Welcome, and thank you for your interest in promoting health in refugee communities.

This toolkit is part of the Points of Wellness - Partnering for Refugee Health and Well-Being Initiative, an effort by the Office for Refugee Resettlement (ORR) to improve the long-term health of refugees in the United States.

Most important, it seeks to do so through helping tobuild the capacity of community-based organizations to promote health and disease prevention among refugees.

What Does It Mean to Promote Health?

Some people think of health simply as the absence of any disease or illness in a person. It is very important to help prevent diseases and illnesses among people, but promoting health requires more effort. Health is about having balance, both personally and socially. It is a state of well-being for all the points of wellness-physical, mental, and social. In promoting health and preventing diseases, we want to make sure that people are free of diseases or illnesses, but also that they have all the opportunities to feel strong, active, wise, and worthwhile.

This toolkit is just one part of the Points of Wellness - Partnering for Refugee Health and Well-Being Initiative.

Other elements include:

• Name and logo
• Consumer-friendly Web site (http://www.refugeewellbeing.samhsa.gov)
• Listserv (http://list.nih.gov)
• Technical assistance workshops

The overall goal of the toolkit is to help ethnic, faith-based, and community organizations engage in activities to promote health and prevent diseases among refugee populations.

How Does It Do This?

It provides practical information and guidance so that groups can work toward improving the quality of life and reducing health disparities for refugees.

Further, it was developed so that any group of individuals who are concerned about refugee health and who have the willingness to work with others in solving basic issues affecting the health of refugees in their community can use it and benefit from it as a resource.

In this toolkit, you will find:

• A Manual. The manual will help you plan and conduct health promotion and disease prevention activities.
• A Training Guide and PowerPoint Slides. These tools are to assist you in effectively sharing the ideas in the manual with others.
• An Article on Health Promotion and Disease Prevention. The article provides a good orientation to the field and activities of health promotion.
• A Video. The video provides an introduction to promoting health among refugees and can be shared in your community.
• A Compact Disk (CD). The CD contains an electronic version of the manual and PowerPoint slides.

The goal of this training is simply to instruct you on how to use this manual with your organization.

You should leave with an understanding of how this toolkit, and its different parts, can assist you in promoting health among refugees in your community.

Then, it will be up to you to learn and become familiar with its content so that you can use it effectively.

At this time, play the provided video on promoting refugee health to the group, if video equipment is available.

Activity One

Take 5 minutes to let members of the group introduce themselves or share a few thoughts about their experiences and interests in refugee health.

Let us now look at the manual portion of the toolkit. The manual is the core of the toolkit, providing both guidance and resources to assist in promoting health and preventing disease among refugees.

The manual is divided into three parts:

• Part One: Developing and Implementing Health Promotion and Disease Prevention Activities for Refugee Communities provides practical guidance for ways your organization can undertake activities to promote health and well-being in refugee communities.
• Part Two: Cultural Sensitivity in Health Promotion Work addresses the importance of culture in working with and supporting refugee communities and shows ways to ensure that your organization's efforts are culturally appropriate for the refugee groups of interest.
• Part Three: Resources for Promoting Health in Refugee Communities serves as an easy reference for information on potential programs, on how to navigate the U.S. health care system, on various screening activities, and on health topics important to refugees and can be used directly to inform members of the refugee community.

It is recognized that all types of organizations may be interested in using the manual-some with experience in working in refugee communities who are seeking to improve on what they are currently doing, and some who are new to the process.

To meet the needs of differing organizations, the manual is organized to function in two ways:

• Reference tool. For some organizations, the toolkit can be used as a reference tool, providing information on issues affecting the health of refugee groups and on methods and skills that can benefit organizations already engaged in health promotion work. Various print and Internet resources, which may be used to obtain additional details on a given subject, are also included.
• Program development guide. Other organizations may need more guidance in starting health promotion activities. For such groups, the toolkit can provide guidance on the program development process from beginning to end.

The manual also points to outside information on promoting health and preventing disease, as well as information on many common health problems that may be encountered in refugee communities.

We hope that the information provided in the manual will encourage and assist you with your efforts to promote health and prevent disease among the members of your community.

PART ONE: Developing and Implementing Health Promotion and Disease Prevention Activities for Refugee Communities

Part One is divided into six separate sections. As a whole, these sections outline a process that can be used in promoting health and preventing disease in communities.

