Karen Health Literacy Study Final Report

Abstract

This study contains information on socio-demographic characteristics and healthcare and health literacy-related features among 201 Karen (a Burmese minority) refugees residing in Buffalo, NY.

Full text

Kim, J., Kim, W., Kim, I., Baltimore, K. & Lin, L. (2021). The Karen
Health Literacy Study: Final Report. Buffalo, NY: Immigrant and
Refugee Research Institute, UB School of Social Work.
The Karen
Health Literacy
Study

1
The Karen Health Literacy Study
Acknowledgment
We are grateful to our bilingual interviewers (Moejoe Greely, Lahmay Paw, Aye
Bay Na Sa, Hsa Tha Bla Wah)* and Research Assistants (Biplab Bhattacharya,
Omeed Sahar Fathi, Mary Keovisai, Qian Zhang).*
Special thanks to our community advisors including ThinThin Conlon, Daniel
Leong, Lin Naing, Faustina Palmatier, Mu Paw, Der Lwe, and many more*. Most
importantly, we thank Karen community members who participated in the survey
and and the support of Karen Society of Buffalo (KSB).
This study was partially supported by Les Brun Research Endownment Grant
from UB School of Social Work, Home Base from UB Industrial & Systems
Engineering, and UB Community for Global Health Equity.
*Names listed in alphabetical order.

2
Table of Contents
BACKGROUND ................................................................................................................................ 4
Study Purpose .......................................................................................................................................... 4
Participants ................................................................................................................................................ 5
Data Collection ......................................................................................................................................... 5
FINDINGS .......................................................................................................................................... 7
Demographic Information ...................................................................................................................... 7
GENDER & AGE 7
MARITAL STATUS 8
NUMBER OF KIDS / CHILDREN UNDER 18 9
EMPLOYMENT 10
INCOME 11
HEALTH INSURANCE 11
Education and Language ..................................................................................................................... 12
EDUCATION 12
LANGUAGE PROFICIENCY 12
Refugee Experiences ............................................................................................................................ 13
REFUGEE CAMP STAY 13
EXILE DURATION 13
Living in The U.S. ................................................................................................................................... 14
U.S. ARRIVAL YEAR 14
AGE OF U.S. ARRIVAL 14
Religion and Participation ................................................................................................................... 15
RELIGIOUS AFFILIATION 15
RELIGIOUS PARTICIPATION 16
Technology Use ...................................................................................................................................... 17
MOBILE DEVICE OWNERSHIP 17
TYPES OF MOBILE DEVICE 17
Health Literacy and Medication Literacy ......................................................................................... 18
BASIC HEALTH LITERACY (HLQ1-10) 18
MEDICATION LITERACY 19
INTERACTIVE HEALTH LITERACY 20

3
Health Status ........................................................................................................................................... 21
SELF-RATED PHYSICAL HEALTH 21
HEALTH CONCERNS 21
Healthcare Service Use ........................................................................................................................ 23
PRIMARY CARE PROVIDER (PCP) 23
PRIMARY CARE PHYSICIAN VISIT 23
CLINIC/PCP EXPERIENCE 25
Mental and Behavioral Health ............................................................................................................. 27
SELF-RATED MENTAL HEALTH 27
TRAUMA SYMPTOMS (RHS-15) 28
DEPRESSION SYMPTOMS 29
ALCOHOL USE DISORDER 30
Social Support ........................................................................................................................................ 31
Dental Care .............................................................................................................................................. 32
DENTAL CARE UTILIZATION 32
SMOKING 33
CHEWED BETEL NUTS 33
References ........................................................................................................................................ 34

4
BACKGROUND
Several decades of political upheaval and civil war resulted in the massive
relocation of several ethnic minorities in Burma to the city of Buffalo. Of the
estimated 10,000 Burmese refugees living in Buffalo, about 5,500 identify as
Karen (Zremski, 2016), an ethnic minority group who have experienced political
violence and persecution by the Burmese military government (Ekeh & Smith,
2007).
In general, refugees are at a higher risk for poor health outcomes, such as
hypertension and diabetes (Dookeran et al., 2010). Due to the deepening crisis
in Burma, refugees residing in refugee camps have experienced limited access
to preventive healthcare measures as well as emergency healthcare provisions
(Hoffman & Robertson, 2016). In addition, trauma and other experiences such
as torture and cultural backgrounds prohibits them from being fully understood
by their primary care physicians after resettlement (Piwowarczyk, 2013). Due to
inadequate knowledge of chronic illnesses as well as the healthcare system in
the United States, they tend to underutilize preventive and other health care
programs. (Ngo‐Metzger et al., 2003).
Study Purpose
Health literacy, defined as the ability to obtain, process, and understand
basic health information, is an important component of assessing an individual’s
general health and health care utilization (Institute of Medicine, 2004; U.S.
Department of Health and Human Services, 2010). Low health literacy poses
additional challenges in accessing and receiving quality healthcare services for
refugees. Due to their forced displacement and conflict-ridden history of

