The document describes research conducted to develop a pictorial scale to examine healthcare-seeking behavior among Tampa Bay Burmese refugees. Researchers created pictorial scales depicting progressively worsening stages of various health issues like lacerations and the flu to use in cognitive interviews with Burmese participants. The feedback received was used to refine the scales for clearer understanding across cultures and languages. The goal was to use the easy-to-understand pictorial tool to identify at what point refugees feel healthcare should be sought, to help address low utilization rates and health disparities in this population.

1. Laceration
 More blood and swelling
 Zoom in closer to cuts
 Breakdown of understanding
 Remove scab picture and add more severe picture
Abdominal Pain
 Remove second person
 Did not notice pain scale
 Thought woman was pregnant
 Should use chest pain instead of abdominal pain
Doctor
 Does not look like a doctor
 “Looks like a Chinese man”
 Image should be smaller and part of each scale
 Need to show man wearing a white coat and a necktie
Dental
 More severity showing disease and decay
 Greater contrast in color of teeth
 “Looks like a hamburger” (yet understood concept)
 Relevant health issue for the Burmese population
Developing a Pictorial Scale to Examine Healthcare-Seeking Behavior
Among Tampa Bay Burmese Refugees
Anna Cable, Jessica Castro, Ian Dollman, Kelly Hogan
University of South Florida, College of Public Health, Department of Global Health
Introduction
 In the U.S. refugees are provided free health insurance and
healthcare. Yet, utilization rates are low.
 Several barriers affect a refugee’s decision to seek healthcare,
and language is one of the most prominent.
 Researchers must first understand when refugees exhibit
certain health-seeking behavior before they are able to
investigate further into why.
 One way to transcend the language barrier and begin the
process of understanding when a refugee seeks healthcare is
through an easy-to-understand, picture based tool that invites
non-English-speaking refugees to the conversation about
health.
 A large Burmese refugee population resides in Tampa and
formed the pilot test group.
Methods
 Sought feedback from community partners about health issues
 Five specific health topics were chosen and visually depicted in a
progressively severe sequence
 A prompt statement and a script to accompany the scale were
developed and translated into Burmese
 Phase 1: Shared initial template and pictorial scale with
community partners to get feedback to refine the tool for
Phase 2
 Phase 2: Burmese participants were recruited, presented with
the scale, and asked cognitive interview questions about the
scale
Goal
 To develop and refine a tool, in the form of a pictorial scale, to
help public health researchers identify when an individual
believes one should first seek healthcare
Discussion
 Phases 1 & 2, of a total of 3 Phases, of cognitive interview
feedback completed, each informing the next
 Gained further insights into Burmese health-seeking behaviors:
Emergency Room over-usage, health financing difficulties for
non-Medicaid Burmese, private insurance confusion, cultural
preference for walk-in appointments
 Targets understanding when, to then begin research on why
there are low utilization rates, and ultimately how to intervene
 Limitations include small sample size and lack of both hand-
drawn and computer-drawn images for all 5 scales
 Scarce research on picture-based tools in healthcare settings
Public Health Implications
 This pictorial scale may serve as a starting point for gaining
insight into effective solutions to health disparities, experienced
by refugees and other minority populations.
 This pictorial scale transcends the language barrier, initiating
the conversation about health and healthcare utilization.
 The next step is to pilot the scale with a larger Burmese
population, further refining the tool based upon feedback.
 This pictorial scale may serve as a unique approach in the public
health toolbox, allowing public health professionals to initiate
the conversation with non-English speakers about health and
healthcare choices.
 This pictorial scale may ultimately lead to the creation of
effective interventions and educational programs to address
access issues and health disparities.
We would like to thank the following partners and community members for their
contributions, guidance, and assistance, without which this research would not
have been possible: Pastor Joseph Germain, Kimberly Hogan, Josh Arroyo,
Florence Ackey, Cho Yee Yee Maung, Dr. Lay Khin, Dr. Jaime Corvin, Wonhee Oh,
Dr. Roberta Baer, the Tampa Bay Refugee Task Force, the Tampa Bay Burmese
Council, Ellen Kent, and Reverend Berhanu Bekele.
Pregnancy
 Baby looks “creepy”
 Clearly understood depiction of health topic
 Put pants on last image and alter facial expressions
 This scale should be shown before abdominal pain
Flu-like Illness
 Add sweating and shivering marks
 Accurately depicted stages of illness
 Darken lines and make images larger
 Preferred hand-drawn scale
Results