As we go over each section individually, starting with Section 1.2, think about how these sections work together to create a plan for promoting health.

Key to learning health needs is doing a Needs Assessment, where you collect information on the concerns and problems of people in your community. You also find out what other resources or organizations are available to help.

The most important reason to do a Needs Assessment is to make sure you understand the community's concerns from their point of view. Their priorities should be your priorities.

You may think that you know what they need, but it is important to hear it from them. If you don't ask them, you may find that they will not accept your program because it is not what they need.

How Do You Conduct a Needs Assessment?

There are three easy steps you can follow in conducting a needs assessment.

1. Ask the right questions. Section 1.2.1 in the manual helps you figure out the most important things you want to learn about your community and how to pick the questions you want to answer.
2. Collect information to answer your questions. In Section 1.2.2, we suggest how you can talk with members of your community to better understand their health concerns and needs.
3. Make sense of what you learned. Section 1.2.3 gives you ideas of how to prioritize what you learned so that you can decide what your organization can do to help.

After you have identified issues affecting the community and selected the particular health issue you want to address, you need to identify who in your community is most affected by this health issue and what you can do to best address their needs.

Key to this step is setting goals that you can meet and selecting a set of activities that will help you meet your goals.

Section 1.3 walks you through three steps to help you focus your health promotion and prevention efforts on the people in your community who have the greatest need:

1. Select your target audience. Section 1.3.1 helps you identify the specific group of people you want your health promotion and disease prevention activities to reach.
2. Determine your target audience's understanding of the health concern. Section 1.3.2 shows you how to explore and gain a better understanding of what your target audience thinks about the health concern and the factors that may influence these thoughts.
3. Select your program efforts. Section 1.3.3 describes how to write a problem statement, determine your behavioral goals, and select the appropriate program activities that your organization can do.

Now that you know what types of health promotion activities you want to do in your community, the next step is to learn about the resources that already exist for you to use.

Using existing resources can save you time and money. This step includes finding other groups in your community that can be your partner and can help you with your program.

All you need to do is take some time to find out about the people, places, and programs already in your community.

A Community Resource is anything that already exists in your area and that you can use to help promote healthy behaviors among people in your community.

Activities as simple as listing and mapping can help identify potential resources in your community.

Partnering is then a matter of selecting those organizations that can further your effort at promoting health and thinking about how both organizations can share and benefit in your health promotion activities.

Activity Two

Divide your audience into small groups of four to five persons. Ask them to think of refugees in their community who have recently entered the United States but have already found housing and jobs and are somewhat settled into a schedule (i.e., their basic living arrangements are met).

Ask groups to brainstorm what they think the health needs of these refugees are in their community. Have them generate a list.

Ask them to generate another list that describes the steps they would take in their community to prioritize this list. Encourage them to answer the following questions:

• What local sources of information would they turn to?
• What other groups would they talk with?
• What types of questions would they ask the refugees in their community if they were to talk with them?

Have each group present their ideas out loud to the other groups. Discuss each group's rationale and process.

Social marketing is a step-by-step process to help you design programs that will meet the health needs of people in your community. Social marketers do not assume that they know what people want or what is best for them. By following this process, you will see the problem through the eyes of people in the community. And you will learn from them what programs they need most from you.

Social marketing is a five-stage process. You may not realize it, but up until now we have been talking about all the activities-Conducting a Needs Assessment, Developing an Understanding of Audience, and Identifying Resources and Partners-that form the first stage in the social marketing model.

The next section of the manual, 1.5, shows you how to take that vital information and use it in the social marketing process as you complete the remaining stages to create a health promotion program.

To understand social marketing, it is important to have a grasp on the principles of commercial marketing, because that is the basis for social marketing. The heart of all commercial marketing can be summed up in what has been termed the "4 P's"-Product, Price, Place, and Promotion. With social marketing, these 4 P's are important, as well as a fifth "P"-Policy:

• Product. The product is what you are marketing. For social marketing, the "product" is a certain behavior you are trying to change. For example, the product might be that refugee children in your community will receive all recommended immunizations, or that adult refugees will exercise, or any other behavior that members of your community want to change.
  
  
• Price. Here, you are considering how much it will cost a person to stop (or start) a certain behavior. In social marketing, price isn't just a question of dollars and cents. It can also be a question of time (how long will it take out of my schedule?) or effort (how difficult will it be to do the behavior?). A lifelong smoker may be the first person to admit that smoking is an extremely expensive habit but may still say that the costs of quitting-in terms of effort, possible weight gain, or nicotine withdrawal-are too high.

