Design and American Assumptions in Refugee Education

(Refugee and Diversity Projects) > Health > Design and Assumptions


Am I fat? is the starting point for health education and good outcomes

American information designed for a general audience is adopted haphazardly for refugees.

For unique populations such as the Montagnards, who speak as many as 6-8 languages but are often preliterate (unable to read or write), such a design approach with its underlying assumptions often fails, even if it succeeds with other, more literate or empowered ethic groups.

Design is inherently connected to culture. The more Americans forget this, the more likely their designs will fail to communicate. In the example given below there are likely to be additional negative consequences such as resentment and frustration on top of failure to follow doctors’ recommendations. Here is a follow up form for  blood glucose screening (testing for high blood sugar, a sign of diabetes):

Here the client is told to make an appointment to see a doctor, a typical recommendation. But if she is poor and without insurance (likely) then what is the chance of follow through? She may defer to the doctor or clinician and not ask questions. If she is with an interpreter friend, the friend may not wish to offend the health professional or admit their inability to pay. The design flaw here is that it does not anticipate these reactions and offers no options.

In this example, the client is asked to reduce risk by changing lifestyle. The majority of Montagnards were farmers used to hard, long days in the field. When they come to America they rarely engage in equally physically demanding work and lead sedentary lives holed up in small apartments. A farmer measures her physical labor differently than the American office worker on the treadmill during her lunch break. Unless she is shown how to jog or do a workout, a refugee will probably not understand exactly what “regular exercise” actually entails for a modern urban dweller.

Click to enlarge

The above flowchart starts with the question, Am I fat? because this was how the women of the Montagnard lay health team approached the problem of diseases associated with diet and lifestyle choices. We followed their question with a talk about BMI and how to look it up on a color-coded chart.

Once we established an objective baseline for weight, we then went on to discuss how could someone of normal weight still have significant health problems, a puzzling question to them because while they knew of many sick community members, few were overweight or obese. 

The chart then asks about diet, whether one has a poor diet or one of balanced meals, terms also used in a food insecurity interview they have been helping with. Finally, the chart identifies foods used in Montagnard cooking as possible high sodium culprits and links them to certain diseases like diabetes.

Through this chart we sought to link a simple question, Am I fat? to weight, food choices, lifestyle and disease. We approached it from the Montagnards’ viewpoint, taking into consideration their knowledge and understanding of the problem as they experience it through the illnesses of their family members, friends and neighbors.

It is possible to effectively communicate with a preliterate, multilingual community and obtain positive outcomes, but only if American designers are willing to incorporate Montagnard views and cultural ideas. Mere translation of existing English language or text is grossly inadequate. One experienced refugee worker insisted that rules (in effect, design guidelines) should be established for all refugee groups (one shoe fits all). Such a policy is certainly convenient for her office and reduces the workload for her staff. But it's unlikely to yield good outcomes.