Paraphrase, summarize, and quote the source.

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Question Description

this should be brief and primarily in your own words. Condense the main points from the source into a paragraph no shorter than 8 sentences and no longer than 12. In this description of what the source is and is about, you should make use of all three condensing modes (paraphrase, summary, quotation) and cite page numbers, according to the style you’ve chosen. Direct quotations should be kept short and should be the sort of material you might quote in your persuasive essay—if you can put the information in your own words without losing anything, do; save quotes for expert testimony and ideas too complex to be summarized accurately. Typically, you would not use more than one quote except for short quoted phrases.

1. summary of the articles

2. Notes from the article

1-15

3. Response to your notes only

4. evaluation

Summary of Source: Write a full paragraph that summarizes and paraphrases information from your source (100% in your own words). This summary should include the main points the source is making, as well as the relevant support the writers use.

Notes from Source: There are several kinds of information that you might find useful or informative in your sources, depending on the rhetorical situation for your research. Below is a list of important concepts and ideas that you should take notes on while reviewing your sources, relevant to this project. Please number your notes!  Direct Quotes of key ideas  Paraphrases of key ideas  Summaries of key ideas  Key vocabulary/jargon  Background information you uncover o About the author o About the subject o About the audience  Information you realize about the specific field of study (is this law scholarship? Anthropology? History? Etc?)  References to other, existing research within this article  References to other positions or sides to the argument/claim being discussed in the article (what other people think about this subject, that differs from the author’s viewpoint)  Information about the research methods – how did this researcher conduct her or his study?

Reaction to Source (Ways to Respond) Respond to the most important of your notes from the source—identify them by number. Your reactions might include any of the following: o An explanation about why you think the note is important o A sentence that explains what you think about the idea(s) the note presents o Why you agree and/or disagree with what the author has written

Evaluation of Source Think about the claims the source makes and the evidence used to back up those claims, or if a report about a scientific study, think about the set up of the study, the sample size, other factors, and what the study discovered. Are you convinced by this article? State why or why not, or any reservations or unanswered questions you have.

