Defining Substance Abuse in the Sudanese and Cambodian Refugee Communities
Final Report

Scott Gagnon and Amanda Lonsdale
Day One

September 2006

Funded by the Office of Substance Abuse of Maine

Table of Contents

Acknowledgments………………………………………………………… ………..1

Executive Summary…………………………………………………………………3

Introduction…………………………………………………………………………5

Literature Review……………………………………………………………………7

Cambodia background……………………………………………………………….9

Sudan background…………………………………………………………………..11

Methodology………………………………………………………………………….12

Challenges in the study………………………………………………………………18

Ethical considerations……………………………………………………………….19

Findings……………………………………………………………………………….20 

What was learned working with these communities?................................................27

Conclusion…………………………………………………………………………….28

References……………………………………………………………………………..29

Appendices……………………………………………………………………………..31

				Acknowledgments

We would like to thank:
•	Our advisory group Pirun Sen, Nyapeni Chouln, Florence Olebe and Edward Laboke for their help in guiding us, in finding participants and for their patience.
•	Professor Lahti for overseeing this project.
•	The Nuer, Acholi and Cambodian communities for participating, for sharing their stories and their concerns with us.
•	The Multi lingual Center in Portland for their support in writing this grant and for the use of their space.
•	The Portland Housing Authority for use of the community room.
•	The Office of Substance Abuse of Maine for giving us this opportunity.

                                               Executive Summary

	The purpose of this study was to study the Sudanese and Cambodian refugee populations in Maine with respect to substance abuse.  Both are growing communities in Maine, particularly in the larger urban centers such as Portland.  As they attempt to integrate into the societies of these localities they encounter many different stresses and pressures.  Substance abuse can be one of those pressures, or, a result of other pressures.
	To be able to offer help to these communities it is important to have a better understanding of how they see things.  It is necessary to see how they define substance abuse and what they feel the situation is in their communities.  While we are looking for answers to help the central question of defining substance abuse, we are also documenting and studying the research effort itself.  There has been little done in the way of research into these communities, let alone the area of substance abuse.  We wished to document was worked for us and what did not while we were trying to gather data.  This can provide a reference point for further research into these communities for substance abuse, and other policy areas.
	To study these communities we implemented focus groups.  We ran four focus groups in total.  There were two for each community.  In the Sudanese communities there was an adult focus group and a youth focus group.  The same structure was implemented for the Cambodian community.  The youth group participants were between the ages of 18 and 24.  The focus groups were run in a “town meeting” fashion.  The researcher went into the focus group with a set of discussion questions and scenarios.  However, the discussions were allowed to be open-ended and unscripted follow-up questions were employed where necessary.  In the end the scenarios proved to not be useful and were scrapped in favor of more time on discussion.
	The proceedings were audio-recorded, with prior consent, and focus groups had scribes to take notes.  The notes and audio transcripts were collated into a corpus of data.  It is from this corpus that we implemented concept mapping to highlight data that coincided with the themes we derived from our literature review.  Those themes were acculturation, family dynamics, and risk and protective factors.  
	We found culture-clashes to be a contributing factor in several of our findings.  It impacts many aspects of the lives of these people.  One is family dynamics.  The children and youth have a strong drive to adapt to their new community in Maine.  The adults are more interested in staying by “the old ways.”  This leads to a perceived cultural erosion on the part of the adults and is a definite cultural disconnect within the family.  This can prove to be a barrier for communication for anything, including substance use.  
	Another tough issue is discipline.  In Sudan and Cambodia, more corporal-styled discipline is allowed.  These methods of discipline, however, are at odds with the United States legal system.  This results in the adults feeling powerless in controlling their families and their children.  They feel at a loss and feel the government needs to be the disciplinarian if they will not allow for the traditional methods.  Also, the adults feel the children use their knowledge of the laws as leverage to get out of trouble and so that they can act the way they wish.  
	Also, we find a common theme of a void in both communities.  It was commented that the youth have a void that needs to be filled whether it be culturally or a literal void in time between school and when their parents come home.  It is here, the communities’ feel that the youth turn to bad influences which can lead to kids getting into substance use.  There was an expressed need for more programs and activities to keep children busy after school.  And, also, to look at the employment situation to find ways for parents to be home with their children.  
	So we see a need for some gaps to be filled.  There is a knowledge gap for the parents in the area of substance abuse.  They need to know more about what substance abuse looks like and what they can do if they, or someone they know, needs help.  There is the time gap after school that needs to be filled.  More programming or access to programming for youth is needed to keep them away from bad influences.  There is a discipline gap that needs to be solved.  Parents need to be educated on discipline methods that may not be traditional but that can get results.  And, the gap between studies and action also needs to be bridged.  Both communities expressed they are happy to answer questions but they are ready to see some results from the research they are participating in.  

