“I wish she would explain the medication in a way I could understand.” A Mixed Methods Study of Chin Burmese Refugee-Pharmacist Relationships

doi:10.21203/rs.3.rs-1639628/v1

Background: Because they face persecution in their native Myanmar, many members of the Chin ethnic group have come to the United States as refugees, where they face language and cultural barriers. Little is known about their perceptions of Western medications or relationships with pharmacists.

Aim: To explore, from the refugees’ perspectives, the meanings that Western medications hold, how they prefer to communicate with healthcare providers and pharmacists, and the strategies they use to take medication properly.

Method: This mixed-methods study used a survey, an assessment of health literacy, and in-depth semi-structured interviews.

Results: The 21 respondents were born in Myanmar, had a median age of 64 years, little formal education, and low health literacy. Respondents reported positive attitudes toward Western medications and high adherence to prescribers’ instruction. Although they usually obtained medication at community pharmacies, respondents reported communication barriers and refugees’ knowledge of services available to them there was limited.

Conclusion: Community pharmacists need to be aware of the needs of their Chin patients and consider strategies to accommodate them.

Chin Burmese have language and knowledge barriers to accessing services in community pharmacies.
Chin Burmese have positive relationships with healthcare providers, but they are not aware of the services they can receive at community pharmacies, and some are not satisfied with their relationships with community pharmacists.
Adult Chin Burmese often have low health literacy.
Community pharmacies need to think consciously about how they can provide appropriate and accessible services to the Chin Burmese community.

The Chin are one of eight major ethnic minority groups in Myanmar. They face harassment, religious persecution (most Chin are Christian, while majority Burmese are generally Theravada Buddhists [1]), forced labor, arbitrary arrest and detention, torture, and sexual assault[2]. Because of this, many Chin have fled to refugee camps in Malaysia or Thailand. They wait there, often for years, until they can be admitted to another country as refugees[3, 4]. Since 2008, the majority have come to the United States, many to the Indianapolis, Indiana area, where an estimated 15,000 currently reside. The Chin speak 31 different dialects; they prefer to speak their own dialects rather than Burmese[5].

As refugees to the United States in the state of Indiana, they are eligible for Medicaid or the Children’s Health Insurance Program (CHIP), both health insurance programs for people with low incomes, for several months[6]. In general, Chin people are satisfied with the Western health care they receive [7, 8]; however, many, especially elders, still retain traditional medicinal practices [8]. Their access to healthcare is limited due to language and cultural barriers [9]. Although a few studies of Chin healthcare utilization have been published[7, 9, 10], little is known about the attitudes of Chin refugees in the United States regarding medication or relationships with pharmacists.

Aim

This mixed-methods study explored, from refugees’ perspectives, the meanings that Western medications hold, how they prefer to communicate with healthcare providers and pharmacists, and the strategies they use to take medication properly

Ethics Approval

This study was approved by the Butler University institutional review board on August 24, 2015 (no approval number).

Twenty-one members of the Chin community were recruited using convenience sampling. The interviewer, a university student and herself a member of the Chin community, helped respondents complete a short survey, an assessment of health literacy, and a semi-structured interview lasting 20–55 minutes. The survey asked questions on sociodemographics, health status, and healthcare utilization and access. Health literacy was assessed using the Rapid Estimate of Adult Literacy in Medicine—Short Form (REALM-SF) instrument[11]. Descriptive statistics were generated from survey results. Oral informed consent was obtained from respondents before data collection. Data collection took place between January and May 2016.

The interview guide was adapted from one used previously by the Principal Investigator (Table 1). Interviews were conducted in the dialect of the participant’s choice: Zophei, Hakha, or Thlantlang at a place of the participant’s choosing, usually in the home. Interviews were digitally audio-recorded, translated into English, transcribed, and analyzed by two researchers. Each researcher coded the transcripts individually then met to determine a final coding strategy. Themes were allowed to emerge inductively from the transcripts.