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Journal of Immigrant & Refugee Studies, 12:331–352, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 1556-2948 print / 1556-2956 online DOI: 10.1080/15562948.2013.848007 Factors Influencing the Acculturation of Burmese, Bhutanese, and Iraqi Refugees Into American Society: Cross-Cultural Comparisons FERN R. HAUCK Department of Family Medicine, University of Virginia School of Medicine, Charlottesville, Virginia, USA ELSBETH LO and ANNE MAXWELL University of Virginia School of Medicine, Charlottesville, Virginia, USA P. PRESTON REYNOLDS Division of General Medicine, Geriatrics, and Palliative Care, Center for Biomedical Ethics and Humanities, University of Virginia, Charlottesville, Virginia, USA We examined the acculturation experiences of Burmese, Bhutanese, and Iraqi refugees living in central Virginia based on the model of acculturation developed by J. W. Berry. We identified themes in examining the effects of English language proficiency, level of social support, financial stability, and expectations about and satisfaction with life in the United States on acculturative stress. Language difficulty and barriers to accessing education, employment opportunities, and health care caused stress in all cultural groups. Nearly all refugees were happy they had immigrated due to the personal freedom, safety, and hope for the future they found in the United States. KEYWORDS Acculturation, refugees, barriers to health care, social support, stress The displacement of refugees continues to be a worldwide problem in the 21st century. The United States admitted close to 76,000 refugees in 2012, with 70,000 projected for 2013 (Proposed Refugee Admissions for FY 2013, 2012). As such, caring for refugees has become a common experience for Address correspondence to Fern R. Hauck, MD, MS, Department of Family Medicine, University of Virginia School of Medicine, P.O. Box 800729, Charlottesville, VA 22908. E-mail: frh8e@virginia.edu 331 332 F. R. Hauck et al. health care professionals. Treating refugees, who have often experienced war, poverty, and political suppression, requires that health care providers and agencies develop and apply a specific set of skills to care for the unique emotional and physical conditions of these patients. Most of the published literature exploring the immigrant experience does not specifically examine the challenges faced by refugees resettling in the United States, whose reasons for flight are nonvoluntary. Furthermore, much of refugee research has focused on Southeast Asian refugees who arrived at the end of the 20th century; meanwhile, current groups of refugees are coming from a greater number of countries and arriving in the context of a different set of U.S. resettlement policies (Allen, 2009). This study examines the experiences of refugees from Burma (Myanmar), Bhutan, and Iraq living in Charlottesville, Virginia. These three groups are among the newest refugees arriving in the United States and other resettlement countries; thus, the literature devoted to these specific groups is still limited. The goal of this study is to better understand the stressors that recent refugees experience during the acculturative process, specifically those arriving from Burma, Bhutan, and Iraq, so that clinicians who provide care to them are better prepared to address their conditions. LOCAL RESOURCES Since opening its doors in 1998, the Charlottesville chapter of the International Rescue Committee (IRC) has resettled close to 2,000 refugees, assisting approximately 150 to 200 new refugees a year. The University of Virginia (UVA) International Family Medicine Clinic (IFMC) was established in 2002 to provide comprehensive care to the growing immigrant and refugee populations in central Virginia. All refugees arriving in Charlottesville receive initial health screenings at the local health department and then are referred to the IFMC for ongoing primary health care. The services provided by the IRC ensure that all refugees are scheduled to see a primary care physician (PCP) at the IFMC; however, continuity of care results from a combination of the clinic’s outreach and patients’ interest in continuing their care. REFUGEE GROUPS IN CHARLOTTESVILLE In the last 5 years, immigrants from Burma, Bhutan, and Iraq have made up the largest proportion of refugees who have settled in Charlottesville, consistent with national settlement patterns. Of the 80,000 refugees who resettled in the United States in 2011, the largest three populations were the Burmese (16,972), Bhutanese (14,999), and Iraqis (9,388—although significantly fewer than the 18,016 admitted in 2010) (FY11 Refugee Admission Statistics, 2012; Acculturation of Refugees 333 FY10 Refugee Admission Statistics, 2010). The Burmese refugees consist of several ethnic minorities, including Karen, Karenni, Chin, and Kachin. During the time this study was conducted, the IFMC provided care to 286 Burmese, 162 Bhutanese, and 177 Iraqi patients. THEORETICAL FRAMEWORK In his 1997 article “Immigration, Acculturation, and Adaptation,” J. W. Berry describes acculturation as the changes that occur when two different cultural groups come together (1997). In our study, we use the term acculturation to explore the experiences of the refugee populations as they attempt to integrate into American society. We use the term acculturative stress to indicate the reduction in health status due to physical, psychological, and social stressors that refugees experience during their acculturation process (Berry, Kim, Minde, & Mok, 1987). Berry’s framework of the acculturation process includes variables both at the group level and the individual level to explain differences in resulting stress and eventual adaptation (2003). Moderating factors at the group level include characteristics of the society of origin and society of settlement. Individual-level variables are divided into preexisting individual characteristics (e.g., education, health, language, expectations, and migration motivation) and those that arise during acculturation (e.g., social support, coping strategies, and resources). STUDY AIMS This project builds upon a pilot study conducted in 2009 designed to explore the process of acculturation and resulting stress, as existing literature has suggested that acculturative stress may be associated with poor health outcomes (Dhooper & Tran, 1998). In the current study, we pose the same research question as the pilot study: “What factors influence the acculturation of refugees who resettle in Charlottesville?” In following with Berry’s framework, we aim to