Fletcher Njororai, PHD, CHES
Assistant Professor, Health Sciences
Department of Health and Kinesiology
The University of Texas at Tyler
APHA 2013 Annual Conference, Nov 2- 6, Boston, USA.
© Fletcher Njororai 2013
Purpose: An exploratory study assessing health disparities among Burundian refugees within 6 years of
arrival in the US resettling in Knoxville, a small mid-southern rural city. Older refugees are particularly
vulnerable to poverty, abuse, neglect or exploitation, depression, chronic health and emotional problems
stemming from: the conditions of refugee flight, family loss and separation, an inability to advocate for
themselves because of cultural, language, or educational barriers; limited access to appropriate health and social
service agencies. Methods and Data: A mixed method research design was used for data collection. A
convenient sample of fifty adults recently resettled (n=50) participated in the study between September 2011 –
May 2012. A structured interview was administered with question items for quantitative data; and open-ended
questions for qualitative data; items elicited information on pre-immigration and migration experiences, initial
resettlement experiences, size and content of refugee social networks; and accessing resources for resettlement,
health and well-being. Findings: Descriptive statistics, correlations and independent samples t-tests were run.
Mean age was 44 years, ranging from 20 -78 years and the elderly, age ≥ 50 were 17 (34%). As age increased,
overall connectedness decreased (r= -.287, ρ=.246); English speaking was significant to overall connectedness
(Yes = 3.27, No = 2.93, ρ = .013); 36 (72%) were in good and 14 (28%) were fair or poor health. Conclusions:
Identifying health protective and risk factors within the context of refugee resettlement by health professionals
and policy makers is crucial to the health outcomes and overall health status of resettling elderly refugees.
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Key words: Social capital, refugee, Burundians, resettlement, health, well-being, policy
© Fletcher Njororai 2013
© Fletcher Njororai 2013
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Population: 10.2 million (2011)
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Capital City: Bujumbura (pop 300 000)
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Burundi is one of the five poorest countries in the world.
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It has one of the lowest per capita GDPs of any nation in the world
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The country has suffered from warfare, corruption, poor access to
education and the effects of HIV/AIDS
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Burundi is densely populated and experiences substantial emigration
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According to a 2012 DHL Global Connectedness Index, Burundi is the
least globalized of 140 surveyed countries
© Fletcher Njororai 2013
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Most of the Burundian refugees fled war in 1972 to
different countries like Congo and Rwanda and Tanzania
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Globally, over 500,000 Burundians have been granted refugee
status
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In 2006, 10,000 Burundians were approved for asylum to the
US.
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Since 2007, the US has received over 10,000 Burundian
refugees.
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Most of the Burundian refugees arrived with little exposure to
education and they are also illiterate in their own national
language, Kirundi
© Fletcher Njororai 2013
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UN definition of refugee:
On arrival in Knoxville these group were the
first refugees from Burundi in this rural midsouthern city in TN.
Arrival of 189 Burundian refugees resettling
in Knoxville starting the year 2007 faced
systems unprepared for their arrival
© Fletcher Njororai 2013
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Assess the early resettlement experiences of
elderly (≥50 years) Burundian refugees in
Knoxville TN.
Identify their perceptions on resettlement
with a focus on their health and health needs
© Fletcher Njororai 2013
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Currently over 300 Burundians have settled in Knoxville within a
short timeframe.
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Older refugees are particularly vulnerable to poverty, abuse, neglect
or exploitation, depression, chronic health and emotional problems
stemming.
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Conditions of refugee flight, family loss and separation.
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Inability to advocate for themselves because of cultural, language,
or educational barriers.
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Limited access to appropriate health and social service agencies
© Fletcher Njororai 2013
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An exploratory study assessing health disparities
among Burundian refugees within 6 years of arrival
in the US resettling in Knoxville, a small midsouthern rural city.

A mixed method research design was used for data
collection. A convenient sample of fifty adults
recently resettled (n=50) participated in the study
between September 2011 – May 2012.
© Fletcher Njororai 2013
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Healing Transitions- is an initiative by UT grounded in Community Based
Participatory Research (CBPR) approach in helping understand the
Burundians’ migration and resettlement experiences in Knoxville.
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50 participants were selected for the study for the overall study.
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This was a convenient sample given that they are a hard-to-reach
population
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A structured interview was administered with question items for
quantitative data.
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Open-ended questions for qualitative data; items elicited information on
pre-immigration and migration experiences, initial resettlement
experiences, size and content of refugee social networks; and accessing
resources for resettlement, health and well-being
© Fletcher Njororai 2013
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Dependent variable (DV) in this study is well-being measured
through self-rated perceptions of health and well-being (poor,
good, very good, excellent)- presence/absence of illnesses,
quality of life.
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Independent variables (IVs) included – family size, Other
contacts, size and content of social networks; strengths of
network ties; and functions of social networks.
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Quantitative data was sought on socio-demographic
characteristics and the IVs
© Fletcher Njororai 2013
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The average length of living in Knoxville is 3
years with a range of less than ½ yr to 5 years.
