“Stuck in between two worlds”: Substance misuse among first generation ethnic-Nepali Bhutanese youth and young adults with a refugee life experience

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Frounfelker, Georgia Bromley, Katherine Blomkvist, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7566409/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objectives There is limited information on the dynamics of alcohol and other drug (AOD) misuse among refugee youth. Over 90,000 ethnic-Nepali Bhutanese refugees have resettled in the United States since 2008, and there is increasing concern for AOD misuse among youth and young adults. The objective of this research was to understand patterns of AOD misuse among Bhutanese youth and young adults (ages 14–24) living in central Pennsylvania. Methods A total of 35 Bhutanese youth and adults participated in key informant interviews. A total of 47 individuals participated in 8 focus groups with Bhutanese parents, Bhutanese youth and young adults, AOD service providers, police and probation officers, Bhutanese business owners, and educators. Data were analyzed using thematic content analysis and informed by the Transnational Theory of Cultural Stress for Alcohol and Other Drug Misuse Risk. Results Findings focus on three themes. Issues related to Bhutanese history and culture included accessibility of AOD and community stigma. Specific to family dynamics, parental engagement, parent-child communication, and family cohesion acted as risk and protective factors. Finally, the theme of communication and trust with external stakeholders revealed that external stakeholders had difficulty engaging with the Bhutanese community and linking people to prevention and intervention services. Conclusions Findings have implications for culturally-tailored approaches to address AOD misuse. Prevention initiatives need to include efforts within the Bhutanese community, with a focus on family functioning and addressing intergenerational conflict. Psychoeducation for other stakeholder groups is critical to facilitate culturally-sensitive responses to community needs and issues. Psychiatry Bhutanese ethnic-Nepali alcohol and drug misuse youth refugees Introduction Alcohol and other drug (AOD) misuse among youth and young adults is a significant public health issue, with adverse consequences for the short and long-term psychosocial wellbeing of young people (Stockings et al., 2016 ). Although there is a large body of literature investigating risk and protective factors for AOD misuse among youth more broadly, there is limited information on the dynamics among youth in refugee and other conflict-affected populations (Greene & Kane, 2020 ). This is a serious shortcoming, as there are well documented disparities in mental health and psychosocial wellbeing of children and youth with a refugee life experience compared to non-refugee populations (Frounfelker et al., 2020 ). As such, these youth may be at greater risk for AOD problems than other adolescents and young adults. In addition, there may be unique risk and protective factors for AOD misuse among war-affected youth that should be taken into consideration when designing and delivering clinical and community-based interventions. AOD misuse among migrant youth There is a small body of research investigating AOD misuse among migrant youth and young adults. Reviews highlight risk factors including exposure to pre-migration trauma, post migration acculturative stress, accessibility of substances, and intergenerational conflict (Aleer et al., 2023 ; Kenin et al., 2025 ; Douglass et al., 2023). There are mixed findings on whether or not identification with one’s heritage culture is protective or risk-enhancing (Kenin et al, 2025 ; Lim et al., 2011 ). Other research has focused on stigma and lack of culturally appropriate services as barriers to accessing care (Posselt et al., 2017 ; McCann et al., 2016 ). Although this work is informative, findings are drawn from various migrant populations (for instance, voluntary immigrants, refugees, unaccompanied minors) resettled in diverse contexts, and may not capture factors relevant for specific cultural groups affected by war and conflict. Additionally, while most studies include quantitative and/or qualitative data from migration youth and parents, relatively few seek insight from key external stakeholders including educators, health and social service providers, and law enforcement. Incorporating these diverse perspectives is useful to develop a more comprehensive understanding of AOD misuse among refugee youth. Theoretical frameworks Cultural stress theory can be used to understand AOD misuse in refugee youth. Cultural stress theory considers how discrimination, negative context of reception, and bicultural stress impact individuals explicitly because they are considered foreign born, or implicitly due to cultural differences between the individuals and the cultural context in their receiving country (Meca & Schwartz, 2024 ). Family functioning (encompassing parental involvement, parent-child communication, and family cohesion) is also relevant to understanding AOD misuse. In the cultural stress model, cultural stressors can have a direct or indirect effect on AOD misuse among youth via the mediating pathway of negative family functioning (Salas-Wright & Schwartz, 2019 ). Conversely, positive family functioning can have a moderating effect on the relationship between cultural stress and AOD misuse (Salas-Wright & Schwartz, 2019 ). The transnational theory of cultural stress builds upon the cultural stress theory by integrating pre-migration, transit, and post-migration factors related to AOD misuse. Pre-migration factors include context of departure, motivations for emigration, and AOD cultural norms and experiences (Salas-Wright & Schwartz, 2019 ). Transit-related factors encompass methods of transportation, exposure to stressful situations, and traumatic experiences (Salas-Wright & Schwartz, 2019 ). This adaptation of the cultural stress model is particularly relevant for refugee populations, since they are often exposed to unique stressors or traumatic events during the pre-migration and transit periods. Researchers can examine how these varied migration-related experiences over the life course influence AOD misuse among youth, along with post-resettlement stressors and family dynamics (Salas-Wright & Schwartz, 2019 ). Bhutanese with a refugee life experience During the 1980s, Bhutan’s “One Nation, One People” or “Bhutanization” policy aimed at enforcing cultural homogeneity in Bhutan resulted in the government forcibly expelling ethnic-Nepali citizens from the country (Hutt, 1996 ). Over 100,000 Bhutanese refugees were exiled to UN-run camps in eastern Nepal where they lived for over two decades (Shrestha, 2018 ). In 2008, the United Nations High Commissioner for Refugees and the International Organization for Migration launched resettlement programs, which relocated Bhutanese refugees to the United States (US) and other countries (Shrestha, 2018 ). Central Pennsylvania became a destination for some of these refugees, with secondary migration resulting in an estimated 40,000 Bhutanese living in the region in 2025. Since third country resettlement began, there has been a small but growing body of literature on the psychosocial well-being of Bhutanese children and youth in the US, driven in part by concern for the high rate of suicide among resettled Bhutanese (CDC, 2013). Among Bhutanese youth, post-resettlement brought stressors that elevated risk for anxiety ( chinteet ), depression ( dookhit ), and behavioral problems ( badmass ) (Betancourt et al., 2015 ). Protective factors include community and family support and collaborating with schools to address children’s needs (Betancourt et al., 2015 ; Cardeli et al., 2020 ). To date there has been limited examination of the issue of AOD misuse in this community. Existing literature emphasizes that Bhutanese may be particularly vulnerable to AOD misuse due to migration history stressors, work pressures, the accessibility of alcohol, and the lack of culturally informed education and awareness on the issue (Mirza et al., 2018 ; Watson et al., 2022 ; Carter, 2020 ). These studies provide important context for AOD misuse in the Bhutanese community, but do not explore in depth how these challenges may specifically impact the youth population. Ethnic-Nepali Bhutanese culture, alcohol and other drugs, and mental health Traditionally, alcohol consumption in Nepali culture is segmented based on caste and ethnic groups. Ethnic groups and those on the lower strata of the Hindu hierarchical caste system have historically consumed alcohol, whereas those from the Brahmin, Chhetri and Thakuri caste were traditionally non-users (Dhital et al., 2001 ). Specific to drugs, cannabis is indigenous to Nepal and one of the major drugs abused in the country (Dhital et al., 2001 ). One epidemiological study of alcohol consumption in an ethnically diverse region in Nepal found that 70% of the population had the opportunity to drink, 38% reported lifetime alcohol use, 32% indicated regular alcohol use, and 6% had developed an alcohol use disorder (Cole et al., 2020). A risk factor for transitioning from opportunity to drink to development of a disorder was being male; compared to high-caste Hindus, all other ethnic groups had greater odds of early-stage transitions from opportunity to drink to regular alcohol consumption (Cole et al., 2020). Caste was not, however, associated with development of an alcohol use disorder (Cole et al., 2020). Specific to ethnic-Nepali Bhutanese with a refugee life experience, one study conducted in refugee camps in Nepal found that 22.4% of men and 6.8% of women reported drinking alcohol; of these individuals, 22.6% of men and 8.6% engaged in hazardous or harmful patterns of drinking (Luitel et al., 2013 ). Home-brewed alcohol, such as Jaandh and Raksi , were frequently consumed in the camps, along with beer (Hewlett et al., 2015 ). Beliefs and attitudes towards mental health and substance use in the ethnic Nepali Bhutanese community are mixed due to cultural and generational differences shaping how these issues are viewed (Maleku et al., 2021 ). Traditionally, trauma and mental illness are often explained through karma or ancestral sins, which can create stigma by framing these problems as personal or family moral failures (Kohrt & Hruchka, 2010; Gurung et al., 2022 ). Because of this, emotional distress is usually silenced, seen as incurable, and families may avoid seeking help to protect their reputation in their community (Gurung et al., 2022 ; Maleku et al., 2021 ). Studies exploring mental illness and AOD use among resettled Bhutanese in the U.S. suggest that while issues with mental health and substance abuse are present, cultural stigma may prevent people from talking about these issues or seeking help (Hewlett et al., 2015 ; Maleku et al., 2021 ). Present study This study is part of a larger program of research being conducted using a community-based participatory research approach (Wallerstein & Duran, 2006 ) in a collaboration between an academic institution and the Bhutanese Community in Harrisburg (BCH), a self-help organization promoting the interests of Bhutanese residing in central Pennsylvania. This initiative developed out of growing concern among resettled Bhutanese over the problem of AOD misuse among youth that they observed in their communities. The goal of this research is to improve our understanding of substance use among youth and young adult Bhutanese with a refugee life experience. Our work was guided by the following research question: What are risk and protective factors for AOD use and misuse among youth and young adult (ages 14–24) Bhutanese living in central Pennsylvania? Method This study was approved by the institutional review board of X (blinded for review). All participants provided informed consent, child assent, and/or parental consent, as required. Participants Eligibility criteria for ethnic-Nepali Bhutanese key informant participants included: 1) living in the Greater Harrisburg, Pennsylvania region, and; 2) being knowledgeable about the topic of AOD use and misuse among youth and young adults in the Bhutanese community. Participants were aged 14 and older, and able to provide informed consent (for those 18+), assent (for those aged 14–17), and obtain parental consent from a parent or guardian (for those aged 14–17). A total of 35 ethnic-Nepali Bhutanese key informant participants were stratified based on age (14–17, 18–20, 21–24, 25+), with almost equal numbers of men and women in each strata (see Table 1 ). Eligibility criteria for focus group participants included: 1) identifying as an educator (ESL teacher, principal, school counselor), AOD service provider, police officer, or probation officer in the Greater Harrisburg, Pennsylvania region, or; 2) identifying as an ethnic-Nepali Bhutanese youth/young adult or parent of a youth/young adult, or; 3) identifying as an ethnic-Nepali Bhutanese business owner who sold alcohol or tobacco products, and; 4) being knowledgeable about the topic of AOD use and misuse among youth and young adults in the Bhutanese community. All focus group participants were aged 18 and older and able to give informed consent. A total of 47 individuals participated in a total of 8 focus groups, stratified by stakeholder group (youth/young adults, parents, AOD service providers, educators, police and probation officers, and Nepali business owners) (see Table 2 ). Table 1 Key Informant Participants (N = 35) Variable N (%) Sex Male 17 (48.57) Female 18 (51.43) Age Group 14–17 8 (22.86) 18–20 9 (25.71) 21–24 8 (22.86) 25+ 10 (28.57) Highest Education Some high school 9 (25.71) High school degree 6 (17.14) Some college 10 (28.57) College degree 6 (17.14) Some graduate school 1 (2.86) Graduate degree 3 (8.57) Range Mean (SD) Years in US 9–18 13.29 (1.62) Years in Greater Harrisburg 1–14 6.34 (4.14) Table 2 Focus Group Participants (N = 47) Group N (%) Youth and young adults Male 6 (46.15) Female 7 (53.85) Parents Male 11(84.62) Female 2 (15.38) Police and probation Male 7 (100) Female 0 AOD service providers Male 2 (50) Female 2 (50) Educators Male 3 (75) Female 1 (25) Nepali business owners Male 6 (100) Female 0 Data collection Both key informant (KI) interviews and focus groups (FG) were used to examine our research question. Key informant interviews were used to provide in-depth information on AOD use and misuse among youth and young adults in the community, including risk and protective factors. KI interviews were chosen given the stigma of AOD misuse in the community and concerns youth and young adults in particular may have over sharing their opinions and experiences on this topic. Focus groups were then used to gather more information on family and community dynamics of AOD misuse, and gain insight from stakeholder groups external to the Bhutanese community. FGs were selected in order to facilitate a sharing of ideas among participants and identify areas of agreement and disagreement among members of these groups. Recruitment for Bhutanese participants took place via community outreach and snowball sampling. Advertising was conducted via on-line forums used frequently by members of the community (BCH website, Facebook page). The BCH Board of Directors identified community leaders and youth who were knowledgeable about the topic of AOD misuse among youth and young adults. After completing interviews, participants were asked for the names of other people they thought were good candidates to participate in the study. Recruitment for non-Bhutanese participants was coordinated by research team members and community leaders who had previously interacted and liaised with these stakeholder groups (law enforcement, school officials, etc.) around the topic of AOD misuse in the community. Community research assistants (RAs) conducted one on one KI interviews and FGs at a location convenient to participants that ensured privacy and confidentiality. RAs also collected basic sociodemographic information from study participants. KI interviews and FGs took approximately 30–60 minutes and were audiotaped with informed consent, parental consent (for those under age 18), and child assent, as required. Interviews were conducted in either Nepali, English, or a combination of both languages depending upon the preferences of participants. RAs used semi-structured KI interview and FG guides to facilitate conversation and discussion. Participants were offered a reimbursement/incentive of a $ 25 gift card for their time. Data analysis Interviews and focus groups were translated into English (as needed) and transcribed. We conducted analysis in MAXQDA mixed methods data analysis software (VERBI Software, 2021 ). Our analysis followed a rigorous, systematic approach to thematic content analysis using a multi-level strategy of (1) coding; (2) reduction of overlapping and redundant codes; (3) theme development; and (4) identification of multiple sources of evidence to support each theme (Boyatzis, 1998 ; Braun & Clark, 2006). In the first phase of analysis, we conducted open coding with all data without prior assumption of theoretical frameworks in order to yield salient codes and topics related to our central research question. Codes and topics informed the development of a coding scheme with core categories. We developed a master qualitative codebook with definitions for codes (Boyatzis, 1998 ). To ensure reliability, at least two team members coded each transcript. The research team comprised a variety of perspectives, including those from the Bhutanese community, a researcher with over 10 years of experience conducting mental health research with the community, as well as individuals new to working on this topic with this cultural group. The research team met weekly during open coding to discuss discrepancies and reach agreement. In the second phase of analysis, we made connections between codes and categories within the context of the transnational theory of cultural stress. We assessed our data for alignment with this theoretical framework, as well as ways in which our data conflicted and/or augmented this framework. To ensure reciprocity and validation of initial findings, the team shared the work with community leaders and asked for their input on results and conclusions. Preliminary findings were presented at an ethnic-Nepali Bhutanese youth mental health conference, with feedback from youth and adults prompting additional analysis and refinement of themes. Results Findings focus on three themes related to risk and protective factors for AOD misuse among Bhutanese youth and young adults: Bhutanese history and culture, family dynamics, and communication and trust with external stakeholders. These themes are discussed in depth below. Bhutanese history and culture Participants discussed several ways in which the refugee life experience of Bhutanese impacted patterns of AOD misuse. To begin with, both youth and adults attributed an increase in AOD misuse to a vast difference in the accessibility of AOD from Nepal to the US. One person noted, “They didn’t have much access when we were living in the refugee camp of all these types of substances, and many of our youth didn’t even know the name [of substances]. But after they come to this country, they have a friend circle. Neighbors, some stores have easy access to these different types of substances.” (Male, 25+) Youth often perceived that despite the increase in access, there was limited monitoring of AOD misuse within the community. A number of individuals discussed the role of Bhutanese businesses. One young adult stated, “the Bhutanese community is growing around here, there’s like vape shops, there’s hookah bars and everything near here that- they’re, like, Nepali-owned businesses and they can just, like, literally walk in and not show ID and the Nepali people will let it be because [you are] Nepali, you know?” (Female, 18–20). Participants talked about easy access to alcohol at community events and celebrations, such as weddings and at outdoor sports venues. One female noted, “I think…big gatherings, right, where everyone’s doing something, celebrating, it’s so easy ‘cause it’s like, who’s gonna ask you, you know what I mean? There’s so many people, no one’s gonna be like, “oh, are you 18? Are you 19? Are you 20?” No one cares. It’s like if everyone is drinking, you can too, right? Because no one’s gonna ask you if you have an ID” (Female, 21–24). Because of family and community relationships, most participants stated that youth were accessing AOD from older youth and young adults in the Bhutanese community, not from outside, non-Nepali influences. One male youth explained “older siblings or like, someone they know older that can get access to that, someone 21 and older they have a good relationship with, I guess? And then they could easily access it with…a fraction of the money” (Male, 14–17). Many participants felt that this access was not paired with communication between adults and youth about the dangers of AOD. One adult female gave the example of use of alcohol during Diwali. She stated, “Some of us have started adapting the habit of, you know, celebrating it [Diwali] with, like some kind of alcohol or something, some few drinks or so. And I don't take it negatively. But you know at the same time you are…doing it in your house, where you have kids. If you do not explain them, you got to be 21…This is not something that will help you in your growth in your studies or anything else. You keep it in your house. It is not safe. It is not locked…Even though you might trust your kids but they tend to be influenced quickly when it comes to negative things.” (Female, 25+) Participants talked about the stigma of substance misuse, with negative implications for the reputation of entire families. One woman explained, “One thing in our community is that we tend to find ways or look for ways to hide it. You know what I mean? If you already know that your kids [are] getting addicted, they still try to cover up for their kids. Like ‘how can I protect it, I can I cover up these issues so people don’t hear about [it]?’ They go do that instead of being open about the issue” (Female, 25+). This contradiction of community-wide access yet extreme stigma was part of larger, complex dynamics of AOD misuse. When asked about the perception of AOD use and misuse in the community, many of the youngest participants seemed confused by the conflicting messages they were receiving; there is an absence of discussion of the issue among Bhutanese despite what they saw as a need for growing concern. For example, a female youth stated, “I think it [the Bhutanese community] doesn’t see it [substance use] as a bad thing, but like they don’t care much about it. Their parents should be the one telling them to not do this stuff. It’s not our problem right now. I don’t know why, because there has been a lot of death[s] from overdose and all that I’ve heard about.” (Female, 14–17) Variations in AOD consumption and norms within the Bhutanese community, based on ethnic subgroups and caste, were also seen to play a role in AOD misuse dynamics. One participant discussed her experiences around AOD use growing up in comparison to individuals from other groups: “In my family, we strictly grew up saying no to alcohol and those things because…religiously, it was told that it’s bad to abuse it. And then I guess [with] Gurung and Matuwali…it’s kinda like a culture to them because in social gatherings and stuff, they make alcohol from fermented rice…it was introduced to them, and they…had…exposure to it more than us…it’s more open for them culturally…I feel like this kinda relates back to, if they [are from] higher castes…we’re more likely to abuse it [alcohol and drugs], and more likely to hide it, because we care so much about what people think because we aren’t supposed to do it in the first place.” (Female, 21–24) Many participants saw connections between AOD misuse, mental health concerns, and broader cultural stigma towards addressing these issues among youth. One youth described AOD misuse as a response to mental health challenges being downplayed by parents: “another reason why youth do substances is because…I feel like in the Bhutanese community and the Nepali community we're not that open to talking about feeling. So…who can they go to if they cannot talk to their own family about it? Because often family members dismiss the, their feelings and their mental health and their struggles saying, ‘this is nothing, back in Nepal…we used to do..harder stuff than this.’” (Youth FG) In addition to a cultural context that did not promote sharing of problems, participants emphasized that mental health and AOD misuse among youth were also the consequences of their own struggles in a post-resettlement context. One young adult shared the challenges she and her older siblings faced in the US: “When they [my siblings] first came to America, I think they were in middle school, early high school stages. And you know, being so new to the culture and their environment, not being able to connect with the people around them, feeling like they were being judged for being different, they definitely went through, like the mental struggles. Yeah, and that’s kinda also what led me to substance abuse because it’s like “oh, well, you know, I am sad. A lot of stuff isn’t going right in my life, you know, I can’t connect with my friends, I can’t connect with my parents,” so I started, you know, just smoking ‘cause it’s like ‘oh it gives me something to do, I don’t have to think about my problems.’ (Female, 21–24) Although the tight-knit, Bhutanese community was sometimes viewed as negative, participants were quick to emphasize that these same characteristics could be extremely positive and harnessed to prevent and solve AOD problems. For instance, young adults highlighted the importance of engagement in Bhutanese community activities for prevention: “Everyone’s…very involved in the community. Like, kids at a very young age, they’re in sports, they’re in dance, they’re doing a lot of things…to kind of be better and then just engage themselves…be busy. I think that would definitely help someone who is trying to…not use drugs as much” (Female, 21–24). Other participants believed that Bhutanese community-led social gatherings focused on the topic of AOD could also be beneficial. One person explained, “in our Nepali community we can do a community fair where we gather…not just parents but kids as well. And at that event we can show them what we can do to help them, like in our Nepali community what kind of problems are happening and…we need to start doing something about it” (Female, 21–24). Family dynamics In addition to discussing risk and protective factors based on the Bhutanese refugee life experience and culture, participants also focused more in depth on family dynamics that were relevant to understanding AOD misuse among youth and young adults. Both youth and parents noted challenges to parental involvement in their children’s lives which opened up opportunities for using substances. For instance, adults noted that economic stressors and the work schedules of parents reduced contact between parents and children. One parent explained, “We have large family groups. The parents will go to work, and the children are taken care of by the grandparents. And most times, grandparents can’t keep an eye on their grandchildren and what they are doing. That might create a chance for the kids to go on those paths that are unhealthy for them.” (Parent FG). Participants expressed a major contributor to lack of parental involvement outside the household was the language barrier. Many parents were less comfortable speaking English than Nepali or had limited English language skills, reducing their involvement and awareness of what was going on when children were at school. One adult explained, “When we ask the parents about their children's behavior, they have a different story about their child, like what they see at home is different from what the teachers see. The parents are unaware of their child’s actions.” (Female, 25+) This lack of parental involvement was connected with challenges in parent-child communication. Cultural norms and stigma around AOD misuse meant that discussions around AOD were discouraged, resulting in a general lack of awareness among parents. Speaking of this dynamic, one youth stated, “it’s [AOD use] kind of ignored, you know, because they [parents] can’t really talk about that openly if they know if their kid is doing it or not. But if they do, then I also feel like that would be a weird conversation to have with you parents as well. So I feel like it’s not paid enough attention to.” (Female, 14–17). In instances where parents discovered their child using substances, youth discussed harsh reactions from their parents: “’Oh, you need to stop or we’re gonna kick you out,’ you know? It’s a lot of, like, very strong approaches instead of being like ‘what can I do to help you?’ It’s not like ‘oh, let me help you. What do you need?’ It’s like ‘oh, you need to do this, this, and this’ because it’s like instead of trying to help the person, it’s like you need to change so we look good, you know? We don’t want to be associated with you because you have these problems, so you need to fix yourself so we also look good.’” (Female, 21–24) Parents themselves saw the shortcomings of this approach: “If a family member has gone down the wrong path…The elders or other family members usually scold that person and threaten them to break their backs if they don’t stop using substances. We have been using the scolding practices for centuries. That might lead the users to more frustration.” (Parent FG) Both limited parental involvement and breakdowns in parent-child communication were part of larger challenges to family cohesion. Both youth and adults discussed how family conflict was a risk factor for AOD misuse. A parent noted connections between parental conflict, AOD misuse among parents, and AOD misuse among youth: “If the parents are having a conflict of their own, and their kids are involved in substance use, then the chances of their children coming out of that situation are low. If the parents are going through a rocky situation, they are not giving each other or their children that time. They will go to work and come back home and then drink, so they do not have to think about the problems.” (Parent FG) Family cohesion was also threatened by the high expectations parents had for their children to succeed in the US and support their families. One female youth explained, “Yeah, they[parents] have this idea obviously of America being a very good place for you to start. Start getting a better job and all that having better life than they, they had in Nepal, but they put some pressure into you doing good in education wise that because of the pressure and you can't handle it you, you go into drinking, smoking, doing other stuff to release all the tension” (Female, 14–17). Youth found it very difficult to speak with their parents about the stress and mental health challenges they had from these expectations; when they did, they felt parents were not receptive to these discussions. One participant relayed her own experience with her parents: “We're so different from our parents, you know? We’re Americanized now and it’s like- for our parents, for them, they kinda see it as a bad thing. “Oh, you’ll get over it, it’s just, you know, it’s just sadness” right, because they themselves don’t understand what it’s like. I remember when I had really bad anxiety…I was telling my parents and they were like “oh, just don’t be anxious” you know? And it’s like, I was so anxious because I couldn’t properly communicate with my parents. I was going through a lot of stuff, but I know my parents can’t relate to it.” (Female, 21–24) Despite these challenges to family functioning, participants highlighted how important family support could be to AOD misuse prevention and intervention. One participant shared the experience she had with her family intervening with a cousin who was abusing substances. She explained, “we’ve [my family] had… sit down conversations with…my cousin that…got a DUI. And it wasn’t yelling. We made it clear going in, like “hey, we want to talk to you because we understand what is happening, right? We don’t know all the stuff you’re doing, but it’s like we understand that this is a problem you have” (Female, 21–24). Close-knit, intergenerational households could also be of benefit to youth. One individual noted, “Right now American kids get thrown out as soon as you are 18 years old. But in our culture, they can stay with us up until we are 25 years old. So, I think there is always that support.” (Female, 25+) Communication and trust with external stakeholders External stakeholders had their own perspective on AOD misuse among youth in the Bhutanese community, and some of the challenges in addressing the problem. Law enforcement and service providers observed that youth attempts to negotiate life in America created stress, with AOD misuse as a consequence. One police/probation officer stated, “I think they’re [youth]…stuck in between two worlds. Uh, maybe there’s a lot of pressure as well…because…they might also be feeling responsible for the wellbeing of the family because you got the old world now living in the new world, you know, how do I manage how to do this? You know? I think that pressure there also and in order for them to escape, they got their crews, they go partying and do the things they need to do. I think it’s that pressure of trying to satisfy the old world with the new. Where do we stand here? You know? Where do we belong?” Teachers viewed AOD misuse among youth as a byproduct of trying to fit in at school and find a community of peers. One teacher explained, “the culture is different from where they came from so now they’re coming in here and they just want to be accepted into a new school alright so it's a natural transition but then when you add the component of a brand-new overall culture and language, they are going to do what they can to- to fit in.” Stakeholders noted that communicating with parents about youth substance use and illegal activity was problematic given the language barrier. In fact, they were oftentimes dependent upon the youth themselves to translate between law enforcement and parents. One police officer stated, “what I’ve noticed is that there’s a huge gap, uh, between the parents and the children… the language barriers that come with it and then the translation. The children speak very fluent English and we have no idea basically what they’re telling them [their parents]. And often we’ve found out that they’re not really telling them [their parents] what we’re trying to give the information at the time for whatever the incident may be.” This language barrier problem extended to services. Probation officers and drug/alcohol counselors explained that there were no Nepali-speaking counselors on staff, leading to treatment dropout or not accessing services to begin with: “one giant missing piece that we have is just the language barrier with the treatment like they’re missing out on at least half of the treatment they would normally get. And I do think that there’s also if someone within the community has a problem, say they want to find an inpatient, I don't know how accessible that is to them with the language barrier. So, there might be people that want that help and they just don't know where to go and there might not be a place to go, which is unfortunate.” These language barriers added to problems stakeholders saw in terms of addressing stigma and building trust with the Bhutanese community. A drug and alcohol prevention counselor stated, “I think too sometimes there's a misunderstanding of resources versus punishment…I've heard that a couple times uh especially in that community…if they [youth] are offered mental health resources or drug and alcohol resources that it's not them getting in trouble it's not some kind of punishment but it's actually here to help. Um, and maybe there being some kind of like stigma as well of people, you know, using treatment in that kind of way too which I think kinda seeps into it. Um, you know they’re not wanting to be identified as, you know, having a kid who has a problem or something like that.” One teacher attributed this hesitancy to a larger problem of a lack of trust: “we ultimately have to be on the same level playing field to say like, hey this is what we want for your student and you have to trust us on this. So how do you develop that trust when you have that natural barrier of language?” A police officer echoed this problem when stating, “It's a close-knit community, right? And they don't always want to let the police into that community…Essentially, we help them get to a certain point as a solution, and as you know, ‘we will take it from here. We will handle it from within our community.’” External stakeholders emphasized that bridging the communication gap was key to addressing AOD misuse. Police officers highlighted that having a Bhutanese police officer, for instance, was helpful for not just addressing language barriers but also educating law enforcement about Bhutanese culture and history. One officer stated, “we have Officer X [and] it's been a game changer. He’s like a celebrity within the community because he broke through this and he’s been great. Like it’s been phenomenal having him just because like he can- he’s helped us educate our guys as far as the community.” Through working with the Bhutanese officer, for instance, one police officer learned about negative experiences Bhutanese had with law enforcement in refugee camps and how that contributed to barriers to building trust. Ultimately, community partnerships were seen as the key to AOD misuse prevention and intervention: “If we have the government coming to them with the way things should be, it’s not gonna be received. If you have the community developing the plan and implementing it within themselves, it’s gonna be trusted and implemented.” Discussion Qualitative findings included three themes relevant to understanding AOD misuse among Bhutanese youth and young adults living in central Pennsylvania. Pre- and post-migration experiences and Bhutanese cultural dynamics around AOD use contributed to misuse; these macro-level factors could also influence family dynamics and functioning. Additionally, barriers to communication and trust with external stakeholders and potential law enforcement, education, and social service partners led to reduced effectiveness in AOD misuse prevention and intervention efforts. Participants emphasized, however, that the same community dynamics that acted as risk factors for AOD misuse could also be, and were, leveraged as protective factors in the community. Our findings align with prior research focused on AOD misuse among other migrant youth populations. As with other migrant communities, family conflict was viewed as a risk factor for AOD misuse (Posselt et al., 2015), and youth used substances as a way to cope with post-migration stressors (Aleer et al., 2023 ). Kenin et al ( 2025 ) indicated mixed findings on family cohesion and collectivist cultural values as risk or protective factors for AOD misuse among migrant youth. Our work suggests that these mixed findings may be because these factors are in fact both; Bhutanese family cohesion and collectivist culture could play a role in promoting prevention and intervention, but also increase access and use of AOD. Specific to Bhutanese, prior research on this topic highlights the role post-migration stressors and greater access to AOD use play in AOD misuse (Mirza 2018; Watson et al., 2022 ). Additionally, Watson et al ( 2022 ) found that peer influence and challenges to parenting youth in the US contributed to the problem. Our research extends these findings by speaking directly with Bhutanese youth and young adults to hear their perspectives on contentious family relationships; our findings suggest that familial expectations and breakdowns in parent-child communication are key to understanding this issue. In addition, this study brings more nuance to understanding AOD misuse within the Bhutanese cultural context, emphasizing the role stigma around both AOD misuse and co-occurring mental health problems plays in stifling family and community discussions and intervention. Finally, this study provides support for the transnational theory of cultural stress and AOD misuse. The Bhutanese historical refugee life experience is relevant for understanding current youth and young adult functioning in a post-resettlement environment. Life in refugee camps in Nepal and the decision to come to the US motivated parental hopes and expectations for their children. It is important to emphasize that youth and young adults were not ignorant or dismissive of the hardships family members faced prior to coming to the US; rather, youth struggled to balance respecting and honoring this past and finding their own path forward in the US. Limitations There are several limitations to this study. First, participants may not be representative of Bhutanese with a refugee life experience elsewhere in the US or other countries of resettlement. Likewise, the external stakeholders that participated in the research may not reflect the views and experiences of educators, social service providers, and law enforcement in other locations. This