identify risk factors and protective factors in refugees by identifying the preexisting individual-level variables that influence acculturative stress. We also explore the moderating factors that arise during the acculturation process, which further elucidate the differences in refugees’ level of stress and adaptation in the United States. METHODS The IFMC maintains a database of all refugee patients seen in clinic. Potential study participants were selected from the database using the following 334 F. R. Hauck et al. parameters: age 18 years and older; country of origin listed as Burma, Bhutan, or Iraq; and date of arrival on or after July 1, 2005. Two medical students were involved in study recruitment, data collection, and data analysis. Between June and August of 2010, 23 Burmese, 16 Bhutanese, and 24 Iraqi potential study participants were contacted by phone, and if they agreed to participate, were scheduled for an in-person interview. Due to potential issues with limited English language proficiency, recruitment was conducted using professional telephone interpreters (CyraCom Company, Tucson, AZ) for Burmese, Karen, Arabic, and Nepali speakers. The study was approved by the University of Virginia Institutional Review Board for Social and Behavioral Sciences. Interviews were conducted privately and lasted approximately 1 hour each. Telephone interpreters were accessed for limited-English-proficient patients. Participants were informed that they could terminate the interview at any time. A scripted questionnaire was used, consisting of 34 questions regarding their employment and education history, expectations and experience of life in the United States, changes in cultural practices and identity following resettlement, social support systems, and levels of perceived stress (Appendix 1). The interviewers assessed participants’ English-language ability and categorized them as fluent, moderately proficient, or minimally proficient. Those who chose to complete the interviews in English were categorized as fluent. Participants who self-identified as not speaking any amount of English or who were unable to answer basic questions about their name, age, and country of origin were categorized as being minimally proficient in English. Those who could answer a few questions in English but still required the use of an interpreter were categorized as moderately proficient. Participants who completed the interview were compensated for their time with a $20 gift card to a local store. All interviews were recorded. Tapes were transcribed with removal of all identifiers, and then they were erased. The interviewees’ responses were analyzed qualitatively, looking for common themes among and across cultural groups. “Majority” or “common theme” was designated for responses that were present in over 50% of cases. “Few” or “minor theme” was designated for responses that were recorded between two and five times within a refugee group. Common themes were identified and organized into categories using a grounded theory approach (Strauss & Corbin, 1990). RESULTS The study population comprised 46 individuals from Burma (n = 15), Bhutan (n = 15), and Iraq (n = 16). The social and demographic characteristics of the study participants are summarized in Table 1. 335 Acculturation of Refugees TABLE 1 Social and Demographic Characteristics of the Burmese, Bhutanese, and Iraqi Participants Characteristic Age Burmese Bhutanese Iraqis Gender Burmese Bhutanese Iraqis Marital Status Burmese Bhutanese Iraqis Children Burmese Bhutanese Iraqis Length of Time in US Burmese Bhutanese Iraqis Point of Emigration (with no. of individuals) Burmese Bhutanese Iraqis Education Burmese Bhutanese Iraqis Religion (with no. of individuals) Burmese Bhutanese Iraqis English-Language Ability Burmese Bhutanese Iraqis (n) (n) (n) 18–24 4 3 5 Male 5 6 9 Single 4 3 9 No 4 3 9 0–1 years 2 0 5 25–49 9 11 8 Female 10 9 7 Married 9 11 6 Yes 11 12 7 1–2 years 11 13 10 50+ 2 1 3 >2 years 2 2 1 Malaysia-2 Nepal-15 Iraq-8 Elementary school 5 2 2 Thailand-11 Burma-2 Other-8 Jr./Sr. high school 8 8 11 College or higher 1 2 3 None Christian-11 Hindu-4 Muslim-6 Buddhist-4 Buddhist-3 Not specified-4 Moderate 3 3 2 Other-5 None-6 None-3 Minimal 12 7 9 Other 2 1 1 1 3 Fluent 0 5 5 English-Language Proficiency English proficiency was similar in the Bhutanese and Iraqi populations; approximately one-third of the participants were fluent. The average length of premigratory formal education was 8 years for the Bhutanese and 11 years for the Iraqi participants. The majority of these patients reported having studied English in school. According to the Iraqi participants, English classes are compulsory in grades 5 through 12. In contrast, none of the Burmese were 336 F. R. Hauck et al. fluent and all but three were minimally proficient, despite reporting having taken English classes before coming to the United States. According to one participant, English is not taught in Burma until the fourth grade, and the average length of education prior to arrival in the United States was 7 years among the Burmese refugees. The majority of Burmese participants were not satisfied with their English ability. Of the Bhutanese who spoke minimal English, half were satisfied with their English ability. Of those who had intermediate to very fluent English, almost all were satisfied with their language skills. Slightly more Iraqis were dissatisfied than were satisfied with their English-language abilities. The majority of refugees believed that their lack of English proficiency was a barrier to finding a job, communicating with health professionals, and making American friends. Among the Bhutanese, a few respondents specifically mentioned difficulties communicating in medical situations, stating that some physicians do not always use interpreters, even when they cannot understand. The Burmese and Bhutanese cited limited English-language proficiency as one of their greatest stressors, in contrast to the Iraqis, who had a greater proportion of members who were fluent in English. Almost all refugees from each ethnic group expected to attend school or English classes in Charlottesville, but only about one-third were currently participating in any formal educational activities—namely, ESL classes. Of the participants who were initially enrolled in ESL classes, the majority discontinued their studies because of work scheduling conflicts or to take care of small children at home. A few refugees from each group expressed disappointment at their inability to continue language studies. Social Support The Burmese and Bhutanese had strong social