Table 1

Interview Guide for Study
Beliefs about Medicines
How does your medicine affect your health? Does it make you more, or less healthy? Why?
What do you think are the advantages of taking your medicine every day?
What worries or bothers you about being on medicine?
How common and how serious are side effects from medicines?
What do your family members or others around you think about you taking medicine?
What do you tell your children or other family members about their medication?
Perceptions of Patient-Prescriber Communication
How does your doctor work together with you to decide on a plan for your health, including what medicines to take?
How easy or hard is it for you to ask your doctor questions or voice your concerns?
What do you wish your doctor would discuss with you or consider about you as an individual before he or she prescribes medicine for you?
What does your doctor, tell you about your medicines?
What do you like or dislike about how they talk to you about your medicines?
What more do you wish they would tell you?
If you think your medicine isn’t working right, who do you talk to about this?
How does this person respond to your concerns?
Relationships with Community Pharmacists
When you go to the drug store to pick up a prescription, do you ever talk to the pharmacist?
How do you feel about your pharmacist?
Do you trust your pharmacist more or less than you trust your doctor?
How could your pharmacist help you with your medications?
How can they help you learn about them?
Barriers and Facilitators to Medication Adherence
What kinds of things make it easy for you take your medicine every day as prescribed?
What kinds of things make it hard for you to take your medicine every day as prescribed?
If you’ve ever skipped a dose or taken less medicine than the doctor prescribed, why was this?
Has your doctor ever given you a prescription you didn’t fill? If so, why?
How does your responsibility to your family or others affect how you take your medicine?

Table 2

Characteristics of Participants (N = 21)
Participant Number	Age	Gender	Years of Education	Employment Status	Marital Status	Years in U.S.	Physical Health Problems in Past 30 Days	Mental Health Problems in Past 30 Days	Self-Rated Health	Takes Prescription Medication Daily	Talked to Pharmacist about Medication in Past 6 months	REALM-SF Score^a
1	52	Female	1–8	unable to work	currently married	more than 10	No	No	Fair	Yes	Yes	3
2	55	Male	1–8	currently employed	currently married	more than 10	No	No	Good	Yes	No	7
3	36	Male	1–8	currently employed	currently married	5–10 years	Yes	Yes	Fair	Yes	Yes	6
4	55	Male	12	unable to work	currently married	more than 10	Yes	No	Poor	Yes	No	7
5	45	Male	0	currently employed	currently married	5–10 years	Yes	Yes	Fair	Yes	Yes	5
6	30	Female	9–11	currently employed	currently married	5–10 years	Yes	Yes	Very Good	Yes	Yes	6
7	29	Female	1–8	currently employed	currently married	5–10 years	No	No	Very Good	Yes	No	4
8	30	Female	9–11	currently employed	currently married	more than 10	No	*	Fair	Yes	Yes	7
9	49	Male	1–8	unable to work	currently married	5–10 years	Yes	No	Poor	Yes	Yes	6
10	47	Male	1–8	unable to work	currently married	less than 5	Yes	No	Poor	No	No	2
11	39	Female	1–8	currently employed	currently married	5–10 years	Yes	No	Fair	No	Yes	5
12	39	Male	1–8	self-employed	currently married	5–10 years	No	Yes	Good	No	Yes	0
13	37	Female	9–11	self-employed	currently married	5–10 years	No	Yes	Good	No	No	0
14	52	Male	University graduate	currently employed	currently married	5–10 years	No	No	Good	Yes	Yes	7
15	50	Female	0	out of work	currently married	less than 5	No	No	Fair	Yes	Yes	0
16	52	Male	9–11	currently employed	currently married	less than 5	No	No	Very Good	Yes	Yes	0
17	64	Female	1–8	unable to work	single, never married	5–10 years	Yes	Yes	Poor	Yes	No	0
18	43	Male	9–11	currently employed	currently married	less than 5	No	No	Fair	No	Yes	5
19	35	Female	9–11	self-employed	currently married	less than 5	Yes	No	Very Good	Yes	Yes	4
20	46	Male	0	unable to work	single, never married	more than 10	Yes	No	Fair	Yes	Yes	4
21	50	Male	1–8	currently employed	currently married	more than 10	Yes	No	Fair	Yes	No	4
Notes
* Did not answer question
^a Rapid Estimate of Adult Literacy in Medicine—Short Form (REALM-SF) scoring:
0 Not able to read most low-literacy materials; will need repeated oral instructions, materials composed primarily of illustrations, or audio or video tapes
1–3 Needs low-literacy materials, may not be able to read prescription labels
4–6 Struggles with most patient education materials; will not be offended by low-literacy materials
7 Able to read most patient education materials