                                              Introduction
The State of Maine, over the past decade and a half, has experienced an immense growth in its racial diversity.  While it is still a predominantly white population, 96.7% at last established, there has been a constant influx of foreign immigrants and refugees.  In the 1990’s alone, the state’s Asian community grew by almost 26% and the Black population increased by 14%.  Further, it is estimated that the Black population will grow by 32% by 2025 while the Asian population increases by a rate of 122%.  The white population, during this period, is projected to grow by 14%.  (Bradshaw Lynn 2002)  While this may not have a big impact on the state as a whole, it is having an impact on the individual communities into which the immigrants are locating and setting up residence.  
Portland, and other larger urban areas, are seeing the most immediate of these changes.  Portland, in particular, is a resettlement community for refugees coming into the United States.  These areas offer the promise of affordable housing and employment plus safety from the persecution and troubles in their home countries.  However, when they arrive to their new communities, trying to navigate the new culture and fitting in can provide new challenges and obstacles.  There are new pressures and stresses for both the adults and the accompanying children or youth to deal with.  Children, in particular, have the stresses of not only fitting into the town or city culture, but also the school and youth culture of their new home.  This can lead to antisocial tendencies such as alcohol and drug use.  
While there has been extensive research done on substance abuse and minority groups in United States, there has been little done on specific ethnic groups. Most data collected breaks down the data in Asian groups which includes Indians, Pakistanis, Chinese, and many other groups. The other ethnic break down we found in data collected was African-American which includes American born and foreign born people of African descent. Much of the data can not be generalized to the specific populations we have chosen to study. According to De La Rose et al the research done to date does little to explain pattern of use, causes or consequences of substance use amongst minorities. The lack of research amongst smaller minority groups may be due to lack of exploration into the role of racial and ethnic factors play in substance abuse. 
			Literature Review
With this lack of data, we found it necessary to first explore each communities’ definition or understanding of substance abuse as it relates to their communities. We decided first to look at level of acculturation; there are many models of acculturation and acculturative stress. These models tend to be complex, with many variables influencing the level of acculturation. Given the limitations of this study, we chose to view acculturation broadly looking at Berry’s(1980) model of acculturation which uses four stages of acculturation, assimilation, integration, rejection and deculturation. This model looks at the extent to which groups fit into the dominate culture, whether they do this by rejecting their own culture, and the loss of the minority culture. According to Rodriguez and Recio (1990), cultural values and loss of cultural identity play a role in drug use. Bicultural models of acculturation show that individuals who have a high level of satisfaction with their lives, often have a balance between the dominate culture and their own culture. They have found ways to adapt to living in a new culture without giving up their cultural identities.(Szapocznik 1980)
  When looking at the Sudanese and Cambodian communities we will be looking to see if members from either community have achieved some level of biculutrism.  Another aspect of acculturation is acculturative stress.  This is where the process of adjusting to a new culture leads to psychological stress which can lead to behaviors that include substance abuse (Vega et al 1985) Vega et al., go on to include family functioning in the acculturative stress model. This led us to a second theme we wished to look at during our focus groups; the family. In Del Rosa et al (2003), they mention the relationship identified by Brook (1988), between family conflict and drug use, and mutual affectionate attachment and drug use in African American families. This study showed that where there was no family conflict and “affectionate mutual attachment relationships” there was a lower rate of drug use. In families with conflict, and where the youth felt greater attachment to their peers, there was a greater level of substance use. Krohn and Thornberry (1974) found that African American, white non-Hispanic and Puerto Rican youth who had strong family networks would have lower levels of substances abuse. 
We decided to isolate themes related to family by using the Risk and protective factors as laid out by Hawkins and Catalano. We focused on Poor Family Management as one risk factor.  We found anecdotal evidence, in working with refugee families, that the issue of family management was often raised as an issue. Secondly we looked at the risk factor of parental attitude towards antisocial behavior; we felt this would give us some indication of how these communities viewed various levels of substance use. For example, did they care if youth drink versus youth using illegal drugs? Given the findings of Brook, Thornberry and Krohn it made sense to include family attachment as a protective factor we wished to look at. 
In most literature found about substance abuse and refugees the connection between mental health and substance abuse is often mentioned. Again, looking at mental health was out of the purview of this study but it does warrant mention when looking at the issue or substance abuse. For many of the refugees living here in the United States, they have witnessed first hand the death of family members and friends; some have be tortured or raped. (Balgopal,2002, Mayadas & Segal 2000)These events may lead to individuals suffering from PTSD, post traumatic stress syndrome (Blair, 2000) Added to witnessing atrocities first hand, there is the added stress of leaving everything you know and understand and to start over. The majority of refugees spent many years in refugee camps before coming to Maine. One man shared that he had spent most of his life in a refugee camp, 20 years; he said he grew up there got married there and his first child was born there. For many Sudanese refugees, coming to the U.S. was a huge cultural change. Many had not seen televisions, microwaves or running water. Some refugees entering the U.S. were unaccompanied minors, who may have been responsible for other siblings.  (Pipher 2002)
While Maine is not a state known for its diversity, the small number of refugees and immigrants have had an impact on the communities they live in. The majority of refugees and immigrants are located in small areas of Maine. As the number of refugees and immigrants grow in Maine so does the need for services tailored to those communities. The 2000 US census shows that in that year there were 1162 Cambodians living in Maine.  Of those, 670 were between 18-25 years of age and the average family size was 4. The median income in 1999 for Cambodian families was at $26,378 versus $37,240 for the average Maine family. There were 444 Cambodian individuals living below the poverty level, 429 of them had graduated from high school with 35 people having achieved a BA or higher. The census does not have data specific to the Sudanese community, so we chose to look at the census numbers for Sub Saharan populations in Maine. The total population in Maine in 2000 was 1414.  Catholic charities put the Sudanese population at 2400 today. The average median income of those, in 1999, was $21,724.  High school graduates numbered 483 and those with a BA degree, or higher, was 196. Maine began accepting Sudanese refugees about 12 years ago and according to National Public Radio, the state has the largest Sudanese community in the United States.