ties to their respective local ethnic communities. They also reported having few American friends beyond coworkers, with whom they only interacted in the workplace. Of the three groups, the Burmese community is the largest group of refugees with the longest residence in Charlottesville. All but two Burmese refugees lived near other Burmese families. For those who did not live near other Burmese families, a commonly cited reason was the prohibitive cost of rent; these individuals were living in subsidized housing, located in a different neighborhood. A majority of patients reported sharing resources such as childcare, car rides, and phone use with other Burmese. Patients also said that they commonly visit other Burmese families, celebrate birthdays, and participate in religious activities together. Most of the Bhutanese participants also described other Bhutanese families in the community as an important source of social support. All of the Bhutanese participants in our study reported living near other Bhutanese families. Acculturation of Refugees 337 While two-thirds of Iraqi participants lived near other Iraqis, only half of these interacted with their Iraqi neighbors. On the other hand, nearly all of the Iraqis had American friends from work, school, the U.S. Army, the neighborhood, or IRC volunteers. Over one-third of Iraqis stated that they found Americans very helpful, and even more reported that relationships with their American friends provided a means to manage the stress in their lives. The majority of participants from all three ethnic groups stated they would like more family members to resettle in Charlottesville. However a few Burmese were concerned about newcomers’ ability to survive here, citing struggles such as language difficulty, job scarcity, and finding affordable living accommodations. The Bhutanese commonly expressed desires for family unity or more family members available for financial support. Nearly all Iraqi patients would like more of their family members to resettle in Charlottesville. Most simply wanted to reunite their family, while a few were concerned about their family’s safety: “Because of the situation in Iraq, which is not safe. Daily explosions. Assassinations. I just wish that my family live in safety.” Separation from family members and worries about the safety of loved ones still living in the Middle East were listed as sources of stress among several Iraqi refugees. The majority of Burmese respondents were actively involved in one community church, which holds services in the Burmese language. Some Burmese also reported receiving help from fellow American and Burmese church members. While the majority of Bhutanese participants reported being religious, most reported that location, transportation, and time constraints were barriers to attending a place of worship regularly. Similarly, Iraqis stated that religion was an important part of their life, yet most chose not to attend the sole mosque located in Charlottesville. Some participants from each group reported that their reliance on a higher power helped them to cope with stress. The most commonly cited source of assistance among all of the refugees was the IRC. Burmese and Bhutanese participants commonly relied on other refugees in their community who had lived in America longer. However, one-third of the Iraqis stated they did not go to the IRC for help, instead attempting to independently meet such needs or seeking help from their American friends. The majority of respondents expressed both appreciation for the institutional support they received from the resettlement agency (IRC) and a need for additional support in areas such as health care, Medicaid, education, employment, and financial assistance. A few Burmese refugees reported expecting more help with interpreting services. A common sentiment among Bhutanese refugees was that help from the IRC should have extended beyond six months. 338 F. R. Hauck et al. Financial Support Participants from all three cultural groups reported feeling significant stress arising from their efforts to secure employment and meet their financial obligations—namely, housing and food. Of the Bhutanese refugees, all were employed but one; three Burmese and seven Iraqis were unemployed. Participants commonly felt that their limited English proficiency posed a barrier to accessing employment opportunities. A few Bhutanese refugees also cited their educational backgrounds as a limiting factor to securing better employment. A common theme among Burmese and Bhutanese was that, considering their qualifications and low English proficiency, participants felt satisfied with their work. However, many Burmese and Iraqi participants commonly expressed discontent with the number of family members who had to work to make ends meet. Meanwhile a majority of the Bhutanese reported that their expectations for who in the family would work (e.g., both husband and wife) met their reality. Refugees from all three groups who arrived in the United States near the age of 18 years were unhappy because they needed to financially support the family and, therefore, were unable to continue their education. Most of these individuals were placed in lower grade levels based on their prior education, but had to leave school after they turned 18 in order to work. The majority were unable to obtain high school diplomas or formal education credentials. Overall, the majority of Burmese and Bhutanese found that they could afford to buy the things that they needed, although with some difficulty. In contrast, the majority of Iraqis, both employed and unemployed, did not feel their income was sufficient for their needs. Half of the Iraqi participants reported that they had run out of money or food stamps before they were able to obtain enough food for themselves and the family at least once; more than half of these respondents were employed. A few participants from the Burmese and Bhutanese groups reported similar problems with food security. A minor theme among all three groups was that the eight months of Medicaid insurance provided to refugees upon arrival was inadequate, since many were still financially unstable or unemployed eight months after arrival. For the Burmese and Bhutanese refugees, health insurance coverage was equally divided among employer-based health insurance, Medicaid, and no health insurance. Half of the Iraqi patients had either employerbased health insurance or Medicaid, while the other half were uninsured. Those who were uninsured and employed were either unable to af ...

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