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Primary resettlement? Secondary migration?
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Descriptive statistics, correlations and independent
samples t-tests were run.
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Mean age was 44 years, ranging from 20 -78 years
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The elderly Age ≥ 50 were 17 (34%)
© Fletcher Njororai 2013
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A measure of overall density of connectedness was derived by
averaging the values for items on the question relating to strength of
networks ties.
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As age increased, overall connectedness decreased (r= -.287,
ρ=.246)
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English speaking was significant to overall connectedness (Yes =
3.27, No = 2.93, ρ = .013);
36 (72%) were in good and 14 (28%) were fair or poor health –
focus on elderly health.
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None of the adults and elderly refugees had an education
© Fletcher Njororai 2013
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Perceptions– Resettlement & self-rated health
No assistance from the resettlement agency,
Catholic Charities, sponsors or other.
Perceived and actual needs
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Loneliness example – 72 year-old lady living alone.
Emotional- separation from family left behind
Poor health (state examples/ and disability)
Unfamiliar foods
Cultural shock
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Need community gardens
Idleness and stress
Disconnect with host community
Complex system to understand/navigate
Not catered for in welfare benefits (how
many)? Why?(age faulted??)
Resettlement policies were indiscriminate of
age and gender
© Fletcher Njororai 2013
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Migration e.g. ran from war 1972 as young woman –
Congo –Tanzania
Secondary migrations (US) –family, resources, friends.
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Injuries from cleaning house/falling
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Language barrier -inability to read labels on
medicines
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Going to nursing home- (mixed feelings)
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Place for burial – should be free
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© Fletcher Njororai 2013
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Apprehension on how to qualify for
citizenship – unable to read
Scared of shootings in the neighborhood –
one went through house
Widowed women
Desire to resettle as family units especially
the elderly
Lack of time to go for ESL for those around
50 years able to work.
© Fletcher Njororai 2013
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Desire to re-unite with those left behind.
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Need for translators
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Experience evictions – rent default
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Poor houses/neighborhoods – danger for raising young children
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Send remittances to those left behind
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Expenses – live in cold house to save on cost (suspect taken
advantage of by owner).
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Desire to visit Africa one day
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1.
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3.
4.
5.
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Caregivers – children; one with a grown child with mental health
issues
Common sicknesses diabetes, arthritis, high BP, back pain :
Diabetes
Arthritis
High Blood pressure
Bones injuries/fractures
Eyesight
Stressful memories
Painful family (permanent) separation e.g. older men refusing
asylum and remain behind, going to other countries e.g South Africa
© Fletcher Njororai 2013
Good experiences:
1. Relative safety, rest and peace
2. Treatment and healthcare available e.g.
eye-care
3. Good houses compared to life in camps
4. Better life generally
5. Cultural events – preserve culture
6. Grandparents teaching language to the
children
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© Fletcher Njororai 2013
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Smaller sample size
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Convenient sampling
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Interview questions were mainly at nominal
scale – causal relationships cannot be
inferred.
© Fletcher Njororai 2013
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Refugee resettlement institutions/organizations should provide
tailored programs that cater for age and gender differences
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Culturally sensitive programs should be designed
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Resettlement policies should focus on the health of the elderly in the
short-term as well as long-term provisions
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(Re)consider the role of secondary migration and implications for
elderly refugees
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Identifying health protective and risk factors within the context of
refugee resettlement by health professionals and policy makers is
crucial to the health outcomes and overall health status of resettling
elderly refugees
© Fletcher Njororai 2013
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Multi-disciplinary longitudinal studies using multiple
methods –the role of social capital in relation to health
disparities among refugees and also assess secondary
migration.
Studies to identify negative outcomes of social capital
among the refugees
Studies focused on identifying evidence-based best or
promising practices
© Fletcher Njororai 2013
1.UNHCR (2007). Group resettlement of “1972” Burundians from Tanzania available at:
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http://www.refugees.org/atf/cf/Burundifactsheet.pdf,
2. U.S. Department of State, Bureau of Population, Refugees and Migration. (2010). Proposed refugee
admissions for year 2011. Retrieved January 2013 from
http://www.state.gov/documents/organization/148671.pdf
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Sirven, N., & Debrand, T. (2008). Social Participation and healthy ageing: An international
comparison using SHARE data. Social Science & Medicine, 67(12), 2017 -2026.
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Unsworth, C.G., & Goldenberg, E. (1998). Psychological sequelae of torture and organized
violence suffered by refugees from Iraq: Trauma-related factors compared with social
factors in exile. The British Journal of Psychiatry, 172, 90-94.
Ott, E. (2011). Get up and go: Refugee resettlement and secondary migration in the USA.
Monograph: Research Paper no.219. New Issues in Refugee Research Series. Policy
Development and Evaluation Service. UNHCR, Geneva,
Switzerland. Retrieved July 1st, 2012 at www.unhcr.org
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© Fletcher Njororai 2013