5
trauma, Karen refugees may be at higher risk for developing various chronic
health problems. The purpose of this study was to explore health literacy among
Karen refugees in Buffalo. Health literacy information will provide useful
information to design a tailored program, increase health literacy among this
population, remove barriers to healthcare access, better manage their chronic
illness, and ultimately improve their overall health.
Participants
A convenience sample of adult Karen community members was recruited
through community network referrals, outreach efforts at community events, and
religious organizations, including churchs and temples. In order to be part of this
study, the participant should: 1) identify as a Karen ethnic group member; 2) be
at least 18 years old; 3) be proficient in S’gaw Karen language; 4) have used
healthcare services in the past 12 months; and, 5) have lived in Buffalo for at
least one year.
Data Collection
A total of 201 Karen ethnic group members participated in this study. The
questionnaire included basic sociodemographic questions (gender, age, marital
status, the average number of kids, employment, income, health insurance,
education), immigration related experiences (refugee camp stay, years living in
the U.S.), exile duration, U.S. arrival year, age of U.S. arrival, language
proficiency), religion (religious affiliation, religious participation), health literacy
(basic health literacy and medication literacy), and health-related information
(self-rated health status, chronic illnesses, healthcare service use, dental care
service use), and behavioral health (trauma, depression, alcohol use, smoking,
betel nut use).

6
The survey questionnaire was developed and translated into the Karen
language. Bilingual interviewers conducted face-to-face interviews in the Karen
language. Informed consent was obtained before the beginning of each
interview. The interview lasted 1 hour and 15 minutes on average and
participants were given a $20 giftcard to a local grocery store for their
participation. A list of local healthcare services was given to the participants
after each interview.

7
FINDINGS
Demographic Information
GENDER & AGE
Of the 201 participants, 73 (36.3%) were men and 128 (63.7%) were women.
The average age of the participants was 40.6 years old (SD=13.3); the largest
age group was between 36-45 (n=58, 28.9%). The majority of the particpants
were between 26 and 55 years old (73.1%). The mean age for men was 42.3
and that for women was 39.7.
18-25
26
(12.9%)
26-35
49 (24.4%)
36-45
58 (28.9%)
46-55
40 (20.0%)
56-65
20 (10.0%)
65+
8 (4.0%)
Age (N=201)

8
MARITAL STATUS
Most participants were married or in a domestic relationship (163, 81.1%); 27
(13.4%) were single or never married; 6 (3%) widowed; 5 (2.5%)
divorced/separated.
Never
married
27 (13.4%)
Divorced/Seperate
5 (2.5%)
Widowed
6 (3%)
Married/Domestic partnership
163 (81.1%)
Marital Status (N=201)

9
NUMBER OF KIDS / CHILDREN UNDER 18
Average Number of Kids
Children Under 18
Men
(n=73)
Women
(n=127)
Total
(N=200)
Men
(n=73)
Women
(n=127)
Total
(N=200)
0
9
(12.3%)
15
(11.8%)
24
(12.0%)
21
(28.8%)
28
(22.0%)
49
(28.5%)
1
6
(8.2%)
7
(5.5%)
13
(6.5%)
7
(9.6%)
19
(15.0%)
26
(13.0%)
2
10
(13.7%)
16
(12.6%)
26
(13.0%)
15
(20.5%)
30
(23.6%)
45
(22.5%)
3
17
(23.3%)
34
(26.8%)
51
(25.5%)
18
(24.7%)
31
(24.4%)
49
(28.5%)
4
11
(15.1%)
20
(15.7%)
31
(15.5%)
8
(11.0%)
10
(7.9%)
18
(9.0%)
5
4
(5.5%)
12
(9.4%)
16
(8.0%)
3
(4.1%)
5
(3.9%)
8
(4.0%)
6
8
(11.0%)
12
(9.4%)
20
(10.0%)
1
(1.4%)
4
(3.1%)
5
(2.5%)
7+
8
(11.0%)
11
(8.7%)
19
(9.5%)
-
-
-
The average number of kids in a household was about 3 (Mean = 3.4). About a
quarter of participants (25.5%) had three kids. Participants who had 2 to 4 kids
made up 54% of the sample; also, households that had 5 or more kids
comprised over a quarter (27.5%) of the sample.
Approximately 28.5% of the participants did not have kids under 18; about
22.5% of the participants had 2 kids that are 18 or under; 28.5% of the
participants had 3 kids that are 18 or under.