is because study participants were recruited in one community in central Pennsylvania. Furthermore, despite the large size of the community, some participants had pre-established social relationships with RAs who conducted the interviews and focus groups. This means participants may have felt pressure to provide desired responses or withheld information. Extensive training was done with RAs around this issue to try to minimize bias in participant responses. Implications Despite these limitations, our findings have implications for AOD misuse prevention and intervention in the Bhutanese community. Overall, there is a need to prioritize: 1) addressing stigma around AOD misuse and mental health; 2) psychoeducation on the consequences and impact of AOD misuse; 3) improving access to culturally-appropriate individual counseling and family services, and 4) strengthening relationships with and educating external stakeholders on the community’s cultural norms and practices. Stigma around AOD misuse in the Bhutanese community is part of a larger issue of community reluctance to talk about mental health challenges and accessing behavioral health services (Poudel-Tandukar et al., 2019 ; Soukenik et al., 2022 ). While broadly speaking there is stigma around AOD misuse in the Bhutanese community, youth and young adults highlighted that there are complex patterns, perceptions, and attitudes about AOD use and misuse based on ethnicity and caste. While alcohol in particular is more acceptable and less stigmatized in some subgroups of the community, there is a perceived higher risk of AOD misuse among subgroups in which alcohol consumption has been historically prohibited. Cultural shifts in AOD norms after resettlement and the emergence of a younger generation that grew up in an environment in which alcohol and drugs are much more accessible than in the past may mean that addressing stigma will require bridging significant age and generational gaps in the community. Additionally, prevention and educational initiatives designed to address stigma may need to be tailored to ethnic and religious subgroups, as opposed to using a one size fits all approach. Given the diversity of AOD use practices in the community, stigma initiatives should include basic psychoeducation on the bio-psycho-social impact of AOD misuse as well as US laws and potential legal consequences of misuse, as knowledge on these topics may be limited. Culturally appropriate AOD services means access to prevention and intervention services that are both linguistically accessible and integrate ethnic-Nepali beliefs and norms about mental health and AOD misuse (Corpus-Espinosa et al., 2025 ). Increasing the number of Nepali-speaking and bicultural service providers and translating psychoeducation material into Nepali are essential steps to mitigate youth risk in this community and build a better relationship between healthcare providers and the community at large. Beyond this, evidence-based AOD services for Bhutanese youth should be adapted to resonate with the post-migration experience of this generation. There exists an impressive body of work on ethnic-Nepali concepts of distress and mental health, and the psychosocial needs of the ethnic-Nepali Bhutanese population in particular, that can be drawn upon in this effort (Kohrt & Hruschka, 2010 ; Kohrt et al., 2012 ; Chase & Sapkota, 2017 ; Chase et al., 2013 ). Research has identified promising interventions adapted to the unique needs of the Bhutanese refugee life experience, particularly as it relates to family functioning (Betancourt et al., 2020 ). Other family-based AOD interventions have been culturally adapted to meet the needs of immigrant youth and families, emphasizing sensitivity to stressors associated with immigration, building social support for immigrant families, and psychoeducation for parents (Li et al., 2024 ). External stakeholders understood that developing a collaborative relationship with the Bhutanese community was key in addressing AOD misuse. A first step in growing these partnerships is increasing knowledge on Bhutanese history, culture, and AOD norms and beliefs among these external partners. In the process of conducting this study, our research team found that police and probation officers, educators, and AOD counselors were genuinely curious and interested in learning more about the Bhutanese community. Ethnic-Nepali Bhutanese self-help organizations can identify individuals that can act as liaisons between the community and these external groups, with a focus on bi-directional information exchange. Our findings suggest that as much as external stakeholders need to learn more about the Bhutanese community, the Bhutanese community also needs to learn more about the work and intentions of external partners. Conclusion AOD misuse among youth and young adults in the ethnic-Nepali Bhutanese community is influenced by complex cultural dynamics and the pre- and post-migration experiences of youth and adults. Forced migration has an impact on the psychosocial wellbeing of individuals, families, and the entire community, even among a younger generation that may have limited memories of life in a refugee camp in Nepal before coming to the US. Interventions should be led by the Bhutanese community and involve partnerships with external stakeholders, ensuring cultural appropriateness and sensitivity. Declarations Acknowledgements: This work was supported by the College of Health, Lehigh University. We would like to thank study participants in the Greater Harrisburg, PA, region for sharing their thoughts and ideas on this topic. Special thanks to our community research team members Manju Gurung, Saurab Bhandari and Gayatra Dangal. Finally, we appreciate the input and feedback from members of Asian Refugees United and New American Youth Mental Health. Data Statement: Data is available from the corresponding author upon reasonable request Funding: This work was supported by the College of Health, Lehigh University. The funding source had no role in the study design; in the collection, analysis and interpretation of data; in the writing of the articles; and in the decision to submit it for publication. Author Contributions: Funding acquisition, conceptualization: RLF; Project administration and supervision: TM; Investigation and methodology: RLF and TM; Formal analysis: RLF, GB, KB, GH, KC; Writing - original draft: RLF, GB, KB, KC; Writing - reviewing and editing: RLF and TM Declaration of Competing Interests: Authors have nothing to declare Declaration of generative AI and AI-assisted technologies in the writing process: Generative AI and AI-assisted technologies were not used in the writing process for this paper References Aleer, E., Alam, K., Rashid, A., Mohsin, M., & Eacersall, D. (2023). 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7566409","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":512063932,"identity":"09d4f915-4e3f-4d65-a9a2-b0ee5902af67","order_by":0,"name":"Rochelle L. 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Although there is a large body of literature investigating risk and protective factors for AOD misuse among youth more broadly, there is limited information on the dynamics among youth in refugee and other conflict-affected populations (Greene \u0026amp; Kane, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). This is a serious shortcoming, as there are well documented disparities in mental health and psychosocial wellbeing of children and youth with a refugee life experience compared to non-refugee populations (Frounfelker et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). As such, these youth may be at greater risk for AOD problems than other adolescents and young adults. In addition, there may be unique risk and protective factors for AOD misuse among war-affected youth that should be taken into consideration when designing and delivering clinical and community-based interventions.\u003c/p\u003e\n\u003ch3\u003eAOD misuse among migrant youth\u003c/h3\u003e\n\u003cp\u003eThere is a small body of research investigating AOD misuse among migrant youth and young adults. Reviews highlight risk factors including exposure to pre-migration trauma, post migration acculturative stress, accessibility of substances, and intergenerational conflict (Aleer et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Kenin et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2025\u003c/span\u003e; Douglass et al., 2023). There are mixed findings on whether or not identification with one\u0026rsquo;s heritage culture is protective or risk-enhancing (Kenin et al, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2025\u003c/span\u003e; Lim et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2011\u003c/span\u003e). Other research has focused on stigma and lack of culturally appropriate services as barriers to accessing care (Posselt et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; McCann et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). Although this work is informative, findings are drawn from various migrant populations (for instance, voluntary immigrants, refugees, unaccompanied minors) resettled in diverse contexts, and may not capture factors relevant for specific cultural groups affected by war and conflict. Additionally, while most studies include quantitative and/or qualitative data from migration youth and parents, relatively few seek insight from key external stakeholders including educators, health and social service providers, and law enforcement. Incorporating these diverse perspectives is useful to develop a more comprehensive understanding of AOD misuse among refugee youth.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eTheoretical frameworks\u003c/h2\u003e\u003cp\u003eCultural stress theory can be used to understand AOD misuse in refugee youth. Cultural stress theory considers how discrimination, negative context of reception, and bicultural stress impact individuals explicitly because they are considered foreign born, or implicitly due to cultural differences between the individuals and the cultural context in their receiving country (Meca \u0026amp; Schwartz, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Family functioning (encompassing parental involvement, parent-child communication, and family cohesion) is also relevant to understanding AOD misuse. In the cultural stress model, cultural stressors can have a direct or indirect effect on AOD misuse among youth via the mediating pathway of negative family functioning (Salas-Wright \u0026amp; Schwartz, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Conversely, positive family functioning can have a moderating effect on the relationship between cultural stress and AOD misuse (Salas-Wright \u0026amp; Schwartz, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2019\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe transnational theory of cultural stress builds upon the cultural stress theory by integrating pre-migration, transit, and post-migration factors related to AOD misuse. Pre-migration factors include context of departure, motivations for emigration, and AOD cultural norms and experiences (Salas-Wright \u0026amp; Schwartz, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Transit-related factors encompass methods of transportation, exposure to stressful situations, and traumatic experiences (Salas-Wright \u0026amp; Schwartz, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). This adaptation of the cultural stress model is particularly relevant for refugee populations, since they are often exposed to unique stressors or traumatic events during the pre-migration and transit periods. Researchers can examine how these varied migration-related experiences over the life course influence AOD misuse among youth, along with post-resettlement stressors and family dynamics (Salas-Wright \u0026amp; Schwartz, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2019\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eBhutanese with a refugee life experience\u003c/h3\u003e\n\u003cp\u003eDuring the 1980s, Bhutan\u0026rsquo;s \u0026ldquo;One Nation, One People\u0026rdquo; or \u0026ldquo;Bhutanization\u0026rdquo; policy aimed at enforcing cultural homogeneity in Bhutan resulted in the government forcibly expelling ethnic-Nepali citizens from the country (Hutt, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e1996\u003c/span\u003e). Over 100,000 Bhutanese refugees were exiled to UN-run camps in eastern Nepal where they lived for over two decades (Shrestha, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). In 2008, the United Nations High Commissioner for Refugees and the International Organization for Migration launched resettlement programs, which relocated Bhutanese refugees to the United States (US) and other countries (Shrestha, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Central Pennsylvania became a destination for some of these refugees, with secondary migration resulting in an estimated 40,000 Bhutanese living in the region in 2025.\u003c/p\u003e\u003cp\u003eSince third country resettlement began, there has been a small but growing body of literature on the psychosocial well-being of Bhutanese children and youth in the US, driven in part by concern for the high rate of suicide among resettled Bhutanese (CDC, 2013). Among Bhutanese youth, post-resettlement brought stressors that elevated risk for anxiety (\u003cem\u003echinteet\u003c/em\u003e), depression (\u003cem\u003edookhit\u003c/em\u003e), and behavioral problems (\u003cem\u003ebadmass\u003c/em\u003e) (Betancourt et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). Protective factors include community and family support and collaborating with schools to address children\u0026rsquo;s needs (Betancourt et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Cardeli et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). To date there has been limited examination of the issue of AOD misuse in this community. Existing literature emphasizes that Bhutanese may be particularly vulnerable to AOD misuse due to migration history stressors, work pressures, the accessibility of alcohol, and the lack of culturally informed education and awareness on the issue (Mirza et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Watson et al., \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Carter, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). These studies provide important context for AOD misuse in the Bhutanese community, but do not explore in depth how these challenges may specifically impact the youth population.