AY, Jorm AF, Wong DF. Mental health first aid training
for the Chinese community in Melbourne, Australia: effects on
knowledge about and attitudes toward people with mental illness.
Int J Ment Health Syst. 2010;4:18.
15. Minas H, Colucci E, Jorm AF. Evaluation of mental health first
aid training with members of the Vietnamese community in Mel-
bourne, Australia. Int J Ment Health Syst. 2009;3(1):19.
16. Subedi P, Li C, Gurung A, etal. Mental health first aid training
for the Bhutanese refugee community in the United States. Int J
Ment Health Syst. 2015;9:20.
17. Griffiths KM, Nakane Y, Christensen H, etal. Stigma in response
to mental disorders: a comparison of Australia and Japan. BMC
Psychiatry. 2006;6:21.

Journal of Immigrant and Minority Health
1 3
18. Jorm AF, Kitchener BA, Mugford SK. Experiences in applying
skills learned in a mental health first aid training course: a qualita-
tive study of participants’ stories. BMC Psychiatry. 2005;5:43.
19. Saunders NR, Lebenbaum M, Lu H, etal. Trends in mental health
service utilisation in immigrant youth in Ontario, Canada, 1996–
2012: a population-based longitudinal cohort study. BMJ Open.
2018;8(9):e022647.
20. Vonnahme LA, Lankau EW, Ao T, Shetty S, Cardozo BL. Fac-
tors associated with symptoms of depression among Bhuta-
nese refugees in the United States. J Immigr Minor Health.
2015;17(6):1705–14.
21. Bishop D, Altshuler M, Scott K, etal. The refugee medical exam:
what you need to do. J Fam Pract. 2012;61(12):E1–E10.
22. Lauber C, Rossler W. Stigma towards people with mental ill-
ness in developing countries in Asia. Int Rev Psychiatry.
2007;19(2):157–78.
Publisher’s Note Springer Nature remains neutral with regard to
jurisdictional claims in published maps and institutional affiliations.