                                 Background on Cambodia
Cambodian refugees began coming to Maine in the early 1980s following the war. Cambodia was under French rule until 1953. At this time, Prince Sihanouk came into power. The Vietnam War created the beginning of the instability in Cambodia. Prince Sihaouk realized the difficulty his country faced in trying to remain neutral between the growing communist force on their border with Vietnam and the United States-supported Vietnamese troops. As the Vietnam War escalated, fighting began to spill over into Cambodia with Vietnamese communist troops launching attacks from Cambodia into Southern Vietnam. In addition to his trouble with the war, Sihanouk had communists within Cambodia beginning to resist his ‘autocratic’ style of ruling. 
In 1969 US force began bombing Cambodia in an effort to fight Vietnamese communists within her borders. In 1970, one year from the bombings, Prince Sihanouk was overthrown by Lon Nol and Prince Siri matak. In response to what he saw as a betrayal, Prince Sihanouk aligned himself with the Khmer Rouge. Lon Nol aligned himself with the U.S. and this alignment led to increased bombings within Cambodia. These bombings continued until 1973. Many Cambodians died in the bombings which resulted in growing resentment of Lon Nol and the Vietnamese. Lon Nol and the Khmer Rouge began executing and torturing ethnic Vietnamese who lived in Cambodia. This had the resulting affect of 200,000 Vietnamese fleeing the country. Many Cambodians felt that Prince Sihanouk was the rightly leader of Cambodia and so support for the Khmer Rouge grew. 
The Cambodian people did not realize that the Khmer Rouge had no intention of letting Prince Sihanouk have any power.  In 1975 the Khmer Rouge overthrew the country and reinstated Prince Sihanouk, who was basically a figure-head imprisoned in the palace. On the day the troops marched into the capital, they began evacuating the cities and Pol Pot the new leader began instituting his 8 point plan to reinvent Khmer Society. The 8 point plan was to purge Cambodia of all Western influence and create a communist society. The plan included defrocking Buddhist monks, executing former Lon Nol supporters, and establishing cooperative farms in the country where all citizens would work and be fed.  He executed intellectuals, doctors, and teachers. Additionally, 100,000 Vietnamese, 225,000 ethnic Chinese and 90,000 Chams (Muslims) were put to death. Many citizens were worked to death.  People were denied food and were not allowed to own anything except for their clothes. Children were made to work in the cooperatives.  In 1977, fighting broke out with Vietnam; the war did not go well for Pol Pot and he blamed his troops. This led to execution of troops on the Vietnam border. Many fled to Vietnam for help. By 1979 hundreds of refugees were fleeing into Thailand. By the end of 1979, Vietnam was occupying Cambodia. Fighting continued. In 1988 Vietnam withdrew from Cambodia. Prince Sihanou returned in 1993 and was reinstated, though, his power was limited. There continued to be fighting with the Khmer Rouge until 1998 when an agreement was signed, since then, things have stabilized in Cambodia.

Cambodians practice Theravada Buddhism, in Maine there is a temple in Buxton. Families tend to live with extended family, and life revolves around the family.

                               Background on Sudan		
Sudan is situated in the Northern part of Africa; it was under British rule until 1956. Democracy lasted until 1958 when there was a military coup, as a result rule of the country as gone between military rule and civilian rule. In the 1980s Gaafar Nimiery began a program of Islamization which was to impose Islamic law on the whole country. This led to civil war that continued on and off until 2002, when a cease fire was signed. . The major groups involved in the fighting were the National Islamic Front which was in the North and the Sudan’s Peoples Liberation Movement and Army which was made of people from the South. 
The population in the South is predominantly agrarian. These people practice mostly Christianity or animism. By the 1980s the military were employing starvation as a means of war. In 1993 it was estimated that 4.7 million Sudanese had fled to neighboring countries and 1.3 had died in flight. The U.S. started accepting refugees from Sudan in the 1990s. They mostly came from the south and there were a few political dissidents from the North. Refugees coming from the Sudan vary greatly in Culture from the Sunni in the North to the tradition “Nilotic” groups in the South. At least 10 different ethnic Sudanese groups settled in the US. Nuer is the largest group amongst the refugees and the second largest are the Dinka, both groups were primarily farmers. 
Within each group there are subpopulations that differ between pagan and missionized groups. Dialect spoken in Sudan can be vastly different from one another and are not always understood by each other. Many groups speak Arabic and English. There are 56 different ethnic groups with over 500 tribes within those groups speaking over 400 different dialects. In Maine there are about 19 of those different tribes represented with the Acholi, Nuer and Azande being the predominant groups. Sudanese families tend to be male oriented and include extended family. 70 % of Sudanese are Sunni Muslims, 5% are Christian with the remaining group practicing traditional ‘religion”.

METHODOLOGY:

	The design for this research was one of qualitative data analysis.  We are engaging in exploratory research; we are exploring how substance abuse is or is not defined in these Sudanese and Cambodian refugee communities.  This results in the data being of anecdotal nature, thus, why we are engaging in this qualitative design.  Through our qualitative and exploratory research we are looking for explanatory patterns within the anecdotal data.  Whether they turn out to be the themes and patterns we were searching for, or perhaps new ones that we did not anticipate.  It is from this beginning research into these communities, with respect to substance abuse, that further research can be done and some of which may delve into quantitative data.  It is one of the aims of this research to open a door for that.  To inform on how it is defined and how best to mine further data on the subject matter from these communities.  
	To further define this design, we used a grounded theory approach to the research.   The theory and recommendations that come from this research will emerge directly from the anecdotal data we collect.  Through our focus groups, we have amassed a corpus of data.  This data, then, was carefully reviewed, line by line.  From this examination we see themes emerge that may mirror those we derived from our literature review.  Additionally, new themes may become evident through the comparison of notes from the different focus groups.  The themes physically emerge from the coding of the data through concept mapping.  Between the information from our focus groups, the literature review, and that of the advisory group, we can triangulate the themes and findings.  Each can inform the other, or one could contradict the other.  This is where we find information gaps that will need to be filled by future research.    
	In this research project we are studying two very verbal cultures.  Both the Cambodian and Sudanese cultures are very oral traditionally, when it comes to sharing information within their communities.  As such, the researchers decided the best way to approach gathering data was to implement focus groups.  The focus groups were designed in a ‘town meeting’ fashion.  What this meant, was that we came into the focus groups with a set of questions and scenarios that were standard for each group.  However, we designed the group such that we would allow for the free-flow of information.  We may ask a question and get a response that beckoned a follow-up question to explore a certain issue or area of information.  It was the estimation of the researchers that this design would allow for a wealth of information and perhaps open up avenues for information we may not have thought during the research design process.
	The focus groups were our main avenue of data collection.  Through these groups, we wanted to collect different types of data.  The most obvious data to mine from these groups is the data that they verbally give to us.  The responses to our questions and the discussions that developed would be a primary source of data.  Further, though, the process of the research design and implementation there is other data we obtained.  As has been stated, the results of this research are two-fold.  We wanted to learn about how these communities define substance abuse.  Simultaneously, we wanted to learn about how to approach these communities for the purposes of research.  An important outcome of this research, with regards to future undertakings, is the information on what worked and what did not work.  Additionally, the information we learned about how the communities are structured and organized will prove to be very informative for future research.  So, while we were collecting and notating the information that was derived from our questions, we were also making notes along the way of roadblocks to getting that information and what we could, or could not do, to overcome them.  More specifics on the latter information will be spelled out in our findings later in this report.  
	When it came to implementing the focus groups, we were interested in interviewing four different groups.  There would be two from each community.  From the Sudanese, we recruited an adult group and a youth group.  The same was done for the Cambodian community.  For the adult groups, we were primarily interested in those who are, or have, raised children here in the United States.  Further, with the adult groups we were hoping to get a good mix of older and younger parents.  This would give us a good representation of the different situations presented here in the United States for refugee immigrant parents.  There will be different experiences for an older parent of an older child versus that of a younger adult with younger children.  A parent who has a child that grew up in the native country will have a different experience than the parent who has a child that is growing up here in Maine.  A parent with a child in middle school will have different experiences than a parent with a child in high school.  It was the hope that these and other scenarios could be properly represented in the make-up of our focus groups.
	When it came to the youth of the communities we focused on those between the ages of 18 and 24.  This was done for a couple of reasons.  One was a simple issue of consent.  For the purposes of time, and efficiency, it was decided that it would be easier to talk to those who can give their own consent to participate.  This route was chosen, as opposed to, trying to enlist children under the age of 18 who may speak limited English.  The processes to get this informed consent may have proven to be very difficult and time consuming.  While it may have been useful to get “real time” data, from children currently in the school systems, we felt the consent difficulties outweighed the promising information. 
However, a benefit of the 18 to 24 age group is that you’ll have young people who very recently went through high school and had those experiences.  They will not have been so far removed that they can’t give pertinent and valuable information.  Additionally, the 18 to 24 year olds represent a transitional stage of life.  This being the stage of life where one graduates from child to young adult.  There are pressures involved in this transition be they college, employment, family relationships, etc.  With this age group we felt we could get some very valuable information in the realm of substance abuse and the pressures and elements that may influence it.  
Through our advisors in each of the communities, we enlisted the focus group participants.  We held four focus groups in all.  Two of the focus groups were for the adults of each refugee community and the other two were comprised of youth.  The two focus groups with the Sudanese were held at Riverton Park at the Community Center.  The two focus groups with the Cambodians were held at Multilingual at the Baxter School.  Both of these locations are in Portland, Maine.  Each focus group was held on a Saturday as this presented the best opportunity to get the most participation from the communities.  This is because many in the respective communities work long hours during the week.  Each focus group was scheduled for three hour sessions.  
The goal, for participation, was to get at least 10 to 15 participants in each focus group.  Incentives were offered for participation in the focus groups in an effort to maximize the numbers.  In addition to providing food at the focus group itself, all participants were given a $25 gift card from Cumberland Farms.  Also, at the conclusion of the focus groups, the participants and advisors were treated to lunch or dinner.  Our participation goal was achieved in both of the adult focus groups.  We were not as fortunate in the focus groups with the youth.  In the Cambodian youth focus group we had five participants.  In the Sudanese youth focus group we had four participants.  
One thing we learned was that it is much more difficult to enlist participation from the 18-24 year old age group in both communities.  We learned that they tend to work just as many hours as the adults.  Additionally, if they are in college the amount of free time they would have to participate in a focus group would be minimal.  Further, we discovered that the Sudanese youth seem to have a structured organization.  We learned that they have regular meetings.  It may be that it would be easier for a researcher to meet with Sudanese young adults in this setting as opposed to trying to get them to meet on their own time.  The researchers recognize that, because of the low turnout in the youth focus groups, that the resulting findings cannot be generalized to the broader population of the youth in both communities.  However, we were still able to get some good insight and information into the areas of substance abuse in both communities.  
At each focus group, the researchers were present to ask the questions and to facilitate the discussion.  We went into each focus group with a set of discussion questions and a set of scenarios.  Attached to this report, in the Appendix, are the protocols that list the questions and scenarios.  As can be seen, the questions were the same between communities but different between age groups.  This is the same for the scenarios.  In addition to the researchers, we enlisted the help of scribes to take notes as the discussions developed.  This would allow the researchers to be able to put all of their focus on the facilitation of the discussions.  Further, with the written and verbal consent of the participants, audio equipment was used to record the sessions.  At the end of each focus group the audio tapes were transcribed into Word documents.  It is from these transcripts and the notes taken by the scribes that our data comes from.  
The researchers had originally intended to go through the attached scenarios with each focus group.  Indeed, we started to use the scenarios in the Cambodian adult focus group and the Sudanese adult focus group.  The idea was that, through responding to the scenarios, we would get some information and insight that we might not through the discussion questions.  For obvious confidentiality reasons we could not ask about personal experiences regarding substance abuse.  The scenarios allow us to attempt to put the participants’ minds in a situation regarding substance use and to see how they react to it or observe it.  However, in the early implementation attempts we discovered we weren’t really getting any extra information out of the scenarios.  The responses that were elicited were brief and were not very illuminating.  We decided that our discussion questions were much more productive and that devoting more time to them would result in more information and information of greater value to our research.  
As with any research involving human subjects, there has to be careful consideration to protecting the participants.  In the design of our research we gave careful consideration to this.  Consent forms were constructed for each focus group.  It gave a summary of why they were being asked to participate and what it was the researchers were trying to learn about.  We stated that all participation would be anonymous and that we would not be seeking personal information or accounts on the subject matter.  No names would be recorded or asked for during the discussions.  Further, the consent forms stressed that the participants were not obligated to stay for the duration of the focus group, they were free to leave at any time.  These consent forms were translated into the respective languages of the Sudanese and Cambodian participants.  These were done by members of our advisory group who were from the two communities.  This was to ensure that the participants had a clear and precise understanding of the content of the consent forms.  
Also in the consent forms was a statement that we were interested in doing an audio recording of the proceedings.  If there was anyone who felt uncomfortable about such a procedure they needed but to inform us and we would not turn the machine on.  Additionally, we would turn it off at any point anyone wished.  We stated in the consent forms and before the focus groups that the audio recordings would be kept at Day One in a secure location. Additionally we informed the participants that the tapes would be destroyed at the conclusion of the research.  
As mentioned elsewhere in this report, we did not seek focus group participants under the age of 18.  The prospects of obtaining informed consent from children under the age of 18, who may not have adequate command of the English language, appeared to be quite daunting.  Being that time and resources were important components of this research; it was decided to not take up this challenge.  So, for the purposes of studying the youth of these communities we decided to compose youth focus groups from the 18 to 24 year old sub-population.  They will not have been so far removed from their school-aged years to not give us good information and insights on the youth experience with substance abuse issues.  As it turned out we culled some very valuable information from these focus groups that gave us some good data on the issues facing the Sudanese and Cambodian youth.  With that said, it still will be useful for further research endeavors to look at methods for obtaining data from the Cambodians and Sudanese of middle and high-school age.  
For the purposes of data analysis, we employed the use of concept mapping.  Upon the completion of the focus groups we collated our transcripts and notes for each group.  We then reviewed these documents in their entireties.  As we reviewed the documents we would code responses on the transcripts and observations in the notes.  They would be coded according to the themes we derived from our literature review.  Again, the three themes we derived from that literature review were acculturation, family dynamics, and risk and protective.  Additionally, we coded responses and observations that represented emerging themes and patterns not identified in the literature review.  The following figure represents this map.