\u003c/p\u003e\n\u003ch3\u003eEthnic-Nepali Bhutanese culture, alcohol and other drugs, and mental health\u003c/h3\u003e\n\u003cp\u003eTraditionally, alcohol consumption in Nepali culture is segmented based on caste and ethnic groups. Ethnic groups and those on the lower strata of the Hindu hierarchical caste system have historically consumed alcohol, whereas those from the Brahmin, Chhetri and Thakuri caste were traditionally non-users (Dhital et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2001\u003c/span\u003e). Specific to drugs, cannabis is indigenous to Nepal and one of the major drugs abused in the country (Dhital et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2001\u003c/span\u003e). One epidemiological study of alcohol consumption in an ethnically diverse region in Nepal found that 70% of the population had the opportunity to drink, 38% reported lifetime alcohol use, 32% indicated regular alcohol use, and 6% had developed an alcohol use disorder (Cole et al., 2020). A risk factor for transitioning from opportunity to drink to development of a disorder was being male; compared to high-caste Hindus, all other ethnic groups had greater odds of early-stage transitions from opportunity to drink to regular alcohol consumption (Cole et al., 2020). Caste was not, however, associated with development of an alcohol use disorder (Cole et al., 2020). Specific to ethnic-Nepali Bhutanese with a refugee life experience, one study conducted in refugee camps in Nepal found that 22.4% of men and 6.8% of women reported drinking alcohol; of these individuals, 22.6% of men and 8.6% engaged in hazardous or harmful patterns of drinking (Luitel et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). Home-brewed alcohol, such as \u003cem\u003eJaandh\u003c/em\u003e and \u003cem\u003eRaksi\u003c/em\u003e, were frequently consumed in the camps, along with beer (Hewlett et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2015\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eBeliefs and attitudes towards mental health and substance use in the ethnic Nepali Bhutanese community are mixed due to cultural and generational differences shaping how these issues are viewed (Maleku et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Traditionally, trauma and mental illness are often explained through karma or ancestral sins, which can create stigma by framing these problems as personal or family moral failures (Kohrt \u0026amp; Hruchka, 2010; Gurung et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Because of this, emotional distress is usually silenced, seen as incurable, and families may avoid seeking help to protect their reputation in their community (Gurung et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Maleku et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Studies exploring mental illness and AOD use among resettled Bhutanese in the U.S. suggest that while issues with mental health and substance abuse are present, cultural stigma may prevent people from talking about these issues or seeking help (Hewlett et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Maleku et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003ePresent study\u003c/h3\u003e\n\u003cp\u003eThis study is part of a larger program of research being conducted using a community-based participatory research approach (Wallerstein \u0026amp; Duran, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2006\u003c/span\u003e) in a collaboration between an academic institution and the Bhutanese Community in Harrisburg (BCH), a self-help organization promoting the interests of Bhutanese residing in central Pennsylvania. This initiative developed out of growing concern among resettled Bhutanese over the problem of AOD misuse among youth that they observed in their communities. The goal of this research is to improve our understanding of substance use among youth and young adult Bhutanese with a refugee life experience. Our work was guided by the following research question: What are risk and protective factors for AOD use and misuse among youth and young adult (ages 14\u0026ndash;24) Bhutanese living in central Pennsylvania?\u003c/p\u003e"},{"header":"Method","content":"\u003cp\u003e This study was approved by the institutional review board of X (blinded for review). All participants provided informed consent, child assent, and/or parental consent, as required.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eParticipants\u003c/h2\u003e\u003cp\u003eEligibility criteria for ethnic-Nepali Bhutanese key informant participants included: 1) living in the Greater Harrisburg, Pennsylvania region, and; 2) being knowledgeable about the topic of AOD use and misuse among youth and young adults in the Bhutanese community. Participants were aged 14 and older, and able to provide informed consent (for those 18+), assent (for those aged 14\u0026ndash;17), and obtain parental consent from a parent or guardian (for those aged 14\u0026ndash;17). A total of 35 ethnic-Nepali Bhutanese key informant participants were stratified based on age (14\u0026ndash;17, 18\u0026ndash;20, 21\u0026ndash;24, 25+), with almost equal numbers of men and women in each strata (see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Eligibility criteria for focus group participants included: 1) identifying as an educator (ESL teacher, principal, school counselor), AOD service provider, police officer, or probation officer in the Greater Harrisburg, Pennsylvania region, or; 2) identifying as an ethnic-Nepali Bhutanese youth/young adult or parent of a youth/young adult, or; 3) identifying as an ethnic-Nepali Bhutanese business owner who sold alcohol or tobacco products, and; 4) being knowledgeable about the topic of AOD use and misuse among youth and young adults in the Bhutanese community. All focus group participants were aged 18 and older and able to give informed consent. A total of 47 individuals participated in a total of 8 focus groups, stratified by stakeholder group (youth/young adults, parents, AOD service providers, educators, police and probation officers, and Nepali business owners) (see Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eKey Informant Participants (N\u0026thinsp;=\u0026thinsp;35)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eN (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSex\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eMale\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e17 (48.57)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eFemale\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e18 (51.43)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge Group\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003e14\u0026ndash;17\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e8 (22.86)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003e18\u0026ndash;20\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e9 (25.71)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003e21\u0026ndash;24\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e8 (22.86)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003e25+\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e10 (28.57)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHighest Education\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eSome high school\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e9 (25.71)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eHigh school degree\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e6 (17.14)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eSome college\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e10 (28.57)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eCollege degree\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e6 (17.14)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eSome graduate school\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e1 (2.86)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eGraduate degree\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e3 (8.57)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eRange\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003eMean (SD)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYears in US\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9\u0026ndash;18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13.29 (1.62)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYears in Greater Harrisburg\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u0026ndash;14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6.34 (4.14)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eFocus Group Participants (N\u0026thinsp;=\u0026thinsp;47)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGroup\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYouth and young adults\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eMale\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 (46.15)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eFemale\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7 (53.85)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eParents\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eMale\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11(84.62)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eFemale\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (15.38)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePolice and probation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eMale\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7 (100)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eFemale\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAOD service providers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eMale\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (50)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eFemale\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (50)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEducators\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eMale\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 (75)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eFemale\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (25)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNepali business owners\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eMale\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 (100)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eFemale\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eBoth key informant (KI) interviews and focus groups (FG) were used to examine our research question. Key informant interviews were used to provide in-depth information on AOD use and misuse among youth and young adults in the community, including risk and protective factors. KI interviews were chosen given the stigma of AOD misuse in the community and concerns youth and young adults in particular may have over sharing their opinions and experiences on this topic. Focus groups were then used to gather more information on family and community dynamics of AOD misuse, and gain insight from stakeholder groups external to the Bhutanese community. FGs were selected in order to facilitate a sharing of ideas among participants and identify areas of agreement and disagreement among members of these groups.\u003c/p\u003e\u003cp\u003eRecruitment for Bhutanese participants took place via community outreach and snowball sampling. Advertising was conducted via on-line forums used frequently by members of the community (BCH website, Facebook page). The BCH Board of Directors identified community leaders and youth who were knowledgeable about the topic of AOD misuse among youth and young adults. After completing interviews, participants were asked for the names of other people they thought were good candidates to participate in the study. Recruitment for non-Bhutanese participants was coordinated by research team members and community leaders who had previously interacted and liaised with these stakeholder groups (law enforcement, school officials, etc.) around the topic of AOD misuse in the community.\u003c/p\u003e\u003cp\u003e Community research assistants (RAs) conducted one on one KI interviews and FGs at a location convenient to participants that ensured privacy and confidentiality. RAs also collected basic sociodemographic information from study participants. KI interviews and FGs took approximately 30\u0026ndash;60 minutes and were audiotaped with informed consent, parental consent (for those under age 18), and child assent, as required. Interviews were conducted in either Nepali, English, or a combination of both languages depending upon the preferences of participants. RAs used semi-structured KI interview and FG guides to facilitate conversation and discussion. Participants were offered a reimbursement/incentive of a \u003cspan\u003e$\u003c/span\u003e25 gift card for their time.