  A good social marketing plan will try to reduce these costs. For example, a smoking cessation group might offer support groups nutrition counseling to counteract weight gain and nicotine patches to reduce the challenges of withdrawal.

• Place. Place refers to how your health promotion and disease prevention messages reach people in the community-these are also called channels. These may include doctors' offices, shopping malls, mass media channels, or in-home demonstrations.

  Section 1.5.2 gives you more information about how to get your messages to the community.

• Promotion. Promotion is the strategy you use to present your message to people in your community. This strategy may include brochures that you mail, public service announcements, health fairs, or other community events.

  Promoting your cause does not need to cost a lot of money. It can also take place through inexpensive methods, such as word of mouth. Convincing people through a one-on-one conversation can be just as effective at changing someone's point of view as the best-made commercial, or even more so. More detailed information about how to promote messages is provided in Section 1.5.2.

• Policy. Policy refers to any changes that might be needed beyond the individual level. Social marketing programs can do well in motivating individual behavior change, but that is difficult to sustain if the person's environment does not support the change for the long run. You might need to consider building a bike path, or changing a local law, or building a day care center, for example, before you can expect people to change.

Developing an Evaluation Plan is an important part of your organization's health promotion and disease prevention program. Evaluation lets you track your program's progress and find out whether your activities are meeting the needs of people in your community.

A Formative Evaluation helps you decide whether your program and messages are appropriate for your target audience before you implement them.

A Process Evaluation measures things like how much activity you are producing.

An Impact Evaluation is used to determine how much a program changes the behavior you are addressing.

An Outcome Evaluation is used to determine how a program affects the overall health issue you are addressing in your program.

In evaluating your health promotion effort, you may need to consider doing one or all of these different types of evaluation.

Activity Three

Pass out copies of the social marketing example from the manual. Divide the audience into four groups. Have each group brainstorm ideas for one type of evaluation (formative, process, impact, or outcome).

Discuss each group's ideas out loud.

PART TWO: Cultural Sensitivity in Health Promotion Work

In Part Two of this manual, we talk about culture. In doing so, we ask the user to think about both your own culture and the culture of people in your community.

We also discuss why culture is important to consider when you design health promotion and disease and prevention programs.

Part Two consists of two sections:

• The first section (Section 2.2) provides you with questions to answer to better understand the cultural groups in your community. We also give you tools to help you and your organization work with the many cultural backgrounds in your community.
• The second section (Section 2.3) walks you through the steps you should follow to develop health promotion materials that are sensitive to the cultural beliefs of people in your community.

Each year, new refugees come to the United States from countries all around the world. Each group brings its own beliefs and preferred way of doing things. These ideas and behaviors represent a group's culture. You might already know some of the different cultural practices in your community. Others may seem new or different to you.

It is important to understand these cultural practices when promoting health in the community:

• It helps you better fit your health promotion efforts to the groups in your community.
• It demonstrates respect and consideration for the groups you are working with.
• It improves communication and helps you overcome any differences or misunderstandings when they arise.

Working with other cultural groups will also benefit your own organization. You will create new relationships and work with people who share a common goal of creating and maintaining a better community. You will see life through the eyes of people whose backgrounds and experiences are different from yours.

This section suggests, first, that it will be important to understand how the various groups have come to a community and what it means in terms of the health challenges that refugees may face in settling into their new communities. You should consider whether refugees may face health challenges that resulted from their experiences before or during their migration or ones that resulted as part of their settling into the new community, which may be very different from the one they left behind.

In addition, we provide manual users an introduction to some of the important elements of culture that might need to be considered for each refugee group to be effective in conducting health promotion.

As a last step, we urge groups to look at their own diversity and how it affects their work with others. To do this, we provide several tools designed to increase awareness of a group's cultural competency.

Promoting health among refugees may also require careful consideration of how to create materials that adequately fit the community. Central to many efforts will be learning how to develop materials and have them translated to meet the language needs of a community.

To help groups create effective materials, we have outlined some activities that can be done to consider the communication needs of the audience.