Substance
Abuse

Acculturation

Risk and Protective Factors

Family Dynamics

Other/
Emerging Themes

So, as we were coding our transcripts and notes, we were sorting the responses and observations into the four categories or themes.  As the figure shows, it is these themes that are informing the central research question of defining substance abuse.  Additionally, we coded and sorted information that informed the other aspect of our research which was the documentation of the research process with regards to these two communities.  We made notes of what approaches worked and which did not.  This was a constant process from the conceptualization to the implementation of the focus groups.  It is the coded data from these two aspects of our research question that form the basis of our findings and recommendations.

Challenges in the study
	
Firstly, we were limited by the lack of research on these two specific populations.  We had no base of information to go on in order to create surveys or other instruments.  We decided to spend our energy finding out how these communities define substance abuse and what their understanding of the issue is.
Language created some difficulty in being able to create a data collection process that we could be confident people understood.  Additionally, there is the challenge of the interpretation of language.  For our focus groups, especially in the Cambodian adult focus group, we had to rely on interpretation.  There is always the possibility you are missing something that you, as a researcher would view as important, but that the interpreter deems to be unimportant.  This provides a certain limitation on the research, though, we don’t feel it played a big role in this particular project.
These two populations are very different from each other.  Even within the Sudanese group there were differences between the two communities of the Nuer and the Acholi.  The two groups we worked with differed from each other in how they interacted with us and in their culture. The advisors from each group had forty hour positions that they were committed to before our project so sometimes accessing them or their services was time consuming.  This put a limitation on how much we could get accomplished during the time allotted for the research.  Additionally, styles of communication differed from group to group and between the advisors and researchers.
In planning how to access the groups the preferred method would have been to go to peoples home and to talk one on one to get the needed information, but with the limited time and resources this just wasn’t a possibility for this piece of research.  It would be recommended, however, for future research that would have the luxury of ample resources to conduct such methodology.

Ethical Issues
For the two populations we are studying, there are some significant issues that arise around ethical consideration. Both groups have members who have suffered greatly under authorities within their own country. In addition there is often a fear on the part of immigrants or refugees that participating or not participating in a study may have consequences that could lead to deportment or other issues. This may have lead to people feeling coerced or to some questionable data being collected. While the researchers are not government employees, and have no legal authority, the very act of studying a group may lead to an implied authority, which must not be abused. In order to address this concern, time was spent educating participants about the study and about the people conducting the study. Trust is an important part of being successful in data collection and taking time to develop that trust is important. 
In addition researchers may face “Dual imperative” (Jacobsen and Landau 2003) where a researcher may witness a social need that needs to be met by the need to gather scientifically sound data, which may lead to compromise of the research design. In addition the very definition of ethics may differ between cultures. Cultural norms are often different and despite living in the U.S., refugees and immigrants may still be governed by the norms of the homeland. With this in mind it was important for the researchers to have a good understanding of both cultures and is why we had an advisory board as part of our team. This board helped navigate both cultures based on the understanding and knowledge of both groups. 
Thirdly, the assumption that every culture shares information in the same way may lead to design flaws in the study. Most research design is taught with Western cultures in mind and caters to meet those needs. Dealing with oral cultures, who share information in a less formal manner, could lead to the researchers’ views or ability to be impartial being skewed. 

FINDINGS
*It is important to note that given the sample size our findings may not represent all Cambodians or Sudanese. We do feel that the literature supports the findings we derived from this research.