\u003c/p\u003e\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003eData analysis\u003c/h2\u003e\u003cp\u003eInterviews and focus groups were translated into English (as needed) and transcribed. We conducted analysis in MAXQDA mixed methods data analysis software (VERBI Software, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Our analysis followed a rigorous, systematic approach to thematic content analysis using a multi-level strategy of (1) coding; (2) reduction of overlapping and redundant codes; (3) theme development; and (4) identification of multiple sources of evidence to support each theme (Boyatzis, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e1998\u003c/span\u003e; Braun \u0026amp; Clark, 2006).\u003c/p\u003e\u003cp\u003eIn the first phase of analysis, we conducted open coding with all data without prior assumption of theoretical frameworks in order to yield salient codes and topics related to our central research question. Codes and topics informed the development of a coding scheme with core categories. We developed a master qualitative codebook with definitions for codes (Boyatzis, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e1998\u003c/span\u003e). To ensure reliability, at least two team members coded each transcript. The research team comprised a variety of perspectives, including those from the Bhutanese community, a researcher with over 10 years of experience conducting mental health research with the community, as well as individuals new to working on this topic with this cultural group. The research team met weekly during open coding to discuss discrepancies and reach agreement.\u003c/p\u003e\u003cp\u003eIn the second phase of analysis, we made connections between codes and categories within the context of the transnational theory of cultural stress. We assessed our data for alignment with this theoretical framework, as well as ways in which our data conflicted and/or augmented this framework. To ensure reciprocity and validation of initial findings, the team shared the work with community leaders and asked for their input on results and conclusions. Preliminary findings were presented at an ethnic-Nepali Bhutanese youth mental health conference, with feedback from youth and adults prompting additional analysis and refinement of themes.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eFindings focus on three themes related to risk and protective factors for AOD misuse among Bhutanese youth and young adults: Bhutanese history and culture, family dynamics, and communication and trust with external stakeholders. These themes are discussed in depth below.\u003c/p\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eBhutanese history and culture\u003c/h2\u003e\u003cp\u003eParticipants discussed several ways in which the refugee life experience of Bhutanese impacted patterns of AOD misuse. To begin with, both youth and adults attributed an increase in AOD misuse to a vast difference in the accessibility of AOD from Nepal to the US. One person noted,\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;They didn\u0026rsquo;t have much access when we were living in the refugee camp of all these types of substances, and many of our youth didn\u0026rsquo;t even know the name [of substances]. But after they come to this country, they have a friend circle. Neighbors, some stores have easy access to these different types of substances.\u0026rdquo; (Male, 25+)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eYouth often perceived that despite the increase in access, there was limited monitoring of AOD misuse within the community. A number of individuals discussed the role of Bhutanese businesses. One young adult stated, \u0026ldquo;the Bhutanese community is growing around here, there\u0026rsquo;s like vape shops, there\u0026rsquo;s hookah bars and everything near here that- they\u0026rsquo;re, like, Nepali-owned businesses and they can just, like, literally walk in and not show ID and the Nepali people will let it be because [you are] Nepali, you know?\u0026rdquo; (Female, 18\u0026ndash;20). Participants talked about easy access to alcohol at community events and celebrations, such as weddings and at outdoor sports venues. One female noted, \u0026ldquo;I think\u0026hellip;big gatherings, right, where everyone\u0026rsquo;s doing something, celebrating, it\u0026rsquo;s so easy \u0026lsquo;cause it\u0026rsquo;s like, who\u0026rsquo;s gonna ask you, you know what I mean? There\u0026rsquo;s so many people, no one\u0026rsquo;s gonna be like, \u0026ldquo;oh, are you 18? Are you 19? Are you 20?\u0026rdquo; No one cares. It\u0026rsquo;s like if everyone is drinking, you can too, right? Because no one\u0026rsquo;s gonna ask you if you have an ID\u0026rdquo; (Female, 21\u0026ndash;24). Because of family and community relationships, most participants stated that youth were accessing AOD from older youth and young adults in the Bhutanese community, not from outside, non-Nepali influences. One male youth explained \u0026ldquo;older siblings or like, someone they know older that can get access to that, someone 21 and older they have a good relationship with, I guess? And then they could easily access it with\u0026hellip;a fraction of the money\u0026rdquo; (Male, 14\u0026ndash;17).\u003c/p\u003e\u003cp\u003eMany participants felt that this access was not paired with communication between adults and youth about the dangers of AOD. One adult female gave the example of use of alcohol during Diwali. She stated,\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;Some of us have started adapting the habit of, you know, celebrating it [Diwali] with, like some kind of alcohol or something, some few drinks or so. And I don't take it negatively. But you know at the same time you are\u0026hellip;doing it in your house, where you have kids. If you do not explain them, you got to be 21\u0026hellip;This is not something that will help you in your growth in your studies or anything else. You keep it in your house. It is not safe. It is not locked\u0026hellip;Even though you might trust your kids but they tend to be influenced quickly when it comes to negative things.\u0026rdquo; (Female, 25+)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e Participants talked about the stigma of substance misuse, with negative implications for the reputation of entire families. One woman explained, \u0026ldquo;One thing in our community is that we tend to find ways or look for ways to hide it. You know what I mean? If you already know that your kids [are] getting addicted, they still try to cover up for their kids. Like \u0026lsquo;how can I protect it, I can I cover up these issues so people don\u0026rsquo;t hear about [it]?\u0026rsquo; They go do that instead of being open about the issue\u0026rdquo; (Female, 25+). This contradiction of community-wide access yet extreme stigma was part of larger, complex dynamics of AOD misuse. When asked about the perception of AOD use and misuse in the community, many of the youngest participants seemed confused by the conflicting messages they were receiving; there is an absence of discussion of the issue among Bhutanese despite what they saw as a need for growing concern. For example, a female youth stated, \u0026ldquo;I think it [the Bhutanese community] doesn\u0026rsquo;t see it [substance use] as a bad thing, but like they don\u0026rsquo;t care much about it. Their parents should be the one telling them to not do this stuff. It\u0026rsquo;s not our problem right now. I don\u0026rsquo;t know why, because there has been a lot of death[s] from overdose and all that I\u0026rsquo;ve heard about.\u0026rdquo; (Female, 14\u0026ndash;17)\u003c/p\u003e\u003cp\u003eVariations in AOD consumption and norms within the Bhutanese community, based on ethnic subgroups and caste, were also seen to play a role in AOD misuse dynamics. One participant discussed her experiences around AOD use growing up in comparison to individuals from other groups:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;In my family, we strictly grew up saying no to alcohol and those things because\u0026hellip;religiously, it was told that it\u0026rsquo;s bad to abuse it. And then I guess [with] Gurung and Matuwali\u0026hellip;it\u0026rsquo;s kinda like a culture to them because in social gatherings and stuff, they make alcohol from fermented rice\u0026hellip;it was introduced to them, and they\u0026hellip;had\u0026hellip;exposure to it more than us\u0026hellip;it\u0026rsquo;s more open for them culturally\u0026hellip;I feel like this kinda relates back to, if they [are from] higher castes\u0026hellip;we\u0026rsquo;re more likely to abuse it [alcohol and drugs], and more likely to hide it, because we care so much about what people think because we aren\u0026rsquo;t supposed to do it in the first place.\u0026rdquo; (Female, 21\u0026ndash;24)\u003c/p\u003e\u003cp\u003eMany participants saw connections between AOD misuse, mental health concerns, and\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003ebroader cultural stigma towards addressing these issues among youth. One youth described AOD misuse as a response to mental health challenges being downplayed by parents:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;another reason why youth do substances is because\u0026hellip;I feel like in the Bhutanese community and the Nepali community we're not that open to talking about feeling. So\u0026hellip;who can they go to if they cannot talk to their own family about it? Because often family members dismiss the, their feelings and their mental health and their struggles saying, \u0026lsquo;this is nothing, back in Nepal\u0026hellip;we used to do..harder stuff than this.\u0026rsquo;\u0026rdquo; (Youth FG)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eIn addition to a cultural context that did not promote sharing of problems, participants emphasized that mental health and AOD misuse among youth were also the consequences of their own struggles in a post-resettlement context. One young adult shared the challenges she and her older siblings faced in the US:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;When they [my siblings] first came to America, I think they were in middle school, early high school stages. And you know, being so new to the culture and their environment, not being able to connect with the people around them, feeling like they were being judged for being different, they definitely went through, like the mental struggles. Yeah, and that\u0026rsquo;s kinda also what led me to substance abuse because it\u0026rsquo;s like \u0026ldquo;oh, well, you know, I am sad. A lot of stuff isn\u0026rsquo;t going right in my life, you know, I can\u0026rsquo;t connect with my friends, I can\u0026rsquo;t connect with my parents,\u0026rdquo; so I started, you know, just smoking \u0026lsquo;cause it\u0026rsquo;s like \u0026lsquo;oh it gives me something to do, I don\u0026rsquo;t have to think about my problems.\u0026rsquo; (Female, 21\u0026ndash;24)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAlthough the tight-knit, Bhutanese community was sometimes viewed as negative, participants were quick to emphasize that these same characteristics could be extremely positive and harnessed to prevent and solve AOD problems. For instance, young adults highlighted the importance of engagement in Bhutanese community activities for prevention: \u0026ldquo;Everyone\u0026rsquo;s\u0026hellip;very involved in the community. Like, kids at a very young age, they\u0026rsquo;re in sports, they\u0026rsquo;re in dance, they\u0026rsquo;re doing a lot of things\u0026hellip;to kind of be better and then just engage themselves\u0026hellip;be busy. I think that would definitely help someone who is trying to\u0026hellip;not use drugs as much\u0026rdquo; (Female, 21\u0026ndash;24). Other participants believed that Bhutanese community-led social gatherings focused on the topic of AOD could also be beneficial. One person explained, \u0026ldquo;in our Nepali community we can do a community fair where we gather\u0026hellip;not just parents but kids as well. And at that event we can show them what we can do to help them, like in our Nepali community what kind of problems are happening and\u0026hellip;we need to start doing something about it\u0026rdquo; (Female, 21\u0026ndash;24).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eFamily dynamics\u003c/h2\u003e\u003cp\u003eIn addition to discussing risk and protective factors based on the Bhutanese refugee life experience and culture, participants also focused more in depth on family dynamics that were relevant to understanding AOD misuse among youth and young adults. Both youth and parents noted challenges to parental involvement in their children\u0026rsquo;s lives which opened up opportunities for using substances. For instance, adults noted that economic stressors and the work schedules of parents reduced contact between parents and children. One parent explained, \u0026ldquo;We have large family groups. The parents will go to work, and the children are taken care of by the grandparents. And most times, grandparents can\u0026rsquo;t keep an eye on their grandchildren and what they are doing. That might create a chance for the kids to go on those paths that are unhealthy for them.\u0026rdquo; (Parent FG). Participants expressed a major contributor to lack of parental involvement outside the household was the language barrier. Many parents were less comfortable speaking English than Nepali or had limited English language skills, reducing their involvement and awareness of what was going on when children were at school. One adult explained, \u0026ldquo;When we ask the parents about their children's behavior, they have a different story about their child, like what they see at home is different from what the teachers see. The parents are unaware of their child\u0026rsquo;s actions.