Survey and health literacy results. Respondents are described in Table 2. Respondents ranged in age from 29 to 64 years (median 46). All respondents were born in Myanmar; 16 out of 21 (76.2%) had been in the United States for five or more years. More than half (61.9%, 13/21) had eight or fewer years of formal education. Nearly all (95.2%, 20 /21) had health insurance; 13 (61.9%) currently received Medicaid and seven with employer-based insurance. Most (85.7%, 18/21) reported getting their medications from community pharmacies. Most (85.7%, 18/21) stated that they had taken their medications as instructed ‘all of the time.’ Few (19.0%, 4/21) scored high enough on the health literacy instrument to be able to read and interpret patient instructions.

Interview results. Themes emerged related to medication beliefs, patient-provider communication, and relationships with community pharmacists.

Medication Beliefs: Respondents agreed that taking medication is necessary for serious health issues, and that they followed their providers’ instructions (Interviewer:” What do you think are the advantages of taking your medicine every day?” Respondent 21: “The medicine makes me feel better and healthy”). Many respondents reported taking their medications according to schedules they had learned in Burma instead of following health care professionals’ instructions. Almost all stated that they encouraged family members to take necessary medication.

Perceptions of Patient-Prescriber Communication and Medication Adherence. Respondents trusted their primary care providers (PCPs) more than their pharmacists. Participant were also more likely to follow medical advice when it was stated in positive terms (Respondent 11:“When the doctor says that the medicine will make me healthy, I like just hearing the word ‘healthy’”). Almost all respondents reported that they adhered to medication instructions (Respondent 6: “I never [skip a dose] when it comes to medication. I always tend to follow the doctor’s instructions. I always refill my prescription on time.”)

Relationships with Community Pharmacies and Pharmacists. Respondents reported communication barriers, especially a lack of interpreters (Interviewer: “Why don’t you talk to your pharmacist?” Respondent 17: “Because she doesn’t understand me.”. Respondent 2: “I wish she would explain the medication in a way I could understand. I can’t read and I don’t speak English.”) Often, adult family members depended on younger family members to interpret (Respondent 1: [had lived in the United States more than 10 years] “I never talk to the pharmacist. My son or my daughters are the ones who talk for me.”). Respondents relied on their doctors to explain medications (Respondent 7: “I rely on my doctor’s instructions. [PCP uses medical interpreter.] Why would I want to hear from the pharmacist again? I don’t understand them”). Some respondents expressed regret about pharmacists’ communication style (Respondent 1: “I wish that they would talk and give me my prescription with a warm expression.” Some reported that they would prefer demonstrations on how to use medications rather than written instructions. Overall, they saw their pharmacists positively (Respondent 14: “I trust them 100% since they are in their positions after going through much training.”) They were unaware of the expanding pharmacist role; however, they were supportive of it when it was explained (“Interviewer: How do you feel about pharmacists taking [more patient services] on? Respondent 16: “I think that it is great since it will be beneficial for others as well.”)

This is the first study to emphasize utilization of community pharmacies by the Chin Burmese community. It underscores that the Chin community is a medically underserved population, especially in community pharmacies. While most Chin use community pharmacies to obtain medications, they are not fully served there. There are language and cultural barriers that keep pharmacists from providing optimum medication oversight. This study is congruent with the findings of White that the Chin people trust Western medicine and have added it to their practices of promoting and maintaining their health [8]. Kercood and Morita-Mullaney [7] also found that language was a significant barrier to obtaining medications.

In general, participants had more positive relationships with their doctors than with pharmacists. This is primarily due to the availability of medical interpreters during doctor visits. It is clear that many Chin lack full access to community pharmacies. Perhaps local pharmacies can recruit “third-culture” young adults [12], who arrived in this country as children, as pharmacy technicians to serve the community. As immigrant communities prize education and success, it is likely that at least some of the technicians will become pharmacists. Once communication been established, the Chin can be educated on proper medication use and drug safety. The expanded role of pharmacists will give them another entrée into wellness and healthy living. Many respondents were receptive to the idea of pharmacists being involved in more patient care, but they felt they couldn’t access those services because of language and cultural barriers.