Acculturation:

It was expressed, more directly by the Sudanese, but there appears to be a feeling of being lost in America by these two groups.  The Sudanese specifically refer to being taken from one war, in their native Sudan, and being dropped into another which has become a cultural war “against their families.”  There is a real feeling of “us against them” amongst both the Cambodian and Sudanese adults.  That is, the law and culture of the United States against the customs and traditions of these refugee immigrants.  They wish for a more collaborative relationship.  One that will help them live and exist within the United States without having to give up their cultural identities.  This, extends right to how they parent their children.  They wish for more flexibility in how they are allowed to raise their children in their traditions, because, as they see it those traditions worked and kept children out of trouble.  
Another part of the acculturation piece is that the children seem eager to adapt to the American culture in a need or desire to “fit in.”  Some children make friends with American children who are “good” and who make “good choices.”  Some, however, get mixed in with a “bad crowd.”  And, with the parents at work, they may have a lot of time to spend with these bad influences.  Furthermore, it was observed in the Sudanese youth focus group that “there’s a void not being filled by parents.  And so it’s being filled by drugs, stealing, and those sorts of things.  It comes with a need, they feel a need to fill the need.”  It was mentioned almost across the board in all of the focus groups that finding less destructive ways for children to “fill the void” and to bridge the culture gap is a very important issue that needs to be addressed. 
There was a great deal of talk of how their children would rather spend time with their friends than with the families. The Cambodian community mentioned that traditionally children would go to school come home and do chores with the family. During this time, parents connected with their kids and talked about issues. Now they struggle to get their children to stay home or to come home at a reasonable hour. The Sudanese mentioned that parents tend to not know what there children are up to or who they are hanging out with. Amongst the Sudanese community it was stated that in Sudan children spent time with people from their own community (tribe) here in Maine all the programs for kids bring them together with all kinds of kids from all different communities.

Family Factors:

One important factor that came out of both communities in all ages was an issue of time.  That is, the amounts of time that parents and children have to spend together.  The parents have to work, and in many cases, long hours with it often being during the hours after school.  Invariably children find other places to be immediately after school.  Many do not go home to be with the family that may be home.  This can lead to some making, in the words of the participants, “inappropriate choices.”  So, it would appear that addressing employment issues within these communities would also be addressing a root problem in the area of substance abuse.  
There also seems to be some disconnect when it comes to adapting to the culture in the United States.  In the Cambodians there is an expressed fear at the children losing their culture as they try to fit in with their native U.S. friends or classmates.  Meanwhile, the parents and adults hold true to their native cultures from Cambodia and Sudan.  It would seem that this can lead to parents and children speaking two different languages, culturally that is.  The Sudanese adults express a concern that children tell them they are stuck “living in the old ways” and need to adapt.  
Discipline becomes a stress between parents and children.  The children know that laws and traditions are different here in the U.S.  They know that physical discipline is not viewed in the same fashion here in the United States as it is in both Cambodia and Sudan.  There it is acceptable and part of growing up.  Here, it is a sticky issue.  Child abuse laws make it hard to navigate.  The parents see children holding a power over them because they can simply call DHHS or the police and they will believe the child over the adults.  A good intentioned discipline could lead to trouble with the law.  The adults of both the Cambodian and Sudanese Focus groups expressed a desire to have the laws be more lenient or allowing of their discipline traditions.  They feel it worked in Sudan and Cambodia and it should be allowed to work here.  
Rebellion is a common theme to both cultures.  That is, the rebellion of the children against their families and of their traditions.  Both adult groups remarked on how in their native countries children were more disciplined in family values.  The Cambodians specifically mention that in their education system family values are taught and reinforced.  They are taught how to be a good child.  They don’t see that reinforcement in the U.S. schools and feel there should be courses or classes on how to be a responsible member of a family and a community.  Furthermore, the youth are getting their own jobs and making their own money.  The youth, therefore, feel empowered to make more of their own decisions and not relying on their family for permission.  The Sudanese specifically mention that their children have more power here and that the parents, specifically the father, are at the bottom.  

Risk and Protective:

Family management is an area of concern with both communities.  Parents feel they have lost the ability to discipline their children; both groups come from societies that are somewhat paternalistic in the approach to family. The school helps parents by disciplining children often through corporal punishment.  Also, the governments and police forces are more likely to incarcerate or punish a youth that does not listen to his parents or who engages in socially unacceptable behavior. Both communities felt that as long as the Maine and U.S. government would not allow them to discipline their children physically then the government should now assume the role of disciplinarian. 
Another part of this risk and protective theme that came from the focus groups was parental attitudes towards antisocial behavior.  The Sudanese have amore narrow view of what is acceptable in connection to alcohol use, whereas the Cambodian community felt it was okay for their kids to use alcohol as long as they behaved appropriately. Other substance use was not condoned.

Emerging/Other Themes:

It is clear from both the Cambodians and the Sudanese participants that they need help defining substance abuse.  That is, they need to be educated on what Americans may view as basics.  They wish to fully understand what a child under the influence of drugs and alcohol looks like.  What are the symptoms?  What are the warning signs?  What drugs are out there?  Where can they go for help?  Additionally, it was observed that there is no literature about drugs for parents that are available in either the native languages of the Cambodians or the Sudanese.  This was specifically mentioned in the Cambodian focus group as something that could be of great benefit to the parents.  

Community readiness 

The Acholi and Nuer communities have some systems in place for addressing substance abuse in their communities. The Acholi have an adult and youth association who discuss issues affecting their communities. The Nuer have a group that meets to discus the needs of the community. We found that both of these groups came to the meeting with ideas for dealing with their issues. The Cambodian have a less formal leadership structure which seems to involve mostly the older members of the community. They do have the temple in H which is viewed by the community as the ideal place to have prevention programs. Both the Sudanese and Cambodian community expressed a need for the parents and the youth to be educated about drugs and alcohol. They both asked that Maine find ways to provide more after school activities for their children that involve cultural education. 
Connection to Schools

Parents from both groups expressed frustration with the local school system. They believe that the schools/teachers work against their families by supporting the rights of their children over the rights of the parents. They feel disconnected form the education system and believe the schools should do more to discipline children. The Sudanese youth noted that children are advanced through the school system based on age rather than ability. They said children from their community are passing grades and graduating high school without the necessary skills to succeed in college.

Housing

The Sudanese live predominately in subsidized housing, they asked the research team to ask the state of Maine to make alternative housing available to them in the form of Habitat for Humanity.  They felt that the housing situation was leading to the increase of drug and alcohol amongst their youth. They said they have no recourse for dealing with youth who are sitting outside their home drinking and smoking. If they report it they put themselves at risk and the community police do not do enough to deter this behavior.