10
EMPLOYMENT
A total of 107 (53.2%) participants were employed; more men (n=58, 79.5%)
were employed than women (n=49, 38.3%). 46 men (61.6%) were working full-
time, whereas 8 men (11%) were in part-time jobs. 5 (6.8%) men were full-time
or part-time students. On the other hand, 24 (18.8%) women worked as full-time
workers, 16 (12.5%) as part-time workers, and 9 (7%) as students.
58 (79.5%) 49 (38.3%)
107 (53.2%)
15 (20.5%)
79 (61.7%)
94 (46.8%)
0
20
40
60
80
100
120
Men Women Total
Employment Status (N=201)
Employed Unemployed

11
INCOME
The major of the participants (n=105, 57.1%) earned between $1001-$2000 of
the study sample. Average income was $1,500 - $2,000 per month with $1,500-
$2,000 for men and $1,000-$1,500 for women.
HEALTH INSURANCE
The majority of participants reported having medical insurance (n=190, 95%).
Of the people that answered the next question as yes, the vast majority (n=166,
90.2%) of them utilized Medicaid (n=157, 83.1%) and Medicare (n=9, 4.8%).
About 17 participants (9.0%) were enrolled in a private insurance.
1 (1.4%)
3 (4.3%) 2 (2.9%)
14 (20.3%)
23 (33.3%)
12 (17.4%)
5 (7.3%) 5 (7.2%) 4 (5.8%)
0
4 (3.5%)
12 (10.4%)
40 (34.8%)
28 (24.3%)
16 (13.9%)
8 (7.0%) 5 (4.3%) 2 (1.7%)
1 (0.5%) 7 (3.8%)
14 (7.6%)
54 (29.3%) 51 (27.7%)
28 (15.2%)
13 (7.1%) 10 (5.4%) 6 (3.2%)
0
10
20
30
40
50
60
None <$500 $501-1000 $1001-1500 $1501-2000 $2001-2500 $2501-3000 $3001-3500 $3501+
Income in Nine Categories (N=184)
Men Women Total

12
Education and Language
EDUCATION
Men
(n=73)
Women
(n=127)
Total
(N=200)
No Education
27 (37.0%)
37 (28.9%)
64 (31.8%)
Less than High school Diploma
31 (42.5%)
77 (60.2%)
108 (53.7%)
HS/GED
6 (8.2%)
6 (4.7%)
12 (6.0%)
AA or More
9 (12.3%)
8 (6.3%)
17 (8.5%)
Most of the sample reported no formal education or less than high school. Most
of the people were not formally educated (n=64, 31.8%) or had education less
than a high school diploma (108, 53.7%). The average education was 5.1 years.
LANGUAGE PROFICIENCY
Karen language
Burmese Language
English Language
Men
(n=73)
Women
(n=127)
Men
(n=73)
Women
(n=127)
Men
(n=73)
Women
(n=127)
Poor/Fair
0
(0%)
2
(1.5%)
48
(65.7%)
89
(69.5%)
61
(83.5%)
108
(84.4%)
Good/Excellent
73
(100%)
126
(98.5%)
25
(34.3%)
39
(30.5%)
12
(16.5%)
20 (15.6%)
● Karen: All but two (n=199, 99%) participants reported Good/Excellent Karen
language proficiency: Average score 3.5 (1-4, 1=Poor, 2=Fair, 3=Good, 4=Excellent)
● Burmese: 64 (32%) participants reporting Good/Excellent.
Average score 2.1 (1-4, 1=Poor, 2=Fair, 3=Good, 4=Excellent)
● English: 32 (16%) participants reporting Good/Excellent.
Average score 1.6 (1-4, 1=Poor, 2=Fair, 3=Good, 4=Excellent)

13
Refugee Experiences
REFUGEE CAMP STAY
The average refugee camp stay was 11.3 years; 94 participants(47.7%) stayed
in a refugee camp for 5 to 10 years, and 51 participants (25.9%) stayed in the
refugee camp for 10 to 20 years. A significant proportion (n=32, 16.2%) of the
people have lived in the refugee camp for more than 20 years.
EXILE DURATION
A vast majority of the sample experienced exile ranging from 5 to more than 20
years. The largest group was 5-10 years (n=70, 35%). On average, the
participants were in exile for 19.8 years.
4 (2.0%)
16 (8.1%)
94 (47.7%)
51 (25.9%)
32 (16.2%)
0
10
20
30
40
50
60
70
80
90
100
Less than 1 year 1-5 year 5-10 year 10-20 year 20+ year
Refugee Camp Stay (N=197)
3 (1.5%) 11 (5.5%)
70 (35%) 65 (32.5%)
51 (25.5%)
0
10
20
30
40
50
60
70
80
Less than 1 year 1-5 year 5-10 year 10-20 year 20+ year
Exile Duration (N=200)