Strengths and Weaknesses.

Although this is the first study to emphasize Chin Burmese utilization of community pharmacies, results cannot be generalized to all refugees, all refugees from Myanmar, or even all Chin refugees. Because of social desirability, respondents may have edited their responses; however, having an interviewer who was Chin herself and who spoke their dialects may have made them comfortable enough to be frank. Analysis of interviews was conducted using the English translations of interviews, so hard-to-translate nuances may have been lost. The survey and interview guide were not constructed de novo for the Chin Burmese population. Although convenience sampling is appropriate for qualitative research [13], survey results cannot be assumed to be representative.

From the perspective of Chin Burmese refugees living in the United States, community pharmacies are not yet accessible places for information on their medications or their health. Chin Burmese respect pharmacists’ education and standing as healthcare professionals but rely on prescribers for medication advice. Community pharmacies need to strategize to provide language and culturally appropriate services in areas where Chin Burmese reside.

Further Research

The pharmacy needs of the Chin Burmese community should be assessed using population-based methods. Programs to overcome barriers need to be developed and evaluated.

Funding

This study was funded by a grant from the Holcomb Awards Committee, Butler University.

Conflicts of Interest

The authors have no conflicts of interest to declare.

Kung LK. Love your enemies: a theology for aliens in their native land: the Chin in Myanmar. Stud World Christianity. 2009;15:81–99.
Human RW. "We Are Like Forgotten People" The Chin People of Burma: Unsafe in Burma, Unprotected in India. 2009. https://www.hrw.org/report/2009/01/27/we-are-forgotten-people/chin-people-burma-unsafe-burma-unprotected-india#. Accessed 30.04.2022.
Gilbert P, Hein M, Losby J, Exploring Refugee Integration. Institute for Social and Economic Development. 2010. https://www.yumpu.com/en/document/read/35383480/exploring-refugee-integration-experiences-in-four-american-. Accessed 29.04.20202.
Khai KS, Irregular Burmese Migrant Workers in Malaysia: A Case Study of Chin Irregular Migrants. 2009. https://scholars.ln.edu.hk/en/publications/experiences-of-chin-irregular-migrant-workers-in-kuala-lumpur-mal. Accessed 27.04.2022.
Burmese American Community Institute. The Burmese Population in The U.S. Reaches Over 130,000, College Going Rate Increasing. 2014. https://thebaci.org/2014/08/. Accessed 04.28.2022.
Indiana Department of Health. Refugee Health Services. 2022 https://www.in.gov/health/refugee-health/refugee-health-services/ Accessed 04.20.2022.
Kercood S, Morita-Mullaney T. Health perceptions and practices of Burmese refugee families: A participatory mixed method study. Journal of Southeast Asian American Education and Advancement, 2015; 10: Article 8.
White M. Cultural definitions of health care: A case study of Burmese refugees in Indianapolis. Journal of the Indiana Academy of the Social Sciences 2012; 15: Article 10.
McHenry MS, Umoren R, Dixit A, et al. Exploring Healthcare Perspectives of Burmese Chin Refugees. J Cult Divers. 2016;23:151–7.
Tanabe M, et al. Family planning in refugee settings: findings and actions from a multi-country study. Confl Health. 2017;11:9.
Arozullah AM, Yarnold PR, Bennett CL, et al. Development and validation of a short-form, rapid estimate of adult literacy in medicine. Med Care. 2007;45:1026–33.
Hussein F. From Burmese to American: Profiles in assimilation. In The Indianapolis Star (newspaper). 2017. http://www.indystar.com/staff/10054522/fatima-hussein/. Accessed 10.30.2017.
Marshall MN. Sampling for qualitative research. Fam Pract. 1996;13:522–6.

“I wish she would explain the medication in a way I could understand.” A Mixed Methods Study of Chin Burmese Refugee-Pharmacist Relationships

Status:

Version 1

Abstract

Impacts On Practice

Introduction

Methods

Results

Discussion

Conclusion

Declarations

References

Status:

Version 1