Sexual Behavior

The Sudanese mentioned seeing an increase in teen pregnancy; they connect this with American youth being able to have boyfriend/girlfriend relationships at a young age. In Sudan there are no girlfriend/boyfriend relationships, marriages are arranged. 

Jobs and access to education

The Cambodian community said as long as they could keep their kids in school and gets them to graduate then they did not worry about being able to pay for college. They did not raise any issues about accessing jobs. The Sudanese expressed concern about their kids future, one man said their was no hope for their youth as they could not afford college and there are no good jobs. The youth relayed similar concerns with finding work and they felt their was discrimination in the work place in Maine. Many of the youth we met in both communities were taking a break from college, some were working on English as Second Language requirements and some needed to work to support families.

Language

Most of the Sudanese spoke good English, the exception seemed to be the women. All of the youth spoke good English. We only met with male youth; we were told the women were working. The Cambodian youth spoke English with American accents. Most of the Cambodian adults needed the interpretation. In the meeting the men spoke most of the time, the women tended to carry on side conversations with the female researcher, 

Substance Use

While we were not able to get prevalence, both groups indicated that their youth uses alcohol and marijuana, which would support the idea of the minority group imitating the dominant culture. Marijuana and alcohol are the two most used substances by Maine youth. The Sudanese community did not feel that their youth was using any stronger drugs, but they did concede that they would not know what those drugs were or what they might look like. The Cambodian youth mentioned that adult use of alcohol is high; one youth commented that there is alcohol present at every function and that “Asians” like to drink and gamble. The Cambodian youth said that they see the age of first use is getting lower, they are seeing younger kids as young as 12 using. This was a great concern to the focus group.

Family violence

In both groups it became clear that what American society would term family violence is viewed as family management by both communities. Both groups lamented that their ability to manage their children is severely limited by the fact that they will get into trouble with the state if they use corporal punishment on their children. The Sudanese often mentioned that people traditionally have always ‘beaten’ children when they misbehave. Thinking the use of the word beat was a language issue we asked if they meant a spanking or literally a beating. They were clear they meant beating. The Sudanese community stated that they felt children had more rights than adults. Both groups felt that if the state had taken away their ability to discipline their children then the state should step in and do more to discipline their children. 
In the Sudanese community the issue of domestic violence was raised. To be clear, the definition of domestic violence is our way of defining the situation. To the community, once again a man’s ability to manage his family was being interfered with as he could not discipline his wife in the way his tradition called for. The men stated that they felt belittled in their own homes because when their wives call the police they put out of their homes in the street unable to return. They see this as attributing to the destruction of their families. IN addition the community said family disputes were traditionally handled by the community and now the courts step in. Men and women felt the the long term removal of men from the home did nothing to help their families. Both Nuer and Acholi feel strongly that children need two parents to raise them. The women expressed resentment at the removal of the men from their homes as now they were left to raise the children by themselves. Domestic violence was alluded to in the Cambodian focus groups but did not emerge as a clear them.

Other observations:

It is probably more useful for researchers to go to the communities instead of making them come to us.  In the Cambodian population they have gatherings at the Temple.  In the Sudanese community there are regular community meetings where matters of many varieties are discussed.  While we did get very useful information from our focus groups it might have worked better for us if we had attended one of each community’s meetings or gatherings and conduct our research there.  Both communities seem to be very oral communities in how they disseminate and share information.  It would be a more natural setting and may be conducive to a more natural flow of information.  

What was learned working with these communities?

While designing our methodology, we were told numerous times that the best way to access these communities was to go to people’s homes and to do face to face interview using the interpreters. Budget and protection of information made it hard for us to do that this time round. Our advisory group was skeptical about us being able to get the information we wanted through focus groups.  They felt people would not want to share information when in groups. This did not turn out to be the case.  When it was clear that we were not after personal information, people opened up. We designed our questionnaires to allow for discussion and for probative conversations. With the exception of the Cambodian youth, we found people very candid. We had some families share personal stories and ask for help. We listened and asked questions for clarification; again people were quick to correct us when we did not get things. 
Communicating with our advisory often proved challenging but as time went on we learned what worked, often we went to where they were to talk. It took time for us to build a rapport with our advisory team; we learned that if we did not ask for specific information they would not tell us things. We discovered information as we went through the focus groups that would have been helpful when designing the project, but we did not ask the right questions. This happened even though we often asked what have we not thought of. One of the researchers is an immigrant from Africa; we think with the Sudanese, this may have helped as there was some shared experience that may have helped when asking questions. It would be preferable to train research assistants or researchers from the populations you wish to work with or study. 
Interpretation can make it hard to know if the information you are getting is accurate, we concentrated on information that was repeated by more than one participant. It takes time to do focus groups or interviews using interpreters, often it can be frustrating.  Often, people would talk for five minutes, there would be much laughter and then the response in English was two sentences that are serious. People from both communities had a more relaxed relationship with time. For example, meetings set for 12 would often begin at 1. Things took a little longer than we were used to but we learned to be flexible and learned to enjoy a more relaxed way of looking time.
Our focus group approach did not work as well with Cambodian youth, they were less willing to participate and conversation did not come easy. The questions were  designed for new immigrants and it became apparent that the Cambodian youth do not view themselves as new immigrants, even thought most of them were born outside of the U.S.

Conclusion

While both of these communities differ greatly in culture, they share common concerns. Most important to both groups was the relationship between children and parents. They both believe that the clash of cultures is leading to their children becoming involved in substance use and other deviant behaviors. They see this relationship as key to their children’s success. In addition, with the exception of the Cambodian youth, all groups see maintaining the culture while learning to accommodate American culture as a necessary component to keeping their youth safe. 
The relationship with schools was raised often by both groups and is seen as contentious. They believe the schools need to do more to support them as parents. Both communities would like to be involved in helping prevent and treat substance abuse in their communities. Both see a need for more prevention starting at a younger age and a need for more education around substance abuse for adults. It was clear from all focus groups that these communities are tired of talking about what they need and not seeing any action to help them. Both groups expressed a need for more after school activities to keep their youth from getting into trouble.