14
Living in The U.S.
On average, the participants had lived in the U.S. for 8.2 years (range: 1-15).
U.S. ARRIVAL YEAR
Most of the participants (71%) arrived in the U.S. from 2007 to 2011.
AGE OF U.S. ARRIVAL
The average age of U.S. arrival was 32.4 years old. The largest group was the
people who have migrated in their young adulthood (n=88, 44%) or adulthood
(n=61, 30.5%).
3…
3 (1.5%)
4 (2.0%) 12 (6.0%)
12 (6.0%)
10 (5%)
9 (4.5%) 22 (11%) 27 (13.5%)
26 (13%) 41 (20.5%)
26 (13.0%)
3 (1.5%)
1 (0.5%)
1 (0.5%)
0 5 10 15 20 25 30 35 40 45
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
Year of Arrival (N=200)
3 (1.5%)
26 (13%)
61 (30.5%)
88 (44%)
22 (11%)
010 20 30 40 50 60 70 80 90 100
Children(0-7)
Schoolage(8-18)
Young adult(19-30)
Adult(30-49)
Older adults(50+)
Age of Arrival (N=200)

15
Religion and Participation
RELIGIOUS AFFILIATION
Most respondents were Protestant (168, 83.6%). Among the Protestants,
Baptist affiliation was the largest (150, 91.5%, N=164). 23 (11.4%) participants
reported they are Buddhist; 9 Catholic (4.5%); 1 Other (0.5%).
Buddhism
23 (11.4%))
Catholicism
9 (4.5%)
Protestantis
m
168 (83.6%)
Other 1
(0.5%)
Religion (N=201)

16
RELIGIOUS PARTICIPATION
Most of the participants (n=122, 60.7%) attended a monastery, church, or
mosque once a week.
Men
(n=73)
Women
(n=127)
Never
9 (12.3%)
8 (6.3%)
Less than 1 time in a month
9 (12.3%)
16 (12.5%)
1 time in a month
9 (12.3%)
8 (6.3%)
2 or 3 times in a month
5 (6.8%)
11 (8.6%)
1 time in a week
39 (53.4%)
83 (64.8%)
2 or 3 times in a week
2 (2.7%)
2 (1.6%)
17 (8.5%) 25 (12.4%) 17 (8.5%) 16 (8.0%)
122 (60.7%)
4 (2.0%)
0
20
40
60
80
100
120
140
Never Less than 1 time
in a month 1 time in a month 2 or 3 times in a
month 1 time in a week 2 or 3 times in a
week
Religious Participation (N=201)
Total

17
Technology Use
MOBILE DEVICE OWNERSHIP
Approximately 85.1% of the sample has had a mobile device; men (82.2%) and
women (86.7%).
TYPES OF MOBILE DEVICE
Of people who reported back on the kind of mobile device that they use, the
majority (61.0%) reported that they use iOS (i.e., iPhone, iPod, iPad). Another
27.3% answered that they use Android (e.g., Google, LG, Motorola, Sa)
followed by 0.6% of Windows mobile.
60 (82.2%)
13 (17.8%)
111 (86.7%)
17 (13.3%)
171 (85.1%)
30 (14.9%)
0
20
40
60
80
100
120
140
160
180
Yes No
Have Mobile Device (N=201)
Men Women Total
105
(61.0%)
47 (27.3%)
1…
19 (11.0%)
Types of Mobile Device (N=172)
iOS (i.e., iPhone, iPod, iPad)
Android (e.g., Google, LG,
Motorola, Sa
Windows mobile
Other