\u0026rdquo; (Female, 25+)\u003c/p\u003e\u003cp\u003eThis lack of parental involvement was connected with challenges in parent-child communication. Cultural norms and stigma around AOD misuse meant that discussions around AOD were discouraged, resulting in a general lack of awareness among parents. Speaking of this dynamic, one youth stated, \u0026ldquo;it\u0026rsquo;s [AOD use] kind of ignored, you know, because they [parents] can\u0026rsquo;t really talk about that openly if they know if their kid is doing it or not. But if they do, then I also feel like that would be a weird conversation to have with you parents as well. So I feel like it\u0026rsquo;s not paid enough attention to.\u0026rdquo; (Female, 14\u0026ndash;17). In instances where parents discovered their child using substances, youth discussed harsh reactions from their parents:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u0026rsquo;Oh, you need to stop or we\u0026rsquo;re gonna kick you out,\u0026rsquo; you know? It\u0026rsquo;s a lot of, like, very strong approaches instead of being like \u0026lsquo;what can I do to help you?\u0026rsquo; It\u0026rsquo;s not like \u0026lsquo;oh, let me help you. What do you need?\u0026rsquo; It\u0026rsquo;s like \u0026lsquo;oh, you need to do this, this, and this\u0026rsquo; because it\u0026rsquo;s like instead of trying to help the person, it\u0026rsquo;s like you need to change so we look good, you know? We don\u0026rsquo;t want to be associated with you because you have these problems, so you need to fix yourself so we also look good.\u0026rsquo;\u0026rdquo; (Female, 21\u0026ndash;24)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e Parents themselves saw the shortcomings of this approach: \u0026ldquo;If a family member has gone down the wrong path\u0026hellip;The elders or other family members usually scold that person and threaten them to break their backs if they don\u0026rsquo;t stop using substances. We have been using the scolding practices for centuries. That might lead the users to more frustration.\u0026rdquo; (Parent FG)\u003c/p\u003e\u003cp\u003eBoth limited parental involvement and breakdowns in parent-child communication were part of larger challenges to family cohesion. Both youth and adults discussed how family conflict was a risk factor for AOD misuse. A parent noted connections between parental conflict, AOD misuse among parents, and AOD misuse among youth:\u003c/p\u003e\u003cp\u003e \u0026ldquo;If the parents are having a conflict of their own, and their kids are involved in substance\u003c/p\u003e\u003cp\u003euse, then the chances of their children coming out of that situation are low. If the parents\u003c/p\u003e\u003cp\u003eare going through a rocky situation, they are not giving each other or their children that\u003c/p\u003e\u003cp\u003etime. They will go to work and come back home and then drink, so they do not have to\u003c/p\u003e\u003cp\u003ethink about the problems.\u0026rdquo; (Parent FG)\u003c/p\u003e\u003cp\u003e Family cohesion was also threatened by the high expectations parents had for their children to succeed in the US and support their families. One female youth explained,\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;Yeah, they[parents] have this idea obviously of America being a very good place for you to start. Start getting a better job and all that having better life than they, they had in\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eNepal, but they put some pressure into you doing good in education wise that because of\u003c/p\u003e\u003cp\u003ethe pressure and you can't handle it you, you go into drinking, smoking, doing other stuff\u003c/p\u003e\u003cp\u003eto release all the tension\u0026rdquo; (Female, 14\u0026ndash;17).\u003c/p\u003e\u003cp\u003e Youth found it very difficult to speak with their parents about the stress and mental health challenges they had from these expectations; when they did, they felt parents were not receptive to these discussions. One participant relayed her own experience with her parents:\u003c/p\u003e\u003cp\u003e\u0026ldquo;We're so different from our parents, you know? We\u0026rsquo;re Americanized now and it\u0026rsquo;s like-\u003c/p\u003e\u003cp\u003efor our parents, for them, they kinda see it as a bad thing. \u0026ldquo;Oh, you\u0026rsquo;ll get over it, it\u0026rsquo;s just,\u003c/p\u003e\u003cp\u003eyou know, it\u0026rsquo;s just sadness\u0026rdquo; right, because they themselves don\u0026rsquo;t understand what it\u0026rsquo;s\u003c/p\u003e\u003cp\u003elike. I remember when I had really bad anxiety\u0026hellip;I was telling my parents and they were\u003c/p\u003e\u003cp\u003elike \u0026ldquo;oh, just don\u0026rsquo;t be anxious\u0026rdquo; you know? And it\u0026rsquo;s like, I was so anxious because I\u003c/p\u003e\u003cp\u003ecouldn\u0026rsquo;t properly communicate with my parents. I was going through a lot of stuff, but I\u003c/p\u003e\u003cp\u003eknow my parents can\u0026rsquo;t relate to it.\u0026rdquo; (Female, 21\u0026ndash;24)\u003c/p\u003e\u003cp\u003eDespite these challenges to family functioning, participants highlighted how important family support could be to AOD misuse prevention and intervention. One participant shared the experience she had with her family intervening with a cousin who was abusing substances. She explained, \u0026ldquo;we\u0026rsquo;ve [my family] had\u0026hellip; sit down conversations with\u0026hellip;my cousin that\u0026hellip;got a DUI. And it wasn\u0026rsquo;t yelling. We made it clear going in, like \u0026ldquo;hey, we want to talk to you because we understand what is happening, right? We don\u0026rsquo;t know all the stuff you\u0026rsquo;re doing, but it\u0026rsquo;s like we understand that this is a problem you have\u0026rdquo; (Female, 21\u0026ndash;24). Close-knit, intergenerational households could also be of benefit to youth. One individual noted, \u0026ldquo;Right now American kids get thrown out as soon as you are 18 years old. But in our culture, they can stay with us up until we are 25 years old. So, I think there is always that support.\u0026rdquo; (Female, 25+)\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eCommunication and trust with external stakeholders\u003c/h2\u003e\u003cp\u003eExternal stakeholders had their own perspective on AOD misuse among youth in the Bhutanese community, and some of the challenges in addressing the problem. Law enforcement and service providers observed that youth attempts to negotiate life in America created stress, with AOD misuse as a consequence. One police/probation officer stated,\u003c/p\u003e\u003cp\u003e\u0026ldquo;I think they\u0026rsquo;re [youth]\u0026hellip;stuck in between two worlds. Uh, maybe there\u0026rsquo;s a lot of\u003c/p\u003e\u003cp\u003epressure as well\u0026hellip;because\u0026hellip;they might also be feeling responsible for the wellbeing of\u003c/p\u003e\u003cp\u003ethe family because you got the old world now living in the new world, you know, how do\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI manage how to do this? You know? I think that pressure there also and in order for them to escape, they got their crews, they go partying and do the things they need to do. I think it\u0026rsquo;s that pressure of trying to satisfy the old world with the new. Where do we stand here? You know? Where do we belong?\u0026rdquo;\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eTeachers viewed AOD misuse among youth as a byproduct of trying to fit in at school and find a community of peers. One teacher explained, \u0026ldquo;the culture is different from where they came from so now they\u0026rsquo;re coming in here and they just want to be accepted into a new school alright so it's a natural transition but then when you add the component of a brand-new overall culture and language, they are going to do what they can to- to fit in.\u0026rdquo;\u003c/p\u003e\u003cp\u003eStakeholders noted that communicating with parents about youth substance use and illegal activity was problematic given the language barrier. In fact, they were oftentimes dependent upon the youth themselves to translate between law enforcement and parents. One police officer stated,\u003c/p\u003e\u003cp\u003e\u0026ldquo;what I\u0026rsquo;ve noticed is that there\u0026rsquo;s a huge gap, uh, between the parents and the children\u0026hellip;\u003c/p\u003e\u003cp\u003ethe language barriers that come with it and then the translation. The children speak very\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003efluent English and we have no idea basically what they\u0026rsquo;re telling them [their parents]. And often we\u0026rsquo;ve found out that they\u0026rsquo;re not really telling them [their parents] what we\u0026rsquo;re trying to give the information at the time for whatever the incident may be.\u0026rdquo;\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThis language barrier problem extended to services. Probation officers and drug/alcohol counselors explained that there were no Nepali-speaking counselors on staff, leading to treatment dropout or not accessing services to begin with:\u003c/p\u003e\u003cp\u003e\u0026ldquo;one giant missing piece that we have is just the language barrier with the treatment like\u003c/p\u003e\u003cp\u003ethey\u0026rsquo;re missing out on at least half of the treatment they would normally get. And I do\u003c/p\u003e\u003cp\u003ethink that there\u0026rsquo;s also if someone within the community has a problem, say they want to\u003c/p\u003e\u003cp\u003efind an inpatient, I don't know how accessible that is to them with the language barrier.\u003c/p\u003e\u003cp\u003eSo, there might be people that want that help and they just don't know where to go and\u003c/p\u003e\u003cp\u003ethere might not be a place to go, which is unfortunate.\u0026rdquo;\u003c/p\u003e\u003cp\u003eThese language barriers added to problems stakeholders saw in terms of addressing stigma and building trust with the Bhutanese community. A drug and alcohol prevention counselor stated,\u003c/p\u003e\u003cp\u003e\u0026ldquo;I think too sometimes there's a misunderstanding of resources versus punishment\u0026hellip;I've\u003c/p\u003e\u003cp\u003eheard that a couple times uh especially in that community\u0026hellip;if they [youth] are offered\u003c/p\u003e\u003cp\u003emental health resources or drug and alcohol resources that it's not them getting in trouble\u003c/p\u003e\u003cp\u003eit's not some kind of punishment but it's actually here to help. Um, and maybe there being\u003c/p\u003e\u003cp\u003esome kind of like stigma as well of people, you know, using treatment in that kind of way\u003c/p\u003e\u003cp\u003etoo which I think kinda seeps into it. Um, you know they\u0026rsquo;re not wanting to be identified\u003c/p\u003e\u003cp\u003eas, you know, having a kid who has a problem or something like that.\u0026rdquo;\u003c/p\u003e\u003cp\u003eOne teacher attributed this hesitancy to a larger problem of a lack of trust: \u0026ldquo;we ultimately have to be on the same level playing field to say like, hey this is what we want for your student and you have to trust us on this. So how do you develop that trust when you have that natural barrier of language?\u0026rdquo; A police officer echoed this problem when stating, \u0026ldquo;It's a close-knit community, right? And they don't always want to let the police into that community\u0026hellip;Essentially, we help them get to a certain point as a solution, and as you know, \u0026lsquo;we will take it from here. We will handle it from within our community.\u0026rsquo;\u0026rdquo;\u003c/p\u003e\u003cp\u003eExternal stakeholders emphasized that bridging the communication gap was key to addressing AOD misuse. Police officers highlighted that having a Bhutanese police officer, for instance, was helpful for not just addressing language barriers but also educating law enforcement about Bhutanese culture and history. One officer stated, \u0026ldquo;we have Officer X [and] it's been a game changer. He\u0026rsquo;s like a celebrity within the community because he broke through this and he\u0026rsquo;s been great. Like it\u0026rsquo;s been phenomenal having him just because like he can- he\u0026rsquo;s helped us educate our guys as far as the community.\u0026rdquo; Through working with the Bhutanese officer, for instance, one police officer learned about negative experiences Bhutanese had with law enforcement in refugee camps and how that contributed to barriers to building trust. Ultimately, community partnerships were seen as the key to AOD misuse prevention and intervention: \u0026ldquo;If we have the government coming to them with the way things should be, it\u0026rsquo;s not gonna be received. If you have the community developing the plan and implementing it within themselves, it\u0026rsquo;s gonna be trusted and implemented.\u0026rdquo;\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eQualitative findings included three themes relevant to understanding AOD misuse among Bhutanese youth and young adults living in central Pennsylvania. Pre- and post-migration experiences and Bhutanese cultural dynamics around AOD use contributed to misuse; these macro-level factors could also influence family dynamics and functioning. Additionally, barriers to communication and trust with external stakeholders and potential law enforcement, education, and social service partners led to reduced effectiveness in AOD misuse prevention and intervention efforts. Participants emphasized, however, that the same community dynamics that acted as risk factors for AOD misuse could also be, and were, leveraged as protective factors in the community.