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A new study in the works published in the BMJ Open is looking at community-engaged mental health promotion intervention with Bhutanese people resettled in Western Massachusetts.

“I have been working with this population since 2015, engaging them in every intervention stage, from need identification to strength assessment, program development, implementation, and evaluation,” study author Kalpana Poudel-Tandukar told us. “We plan to provide a program to 112 families by 2023.”

Stress resulting from attempts to integrate into a new culture while trying to maintain one’s own culture takes a heavy toll on the mental health of newly settled immigrants. Immigrants’ risk for mental health problems increases during their acculturative process due to exposure to multiple stressors, such as adjusting to a new culture with limited language and socio-cultural skills and lacking culturally-mediated and protective social support resources.

“Mental health burden is high among immigrant and refugee populations due to various socio-cultural stressors while acculturating to a new cultural environment of the host country,” Poudel-Tandukar told us. “Our study aims to assess an effect of a peer-led family-centered preventative behavioral intervention to reduce stress, anxiety, and depressive symptoms among Bhutanese adults resettled in Western Massachusetts using a randomized controlled trial.”

The program includes multi-component evidence-based approaches such as psychoeducation, behavioral activation, and mind-body interventions to address multiple social and emotional stressors. Researchers are hoping to find out the program's effectiveness in promoting coping, self-efficacy, family-conflict resolution, and social networking skills and reducing stress, anxiety, and depressive symptoms among Bhutanese adults.

“Our study is guided by Lazarus and Folkman’s stress and coping theory,” Poudel-Tandukar told us. “This theory posits that individuals feel stress when they perceive a discrepancy between the demands of a situation and their ability to cope with those demands. Such stress can prevent efficient use of resources.”

According to Bandura’s self-efficacy theory, self-efficient individuals are better equipped to cope with stress due to their effective use of coping resources in their environment (e.g., family or social support) and their ability to interpret outside stressors positively. An individual's knowledge and implementation of positive adaptive strategies predict positive mental health outcomes.

“Guided by these theoretical constructs, our program aims to reduce stress, anxiety, and depressive symptoms by improving individuals’ coping, self-efficacy, and social support, which are identified as essential target mechanisms to promote mental health,” Poudel-Tandukar told us. “Identifying and strengthening available coping resources will help immigrants reduce stress.”

The literature suggests that existing interventions are primarily based on treatment models to improve the quality of care and language issues to address mental health disparities in minority groups. Interventions designed to reduce mental health problems among those with diagnosed conditions do little to help prevent disorders.

“For prevention, culturally-tailored programs that address different social-cultural and emotional stressors hold the most promise, as evidence shows a strong link between stress and poor mental health,” Poudel-Tandukar told us. “Thus, our research aimed to investigate potential preventive solutions to reduce stress and assess their effective implementation among immigrants using a community-based participatory approach.”

The primary analyses will test whether outcomes (stress, anxiety, and depression) for participants in the intervention group (58 families) differ from those in the control group (58 families). Multilevel modeling will compare outcomes of each treatment group while accounting for clustering of participants within families. Continuous outcomes will be analyzed using hierarchical linear modeling, and dichotomous outcomes will be analyzed using multilevel generalized linear models with a Bernoulli distribution appropriate to nonlinear binary outcomes.

“In the summer of 2021, we trained six community interventionists (12 full days), Bhutanese adults with a high school degree, following the World Health Organization’s training guidelines to make them competent in delivering the program,” Poudel-Tandukar told us. “Our trained community people have been actively working to implement a program for 116 families by 2023.”

Results of the current study are expected in mid-2024. Researchers hope their integrated, preventative, behavioral intervention builds on cultural strengths and community resilience to help immigrants and their families reduce stress by developing behavioral abilities to cope positively with stress and enhance mental health.

“Our contribution will be developing, implementing, and evaluating a culturally competent psycho-socio mental health preventative intervention using a Community Based Participatory Research approach,” Poudel-Tandukar told us. “We have been working with the Bhutanese community since 2015 to develop a mental health promotion program.”

From the beginning, researchers have been engaging community people in their research, including analyzing community health problems, setting health priorities, assessing community strengths, setting program goals and objectives, developing program strategies, planning, implementing, and evaluating programs, and disseminating results publishing peer-reviewed articles and presenting at conferences.

First, they conducted meetings with community people and identified the priority health problems. Second, they engaged community research assistants to conduct a health assessment survey in 225 Bhutanese adults. Third, they presented the findings to the community and explored culturally tailored stress management interventions to address their needs. Fourth, they identified evidence-based mental health promotion interventions, including psychoeducation, problem-solving, and mind-body interventions, and designed the social and emotional well-being (SEW) program together with community people. Fifth, with foundation grant support, they trained local people as community interventionists who successfully delivered SEW programs in a group and family settings.

“Our pilot program evaluation results showed more than a 50% reduction in the prevalence of anxiety and depression among Bhutanese adults after the intervention,” Poudel-Tandukar told us. “The program also resulted in improved skills in coping adaptively in a new culture, seeking help and support for mental health problems, and other life skills opportunities that could improve their quality of life.”

The current research project will be among the first to adapt and pilot test the feasibility and acceptability of a family-based, community-led, culturally tailored, integrated preventative behavior intervention to reduce immigrant stress. The study will lay the basis for a clinical trial with a large, adequately powered sample. If effective, this community-engaged intervention may be applied more widely to other immigrants and the general population.