18
Health Literacy and Medication Literacy
BASIC HEALTH LITERACY (HLQ1-10)
1
Out of 9 questions, most participants scored 4 (n=44, 21.9%), 5 (n=54, 26.9%),
or 6 (n=29, 14.4%) questions. The average score was 4.1, men 3.9, and women
4.2 (1-9).
Basic Health Literacy Question & Correct Answers
Questions
Men
(n=73)
Women
(n=127)
Total
(N=201)
HLQ1 “You will lose Medicaid if you get a job no matter how much you make”
35 (47.95%)
52 (40.62%)
87 (43.28%)
HLQ2 “You need to recertify Medicaid every ______”
33 (45.21%)
62 (48.44%)
95 (47.26%)
HLQ3 “If you run out of medication prescribed by my doctor, you should”
10 (13.70%)
32 (25.00%)
42 (20.90%)
HLQ4 “When your PCP refers you to a specialist, you need to go before next
appt”
37 (50.68%)
75 (58.59%)
112 (55.72%)
HLQ5 “You have a blood test scheduled at 8 am tomorrow, when should you
stop eating?”
26 (35.62%)
42 (32.81%)
68 (33.83%)
HLQ6 “The first thing you need to do when you got the hospital is to…”
56 (76.71%)
104 (81.25%)
160 (79.60%)
HLQ7 “If you need to go to the emergency room, you have to call 911 for an
ambulance”
2 (2.74%)
5 (3.91%)
7 (3.48%)
HLQ8 “You should get my teeth cleaned at the dentist ______”
30 (41.10%)
83 (64.84%)
113 (56.22%)
HLQ9 “[For men] Men can get sexually transmitted diseases”
55 (75.34%)
HLQ10 “[For women] After turning 50years old, you should get a
mammogram _____”
82 (64.06%)
1
Basic Health Literacy was measured using the questionnaires developed by community leaders and
the researchers. The overall score was measured to assess the knowledge level that the Karen
people had in regards to health literacy.
1 (1.4%)
7 (9.6%)
9 (12.3%) 10 (13.7%) 16 (21.9%) 20 (27.4%)
7 (9.6%)
3 (4.1%)
0
2 (1.6%)
7 (5.5%)
14 (10.9%)
15(11.7%)
28 (21.9%)
34 (26.6%)
22 (17.2%)
5 (3.9%)
1 (0.8%)
3 (1.5%)
14 (7.0%)
23 (11.4%) 25 (12.4%)
44 (21.9%)
54 (26.9%)
29 (14.4%) 8 (4.0%)
1 (0.5%)
0
10
20
30
40
50
60
0 1 2 3 4 5 6 7 8
Basic Health Literacy Score (N=201)
Men Women Total

19
MEDICATION LITERACY
Medication Literacy was measured by using a subset of questionnaires
developed by the community leaders and researchers. A large portion of the
participants scored 3 (56, 27.9%), 4 (27.4%), and 5 (36, 17.9%). The average
score was 3.6, men 3.4; women 3.7 (1-10).
Medication Health Literacy Questions and Correct Answers
Questions
Men
(n=73)
Women
(n=127)
Total
(N=201)
MLQ1 “You can take the medicine to NOT get sick.”
47 (64.38%)
61 (47.66%)
108 (53.73%)
MLQ2 “You need to finish antibiotic medication as prescribed, even
if you don’t feel sick anymore”
63 (86.30%)
113 (88.28%)
176 (87.56%)
MLQ3 “If you have bad rashes or swollen tongue after taking a
medication, you should”
11 (15.07%)
22 (17.19%)
33 (16.42%)
MLQ4 “If you have diarrhea after taking a medication, you should
_______”
6 (8.21%)
15 (11.72%)
21 (10.45%)
MLQ5 “If you are taking any medication from another country:”
11 (15.07%)
34 (26.56%)
45 (22.39%)
MLQ6 “Which medication is stronger, red or white?”
7 (9.59%)
11 (8.59%)
18 (8.96%)
MLQ7 “An adult gets a bigger pill than a child”
25 (34.25%)
53 (41.41%)
78 (38.81%)
MLQ8 “You can ask for an interpreter at a pharmacy. It is required by
law.”
54 (73.97%)
95 (74.22%)
149 (74.13%)
MLQ9 “Circle (or point) the names of the medication on the
medication label below.”
20 (27.40%)
48 (37.5%)
68 (33.83%)
MLQ10 “Circle all of the items you can use for giving liquid
medications”
5 (6.85%)
21 (16.41%)
26 (12.94%)
0
7 (9.6%) 8 (11.0%)
23 (31.5%) 21 (28.8%)
11 (15.1%)
3 (4.1%) 0
2 (1.6%)
4 (3.1%) 18 (14.1%)
33 (25.8%) 34 (26.6%)
25 (19.5%)
11 (8.6%) 1 (0.8%)
2 (1.0%)
11 (5.5%)
26 (12.9%)
56 (27.9%) 55 (27.4%)
36 (17.9%)
14 (7.0%)
1 (0.5%)
0
10
20
30
40
50
60
0 1 2 3 4 5 6 7
Medication Literacy Score (N=201)
Men Women Total