\u003c/p\u003e\u003cp\u003eOur findings align with prior research focused on AOD misuse among other migrant youth populations. As with other migrant communities, family conflict was viewed as a risk factor for AOD misuse (Posselt et al., 2015), and youth used substances as a way to cope with post-migration stressors (Aleer et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Kenin et al (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2025\u003c/span\u003e) indicated mixed findings on family cohesion and collectivist cultural values as risk or protective factors for AOD misuse among migrant youth. Our work suggests that these mixed findings may be because these factors are in fact both; Bhutanese family cohesion and collectivist culture could play a role in promoting prevention and intervention, but also increase access and use of AOD. Specific to Bhutanese, prior research on this topic highlights the role post-migration stressors and greater access to AOD use play in AOD misuse (Mirza 2018; Watson et al., \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Additionally, Watson et al (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) found that peer influence and challenges to parenting youth in the US contributed to the problem. Our research extends these findings by speaking directly with Bhutanese youth and young adults to hear their perspectives on contentious family relationships; our findings suggest that familial expectations and breakdowns in parent-child communication are key to understanding this issue. In addition, this study brings more nuance to understanding AOD misuse within the Bhutanese cultural context, emphasizing the role stigma around both AOD misuse and co-occurring mental health problems plays in stifling family and community discussions and intervention.\u003c/p\u003e\u003cp\u003eFinally, this study provides support for the transnational theory of cultural stress and AOD misuse. The Bhutanese historical refugee life experience is relevant for understanding current youth and young adult functioning in a post-resettlement environment. Life in refugee camps in Nepal and the decision to come to the US motivated parental hopes and expectations for their children. It is important to emphasize that youth and young adults were not ignorant or dismissive of the hardships family members faced prior to coming to the US; rather, youth struggled to balance respecting and honoring this past and finding their own path forward in the US.\u003c/p\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eLimitations\u003c/h2\u003e\u003cp\u003eThere are several limitations to this study. First, participants may not be representative of Bhutanese with a refugee life experience elsewhere in the US or other countries of resettlement. Likewise, the external stakeholders that participated in the research may not reflect the views and experiences of educators, social service providers, and law enforcement in other locations. This is because study participants were recruited in one community in central Pennsylvania. Furthermore, despite the large size of the community, some participants had pre-established social relationships with RAs who conducted the interviews and focus groups. This means participants may have felt pressure to provide desired responses or withheld information. Extensive training was done with RAs around this issue to try to minimize bias in participant responses.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eImplications\u003c/h2\u003e\u003cp\u003eDespite these limitations, our findings have implications for AOD misuse prevention and intervention in the Bhutanese community. Overall, there is a need to prioritize: 1) addressing stigma around AOD misuse and mental health; 2) psychoeducation on the consequences and impact of AOD misuse; 3) improving access to culturally-appropriate individual counseling and family services, and 4) strengthening relationships with and educating external stakeholders on the community\u0026rsquo;s cultural norms and practices. Stigma around AOD misuse in the Bhutanese community is part of a larger issue of community reluctance to talk about mental health challenges and accessing behavioral health services (Poudel-Tandukar et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Soukenik et al., \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). While broadly speaking there is stigma around AOD misuse in the Bhutanese community, youth and young adults highlighted that there are complex patterns, perceptions, and attitudes about AOD use and misuse based on ethnicity and caste. While alcohol in particular is more acceptable and less stigmatized in some subgroups of the community, there is a perceived higher risk of AOD misuse among subgroups in which alcohol consumption has been historically prohibited. Cultural shifts in AOD norms after resettlement and the emergence of a younger generation that grew up in an environment in which alcohol and drugs are much more accessible than in the past may mean that addressing stigma will require bridging significant age and generational gaps in the community. Additionally, prevention and educational initiatives designed to address stigma may need to be tailored to ethnic and religious subgroups, as opposed to using a one size fits all approach. Given the diversity of AOD use practices in the community, stigma initiatives should include basic psychoeducation on the bio-psycho-social impact of AOD misuse as well as US laws and potential legal consequences of misuse, as knowledge on these topics may be limited.\u003c/p\u003e\u003cp\u003eCulturally appropriate AOD services means access to prevention and intervention services that are both linguistically accessible and integrate ethnic-Nepali beliefs and norms about mental health and AOD misuse (Corpus-Espinosa et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). Increasing the number of Nepali-speaking and bicultural service providers and translating psychoeducation material into Nepali are essential steps to mitigate youth risk in this community and build a better relationship between healthcare providers and the community at large. Beyond this, evidence-based AOD services for Bhutanese youth should be adapted to resonate with the post-migration experience of this generation. There exists an impressive body of work on ethnic-Nepali concepts of distress and mental health, and the psychosocial needs of the ethnic-Nepali Bhutanese population in particular, that can be drawn upon in this effort (Kohrt \u0026amp; Hruschka, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2010\u003c/span\u003e; Kohrt et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; Chase \u0026amp; Sapkota, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Chase et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). Research has identified promising interventions adapted to the unique needs of the Bhutanese refugee life experience, particularly as it relates to family functioning (Betancourt et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Other family-based AOD interventions have been culturally adapted to meet the needs of immigrant youth and families, emphasizing sensitivity to stressors associated with immigration, building social support for immigrant families, and psychoeducation for parents (Li et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2024\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eExternal stakeholders understood that developing a collaborative relationship with the Bhutanese community was key in addressing AOD misuse. A first step in growing these partnerships is increasing knowledge on Bhutanese history, culture, and AOD norms and beliefs among these external partners. In the process of conducting this study, our research team found that police and probation officers, educators, and AOD counselors were genuinely curious and interested in learning more about the Bhutanese community. Ethnic-Nepali Bhutanese self-help organizations can identify individuals that can act as liaisons between the community and these external groups, with a focus on bi-directional information exchange. Our findings suggest that as much as external stakeholders need to learn more about the Bhutanese community, the Bhutanese community also needs to learn more about the work and intentions of external partners.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eAOD misuse among youth and young adults in the ethnic-Nepali Bhutanese community is influenced by complex cultural dynamics and the pre- and post-migration experiences of youth and adults. Forced migration has an impact on the psychosocial wellbeing of individuals, families, and the entire community, even among a younger generation that may have limited memories of life in a refugee camp in Nepal before coming to the US. Interventions should be led by the Bhutanese community and involve partnerships with external stakeholders, ensuring cultural appropriateness and sensitivity.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch5\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003e\u003c/h5\u003e\n\u003ch5\u003eThis work was supported by the College of Health, Lehigh University. We would like to thank study participants in the Greater Harrisburg, PA, region for sharing their thoughts and ideas on this topic. Special thanks to our community research team members Manju Gurung, Saurab Bhandari and Gayatra Dangal. Finally, we appreciate the input and feedback from members of Asian Refugees United and New American Youth Mental Health.\u003c/h5\u003e\n\u003cp\u003e\u003cstrong\u003eData Statement:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData is available from the corresponding author upon reasonable request\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by the College of Health, Lehigh University. The funding source had no role in the study design; in the collection, analysis and interpretation of data; in the writing of the articles; and in the decision to submit it for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFunding acquisition, conceptualization: RLF; Project administration and supervision: TM; Investigation and methodology: RLF and TM; Formal analysis: RLF, GB, KB, GH, KC; Writing - original draft: RLF, GB, KB, KC; Writing - reviewing and editing: RLF and TM\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of Competing Interests:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAuthors have nothing to declare\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of generative AI and AI-assisted technologies in the writing process:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGenerative AI and AI-assisted technologies were not used in the writing process for this paper\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAleer, E., Alam, K., Rashid, A., Mohsin, M., \u0026amp; Eacersall, D. 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(2022). An intersectional approach to problem drinking in the Nepali/Bhutanese community in Northeast Ohio. Human Organization, 81(1), 60-70.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[{"identity":"2ca2244e-9bcf-4e1a-877b-5614c43d3660","identifier":"10.13039/100008234","name":"Lehigh University","awardNumber":"N/A","order_by":0}],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Lehigh University","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Bhutanese, ethnic-Nepali, alcohol and drug misuse, youth, refugees","lastPublishedDoi":"10.21203/rs.3.rs-7566409/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7566409/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjectives\u003c/h2\u003e\u003cp\u003eThere is limited information on the dynamics of alcohol and other drug (AOD) misuse among refugee youth. Over 90,000 ethnic-Nepali Bhutanese refugees have resettled in the United States since 2008, and there is increasing concern for AOD misuse among youth and young adults. The objective of this research was to understand patterns of AOD misuse among Bhutanese youth and young adults (ages 14\u0026ndash;24) living in central Pennsylvania.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA total of 35 Bhutanese youth and adults participated in key informant interviews. A total of 47 individuals participated in 8 focus groups with Bhutanese parents, Bhutanese youth and young adults, AOD service providers, police and probation officers, Bhutanese business owners, and educators. Data were analyzed using thematic content analysis and informed by the Transnational Theory of Cultural Stress for Alcohol and Other Drug Misuse Risk.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eFindings focus on three themes. Issues related to Bhutanese history and culture included accessibility of AOD and community stigma. Specific to family dynamics, parental engagement, parent-child communication, and family cohesion acted as risk and protective factors. Finally, the theme of communication and trust with external stakeholders revealed that external stakeholders had difficulty engaging with the Bhutanese community and linking people to prevention and intervention services.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eFindings have implications for culturally-tailored approaches to address AOD misuse. Prevention initiatives need to include efforts within the Bhutanese community, with a focus on family functioning and addressing intergenerational conflict. Psychoeducation for other stakeholder groups is critical to facilitate culturally-sensitive responses to community needs and issues.\u003c/p\u003e","manuscriptTitle":"“Stuck in between two worlds”: Substance misuse among first generation ethnic-Nepali Bhutanese youth and young adults with a refugee life experience","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-09 11:37:02","doi":"10.21203/rs.3.rs-7566409/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6eae8d7c-1a64-4bed-8c05-1bfb0400ee7a","owner":[],"postedDate":"September 9th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":54387830,"name":"Psychiatry"}],"tags":[],"updatedAt":"2025-09-09T11:37:03+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-09 11:37:02","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7566409","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7566409","identity":"rs-7566409","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}