Health through a New Lens: Photovoice Exploration of Bhutanese Refugee Newcomers' Perspectives on Healthy Living in the U.S

Background & Purpose: Refugees resettled in the U.S. experiences high rates of mental and physical health issues, such as an increased risk for depression, hypertension, obesity, and diabetes. These challenges are exacerbated by sociocultural factors, including limited health literacy, difficulties navigating the U.S. healthcare system, and changes in lifestyle. Health promotion is particularly challenging due to culturally different beliefs, values, and practices around illness management and health care. Adopting a critical systems theory that prioritizes community and participant-oriented knowledge generation, we conducted a photovoice study that captured and emphasized the perspectives and voices of Bhutanese refugees about their health, specifically focusing on the cultural meanings of healthy living and wellness among Bhutanese refugee newcomers in the U.S.

Methods: As part of a community-based participatory research project, this study incorporated the photovoice method into a wellness workshop curriculum to facilitate active engagement and self-reflection on the meaning of healthy living among participants. Using purposive sampling, we recruited 24 Bhutanese refugees aged between 24 and 67 years (12 males and 18 females) and six peer facilitators, equally split by gender. Participants were provided with digital cameras and instructed to capture images of their perceptions of healthy living in the context of resettlement as a refugee newcomer and to create accompanying brief narratives. Group discussions were conducted to explore their experiences and narratives further. Data analysis entailed a hybrid thematic approach involving coding and categorizing narratives into themes related to the concept of health capital in ecological systems through an iterative process of thematization.

Results: Findings revealed various overarching themes related to how participants define the meaning of healthy living at different socioecological levels. At the individual level, themes such as healthy eating, physical activity, illness management, sanitation, mental stress management, and spiritual health emerged. At the interpersonal/relational level, relational health and family well-being themes emerged as crucial factors for participants' adjustment and integration into the new community. Other overarching themes also include developing relationships with fellow community members and aiming to thrive within the new community. Participants stressed the importance of peace and safety in the community, feeling free from violence in their home countries and neighborhoods, and the need for strong community relationships. Findings also showed that connectivity to the land is an important element of healthy living for the Bhutanese community, reflecting participants' connections to their cultural heritage and desire to maintain their traditional practices.

Conclusion: The study highlights the importance of considering multiple socioecological factors in understanding refugees' health behaviors and practices. Effective health interventions for refugees should consider the various levels of influence on health behaviors.By centering cultural perspectives and empowering community members for community-led initiatives, this study discusses implications for social work research to amplify marginalized voices and recenter knowledge in health and mental health research with underrepresented Bhutanese refugee community members.