20
INTERACTIVE HEALTH LITERACY
Interactive Health literacy measures the knowledge about the procedures of
healthcare services and knowledge of the supportive measures in the hospital
setting.
Often
Sometimes
Rarely
Not
Applicable
AAHLS1. How often do you need someone to help you when you
are given information to read by your doctor, nurse, or pharmacist?
108 (53.73%)
44 (21.89%)
39 (19.40%)
10 (4.98%)
AAHLS2. When you need help, how often can you easily get hold of
someone to assist you?
107 (53.23%)
68 (33.83%)
19 (9.45%)
7 (3.48%)
AAHLS3. How often do you need help to fill in official documents?
138 (68.66%)
37 (18.41%)
23 (11.44%)
3 (1.49%)
AAHLS4. When you talk to a doctor or nurse, how often do you give
them all the information they need to help you?
143 (71.14%)
37 (18.41%)
13 (6.47%)
8 (3.98%)
AAHLS5. When you talk to a doctor or nurse, how often do you ask
the questions you need to ask?
80 (39.80%)
80 (39.80%)
36 (17.91%)
5 (2.49%)
AAHLS6. When you talk to a doctor or nurse, how often do you
make sure they explain anything that you do not understand?
105 (52.24%)
64 (31.84%)
22 (10.95%)
10 (4.98%)
AAHLS7. How often do you like to find out lots of different
information about your health?
53 (26.37%)
65 (32.34%)
66 (32.84%)
17 (8.46%)
AAHLS8. How often do you think carefully about whether health
information makes sense in your particular situation?
62 (30.85%)
60 (29.85%)
54 (26.87%)
25 (12.44%)
Yes,
definitely
Maybe/Some
times
Not really
Not
Applicable
AAHLS9. Do you try to work out whether information about your
health can be trusted?
53 (26.37%)
57 (28.36%)
91 (45.27%)
-
AAHLS10. Are you the sort of person who might question your
doctor or nurse’s advice based on your own research?
33 (16.42%)
41 (20.40%)
127 (63.18%)
-

21
Health Status
SELF-RATED PHYSICAL HEALTH
As for self-rated physical health, the majority (n=133, 66.1%) responded
“Good/Very Good/Excellent”: 52 men (71.2%) and 81 women (63.3%).
HEALTH CONCERNS
On average, participants had 1.5 health conditions (men 1.4; women 1.5).
Health Problems
Men (n=73)
Women (n=127)
Total (N=201)
Arthritis/rheumatism
28 (38.9%)
45 (35.4%)
73 (36.7%)
Asthma
4 (5.6%)
9 (7.1%)
13 (6.5%)
Back/neck problem
23 (31.9%)
51 (40.2%)
74 (37.2%)
Cancer
1 (1.4%)
0 (0.0%)
1 (0.5%)
Depression/anxiety
7 (9.7%)
23 (18.1%)
30 (15.1%)
Diabetes
8 (11.1%)
17 (13.4%)
25 (12.6%)
Heart problems
3 (4.2%)
7 (5.5%)
10 (5.0%)
High blood pressure
12 (16.7%)
17 (13.4%)
29 (14.6%)
Stroke
2 (2.8%)
6 (4.7%)
8 (4.0%)
Other
16 (22.2%)
10 (10.2%)
29 (14.6%)
None
20 (27.8%)
44 (34.9%)
64 (32.3%)
7 (9.6%) 14 (19.2%)
26 (35.6%)
11 (15.1%) 15 (20.6%)
8 (6.3%)
39 (30.5%)
48 (37.5%)
17 (13.3%) 16 (12.5%)
15 (7.5%)
53 (26.4%)
74 (36.8%)
28 (13.9%) 31 (15.4%)
0
10
20
30
40
50
60
70
80
Poor Fair Good Very Good Excellent
Self-rated Physical Health (N=201)
Men Women Total

22
Top five health concerns participants reported are: back/neck problems,
arthritis/rheumatism, depression/anxiety,high blood pressure, and diabetes.
Sixty-four participants (32.3%) reported none. As for men, the top five health
problems were arthritis/rheumatism (38.9%), back/neck problem (31.9%), high
blood pressure (16.7%), diabetes (11.1%), and depression/anxiety (9.7%). As
for women, top five health problems were back/neck problem (40.2%),
arthritis/rheumatism (35.4%), depression/anxiety (18.1%), diabetes (13.4%),
and high blood pressure (13.4%).
74 (37.2%) 73 (36.7%)
30 (15.1%) 29 (14.6%) 25 (12.6%)
0
5
10
15
20
25
30
35
40
Back/neck problem Arthritis/rheumatism Depression/anxiety High blood pressure Diabetes
Top 5 Health Conditions (N=199)