                                         RECOMMENDATIONS:
1.	Throughout the project in communicating with members of both communities there were two underlying criticisms of groups attempting to work with refugee/immigrant groups. Firstly that people do not follow through, there is a lot of information gathering but no action and secondly when groups do follow through there is a tendency to lump all the different ethnic groups together in programs. It is important to work with individual groups as much as possible.
2.	Train prevention or treatment professionals from the communities you wish to work with, again being sensitive to the differentiations from tribe to tribe. 
3.	Create programs that are where people live, the majority of families indicated that they work over 40 hours a week and do not have time to take children to places. For the Cambodian community they indicated that they would like to see more programs offered at the temple as this is where families come together. 
4.	Creation of an intervention program for families where families violence is prevalent, while we recognize the need to remove offenders from the home, we fear that the loss of one parent may lead to women and children not reporting instances of abuse. Working with families on how to manage anger without violence is key.
5.	Both communities requested more parent education programs around alternative ways to discipline their children, on signs of drugs use, drug identification and after school programs. It is important to provide these services to thee communities while creating a pool of educators who come from these communities.
6.	Building community coalitions within the housing developments that include the community police force, we see these coalitions as working towards mutually agreeable ways to deal with the social issues confronting these communities. We believe coalitions that bring the elders, youth and police together would foster a better understanding of each group’s role in the community.
7.	Money set aside to translate relevant health information and how to access help; this information should include information do substance abuse, family violence, early child care, nutrition, and navigating the school system.
8.	Creation of after school programs, looking to the community to help create programs that will help foster cultural identification for the individual groups.

                                                        

                                                      References.
Balgapol, P. (2000)  Social Work Practice with immigrants and refugees. New York Columbia University Press.

www3.baylor.edu

Berry, J. Acculturation as varieties of adaptation. In Padilla, A. ed. Acculturation: Theory Models and Some New Findings. Boulder, CO: Westview Press 1980

Blair, R. (2002) Risk factors associated with PTSD and major depression among  Cambodian refugees in Utah, Health and Social Work, 25.

Brook, J.S.; Whiteman, M.; Noruman, C: Gordon, A. and Cohen, P.: Personality, Family and ecological influences on adolescent drug use: A developmental analysis. J Chem Depend Treat 1988: in Drug Use Among Racial/Ethnic Minorities: a monograph: NIDA. 2003

Del a Rosa, M.; Adrados, J.; Kennedy, N.J.; and Milburn, N. Drug Use Among Racial/Ethnic Minorities by NIDA. a monograph: 2003

www.Ethnomed.org

Krohn,M.D. An investigation of the effect of parental and peer association on marijuana use. An empirical test of differential association theory: in Drug Use Among Racial/Ethnic Minorities: a monograph: NIDA. 2003

Hawkins,  Catalano, R. and Miller, J. Risk and Protective Factors Alcohol and Other Drug Problems for  Adolescence and Early Adulthood  : Implications for Substance Abuse Prevention. Psychological Bulletin 1992, vol.112.

Mayadas, N. and Segal, U. (2000) Refugees in the 1990s: a U.S. perspective, in P. Balgopal (ed.), Social Work Practice with immigrants and refugees. New York Columbia University Press.
MYDAUS Technical Report 2002: Office of Substance.

Pipher, M. (2002) The Middle of Everywhere: helping refugees enter the American Community. FL: Harcourt, Inc.

Rodrigues, O. and Recio, A. The applicability of the Integrated Social control model to Peurto Rican drug use. J Crime Justice, in Drug Use Among Racial/Ethnic Minorities: a monograph: NIDA. 2003
Szapocznik, J and Kurtines , W.M. Acculturation, biculturalism, and adjustment among Cuban Americans: Padilla, A. ed. Acculturation: Theory Models and Some New Findings. Boulder, CO: Westview Press 1980.

Thornberry, T. Social Network Approach to Drug Use of Minority Youth: in Drug Use Among Racial/Ethnic Minorities: a monograph: NIDA. 2003

Vega , W.A. Patterns of Drug Use : Hispanic and non Hispanic male teens. Research grant application DA-05523 submitted to the National Institute on Drug Abuse, Rockville, MD, 1988:  in Drug Use Among Racial/Ethnic Minorities: a monograph: NIDA. 2003
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                                                      Focus Group Protocols  
Questions and Scenarios
Adult Groups:
Discussion Questions:
1.  What are some of the things parents in your community worry about when it comes to their children? 
2.  How are things different in Maine for parents and for children , compared to back in Cambodia/Sudan? 
3.  Do you talk about drug and alcohol use with your children?
4.  Do you talk about drug use together as a community?
5.  Where do people go if they think their child drinks too much or if their child is on drugs?
Scenarios:
1.  A 13 year old child has been out with friends, he/she comes home and smell of cigarettes and beer. . What do you think of this situation?
2.  Every night there is a group of boys hanging out on the street, they are smoking, being loud and they stay out all night. What do you think of this situation? 
3.  A child from your community, who has always been a good child, suddenly starts acting different.  What do you think of this situation?
Youth Groups:
Discussion Questions:
1.  What are some issues/challenges teens from your community might have to deal with on a daily basis?
 2.  How are things different in Maine for parents and for children, compared to back in Cambodia/Sudan? 
3.  What is substance abuse and how much of a problem is it in your community?
4.  Do you talk about drug and alcohol use with your children?
5.  Do you talk about drug use together as a community?
6.  What do people do if they think their child drinks too much or if their child is on drugs?
Scenarios:
1.  A kid is invited to a party, his parents say no, but he wants to want to go. How might some of the kids in your community respond to this?

2.  A kid goes to a friend’s house where everyone is smoking pot and drinking. They offer him a beer and some pot.  How might the kids in your community respond to these offers?

3.  A kid goes to a party with his younger brother, both kids are drinking. The younger boy has 2 beers and stops. The older boy keeps drinking, he has 8 beers. What do you think about this situation?