These include:

• Selecting the appropriate type of communication, whether oral or written
• Determining how to go about getting materials translated
• Deciding what steps to take if you are adopting existing materials to make sure they will work with new groups

Activity Four

Adapting and Testing Health Materials

As a group, read the brochure provided in the Appendix of this training manual. (Trainers: You may want to make copies before the training session so that people can view and write on the brochures.) After the group has finished looking over the brochure, discuss and answer the three questions that follow. You may want to write the questions and the group's answers on a piece of poster paper to help promote discussion:

1. What words, sentences, or concepts found in the brochure might be hard for members of refugee groups to understand?
2. If you were to give a pretest on this brochure before sharing it with members of the refugee community, what questions might you ask?
3. What changes might you make to improve the understanding of the brochure?

The following are some points to share with the group, if not brought up in the discussion:

• Some medical terms, such as rectum, polyps, and sigmoidoscopy, may need clarification.
• The headings could be made easier to read, by using differing size or bold font.
• The text uses percentages as a concept, as in the following sentence: "If everybody age 50 or older had regular screening tests, at least 33% of deaths from this cancer could be avoided." There may be easier ways to share number information, such as visual diagrams that show one out of three people having colon cancer.
• Offering an example of alternatives can help create better understanding. Look at how the following passage is improved with the addition of a few words:

Some people with colorectal polyps or colorectal cancer do have symptoms. They may include:

• Blood in or on your stool (bowel movement)
• Pain, aches, or cramps in your stomach that happen a lot and you don't know why
• A change in bowel habits, such as having stools that are narrower than usual
• Losing weight and you don't know why

• The last line of the brochure suggests going to see a doctor for more information. This statement fails to provide members of the refugee community with clear steps or actions they can follow to address the risk of colon cancer. Names and telephone numbers of providers or other resources that can help people find the appropriate care would improve this brochure.
• Pictures are an important and helpful way to share information. They can help clarify concepts that otherwise might be difficult to understand. However, a bad picture or one that does not provide enough information is not useful. The picture in the brochure could be improved by adding an outline of the body to show where the colon is in relation to other parts of the body.

PART THREE: Resources for Promoting Health in Refugee Communities

In Parts One and Two, we took you through the steps to develop health promotion and disease prevention activities that best meet the needs of people in your community. Now, in Part Three, we will focus on specific types of activities that you can do and resources you can use to improve the health of people in your community.

In Part Three, you will find information to help address specific health needs:

• Section 3.2 offers ways to help people better understand the U.S. health care system and get the health care they need.
• Section 3.3 describes types of community programs that can be used to address health issues in your community.
• Section 3.4 describes types of health screenings that can be used to identify health concerns in your community.
• Section 3.5 provides fact sheets that provide basic information on various health concerns, designed specifically for you to use within your community.

One of the most common barriers to people accessing health care is their unfamiliarity with the U.S. health care system. Organizations can help by providing them with information so that they get the care they need.

People need such basic information as:

• Where to get health care
• What different types of health care providers are available
• How to pay for health care
• How to communicate with their health care provider

To get groups thinking about community health promotion and disease prevention programs, this section provides some examples of programs that organizations can develop and maintain to help the members of their community. These descriptions are meant to be informative and encouraging. Discussed are four types of programs:

• Support groups
• Chronic illness management programs
• Health fairs
• Walking programs

Health screenings are another type of activity that groups can consider to promote health and prevent disease. Provided, here, are background information on screening and some specific information about different types of screenings.

Examples of Types of Screenings

The final section of the manual provides organizations with a series of fact sheets on various health concerns-chronic and infectious-for refugee communities. These fact sheets contain basic information, including definitions, risk factors, and suggestions for what refugees can do to lower their risk of specific diseases and organizations they can contact for more information.

Activity Five

The 5-Minute Web Master

Have members of the group take a few minutes to select and read one of the fact sheets in this section. Provide each person with paper and a pen, and have them turn the paper so that its long side is horizontal.

Now ask them each to design a Web site that shares the information on the fact sheet with members of the refugee community, by sketching its pages and links on the sheet of paper.

Prompt them to consider the following:

• What information would they want to include and how would they place it on the pages?
• What title would they use for their pages?
• What pages would they have as part of their Web site?
• What images would they want to include?
• What resources would they want to provide links to?

Topics covered:

• Chronic illness (Section 3.5.1)
• Communicable diseases (Section 3.5.2)
• Behavioral health concerns (Section 3.5.3)
• Maternal and child health (Section 3.5.4)
• Older adult issues (Section 3.5.5)

Thank you for participating.