23
Healthcare Service Use
PRIMARY CARE PROVIDER (PCP)
Most of the participants utilized Jericho Road Community Center (164, 81.6%).
PRIMARY CARE PHYSICIAN VISIT
In the past 12 months, a significantly higher number of women visited their PCP
(n=118, 92.9%) than men (n=51, 69.9%).
1 (1.4%)
59 (80.8%)
7 (9.6%) 6 (8.2%)
0
105 (82.0%)
18 (14.1%) 5 (3.9%)
1 (0.5%)
164 (81.6%)
25 (12.4%) 11 (5.5%)
0
20
40
60
80
100
120
140
160
180
Community Health Center
of Buffalo Jericho Road Commnuity
Center Neighborhood Health
Center Other
Primacy Care Provider (N=201)
Men Women Total
51 (69.9%)
22 (30.1%)
118 (92.9%)
9 (7.1%)
169 (84.5%)
31 (15.5%)
0
20
40
60
80
100
120
140
160
180
Yes No
PCP Visit (N=200)
Men Women Total

24
In the past 12 months, the majority of the participants (n=122, 61%) visited PCP
more than once. On average, women visited PCP 2.6 times (2-3 times); men
1.8 times (less than twice) a year.
22 (30.1%) 20 (27.4%)
31 (42.5%)
9 (7.1%)
27 (21.3%)
91 (71.7%)
31 (15.5%)
47 (23.5%)
122 (61.0%)
0
20
40
60
80
100
120
140
None Once 2+
Number of PCP Visit -Last 12 Months (N=200)
Men Women Total

25
CLINIC/PCP EXPERIENCE
Clinic Experience Upsides
o The majority of participants (n=123, 61.8%) stayed with current PCP for 5
years or more.
o The majority of participants (n=106, 52.7%) could “usually” or “always” get an
appointment when they needed care right away.
o The majority of participants (n=157, 78.1%) could book an appointment for
check-in/routine care when needed.
Clinic Experience Downsides
o The majority of participants (n=80, 40.6%; N=197) “never” saw their provider
within 15 minutes of their appointment time.
o The majority of participants (n=111, 56.1%, N=198) were “never” informed of
how long they would need to wait for their appointment to start.
Experience with PCP
o 159 (79.5%) participants: PCP “usually” or “always” asked questions about
their health.
o 133 (67.5%) participants: PCP “usually” or “always” understandably
explained things.
o 182 (91%) participants: PCP “usually” or “always” listened to them carefully.
o 111 (56.1%, N=198) participants: PCP “always” knew about their medical
history.
o 161 (80.9%, N=199) participants: PCP “always” showed respect for what
they had to say.
o 148 (74%) participants: PCP “always” spent enough time with them.

26
o Medication: 85 (80.2%, N=106) participants – PCP “always” gave easy-to-
understand instructions on how to take medications.
o Medication side-effect: 47 (44.3%, N=106) participants - PCP “always”
explained possible side effects of medications in a way that was easy to
understand.
o Medication: 57 (53.7%, N=106) participants –PCP suggested ways to help
them remember to take medications.
o Other Medication: 82 (44.6%, N=184) participants-- PCP “never” talked to
them about all the medications they were taking.
Before Lab Tests
o 87 (48.3%, N=180) participants-PCP “always” explained what tests were for
o 84 (64.1%, N=131) PCP explanation for what test was for was “always” easy
to understand
Before Lab Tests
o 86 (48%, N=179) participants-PCP “always” followed up with them on test
results;
o 72 (56.3%, N=128) participants-results of test “always” easy to understand
Prescription medication (past 6 months)
o 66 (62.3%, N=106) of participants were knowledgeable of medication that
was prescribed to them (men 53%; women 66%).
o Prescription Medication Literacy average score: 3.1 (1-4, N=200)

27
Mental and Behavioral Health
SELF-RATED MENTAL HEALTH
As for self-rated mental health, a vast majority of the participants (n=162,
80.6%) rated themselves as “Good/Very Good/Excellent”: men (n=59, 80.9%)
and women (n=103, 80.5%).
5 (6.9%) 9 (12.3%)
30 (41.1%)
11 (15.1%) 18 (24.7%)
3 (2.3%)
22 (17.2%)
63 (49.2%)
22 (17.2%) 18 (14.1%)
8 (4.0%)
31 (15.4%)
93 (46.3%)
33 (16.4%) 36 (17.9%)
0
10
20
30
40
50
60
70
80
90
100
Poor Fair Good Very Good Excellent
Self-rated Mental Health (N=201)
Men Women Total

28
TRAUMA SYMPTOMS (RHS-15)
Trauma Score, RHS-15
2
, for the Karen refugees that reside in Buffalo was 10.9;
women's RHS score (12.4) was higher than that of men (mean=8.3). Also,
women (56, 43.8%) were higher in the screen-in for trauma than men (n=20,
27.4%).
2
Trauma was measured by the Refugee Health Screener-15 (RHS-15). RHS 15 is a 15-item measure
that measures somatic and psychological symptoms and is predictive of post-traumatic stress
disorder (PTSD) based on DSM-IV criteria.
20 (27.4%)
53 (72.6%)
56 (43.8%) 72 (56.3%)
76 (37.8%)
125 (62.2%)
0
20
40
60
80
100
120
140
Yes No
Trauma Symptoms (N=201)
Men Women Total

29
DEPRESSION SYMPTOMS
On average, the depression score (Kessler-10 Score
3
) was 15.2 for all
participants: men (mean= 14.7) and women (mean=15.5). As for the screen-in
rate, about 20.5% (n=41) of the sample screened in for mild to severe
depression. More women (21.9%) were screened in for depression than men
(17.8%).
3
Depression was measured with a 10-item scale of the Kessler Psychological Distress Scale (K-10)
(Kessler et al., 2003). Each item was scored from None of the time (1) to All the time (5), ranging from
10 to 50.
60 (82.2%)
4 (5.5%) 6 (8.2%) 3 (4.1%)
100 (78.1%)
16 (12.5%) 10 (7.8%) 2 (1.6%)
160 (79.6%)
20 (10.0%) 16 (8.0%) 5 (2.5%)
0
20
40
60
80
100
120
140
160
180
None Mild Depression Moderate Depression Severe Depression
Depression (N=201)
Men Women Total

30
ALCOHOL USE DISORDER
The average score for Alcohol Use Disorders Identification Test (AUDIT)
4
was
1.43 for the sample: mean (mean=3.74) and women (mean=0.12). A
substantive portion (n=25, 34.2%) of men scored 3 or higher whereas no
women scored above 2. Some Karen men (n=15, 20.5%) were screened in for
alcohol abuse disorder.
4
Alcohol intake, dependency, and experience of harm was measured using Alcohol Use Disorders
Identification Test (AUDIT) scale developed by Saunders (Allen et al., 1989).
15 (20.5%)
58 (79.5%)
0
128 (100.0%)
15 (7.5%)
186 (92.5%)
0
20
40
60
80
100
120
140
160
180
200
Yes No
Alcohol Use Disorder (N=201)
Men Women Total

31
Social Support
Women had slightly higher level of social support
5
by family, whereas men
exhibited more social support from friend networks. The average score of the
social support in general was 2.32; family support 2.53; friend support 2.12.
5
Social support was measured using a 6-item questionnaire of the Lubben Social Network Scale
(Lubben, 1988).
2.33 2.39 2.26
2.32 2.6
2.04
2.32 2.53
2.12
0
0.5
1
1.5
2
2.5
3
Social Support - Total Social Support - Family Social Support - Friend
Social Support (N=199)
Men Women Average

32
Dental Care
DENTAL CARE UTILIZATION
The majority of participants (n=153; 77.3%) did NOT visit a dentist in the last 12
months. Women had slightly more dental care utilization than men. Of those
who did, 31 participants (68.9%) went for routine checkups/cleaning.
12 (16.9%) 33 (26.0%) 45 (22.7%)
59 (83.1%)
94 (74.0%)
153 (77.3%)
0
20
40
60
80
100
120
140
160
180
Men Women Total
Dentist Visit- Last 12 Months (N=198)
Yes No

33
SMOKING
Of all participants, 40 (20.1%) participants reported smoking cigarettes: 30 men
(41.7%) and 10 women (7.8%).
CHEWED BETEL NUTS
The majority of the participants (n=133, 66.8%) chewed betel nuts. 50 men
(69.5%) and 83 women (65.4%).
30 (41.7%) 10 (7.8%)
40 (20.1%)
42 (58.3%)
117 (92.2%)
159 (79.9%)
0
20
40
60
80
100
120
140
160
180
Men Women Total
Smoking - Last 12 Months (N=199)
Yes No
50 (69.5%)
83 (65.4%)
133 (66.8%)
22 (30.5%)
44 (34.6%)
66 (33.2%)
0
20
40
60
80
100
120
140
Men Women Total
Chewed Betel Nut Last 12 Months (N=199)
Yes No

34
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