Stretching a model to serve a community

March 25, 2016

Lal Nun Puii holds her 2-year-old daughter Bethany during a meeting with her home visitor from IRCO, Sivheng Ung.

Lal Nun Puii sits on the freshly-vacuumed carpet of her southeast Portland apartment, her bare feet curled to one side. Her flip flops are behind her, side-by-side, at the edge of the kitchen linoleum. 

Two-year-old Bethany sleeps against Lal Nun Puii’s chest, secured there by a hand-woven blanket tied snug into sling. 

It is the perfect kind of day to be a child asleep warm and safe; to never have known the terror of war or the pain of fleeing, as her mother did from Burma. Light from the heavy-lidded February afternoon filters in, defused by the early fade of day and by low clouds. There’s a steady hum of engines as commuters stream east along Division Street.

The apartment is immaculate; sparsely furnished -- mattresses stacked on the floor in a bedroom, a table and chairs pressed against the kitchen wall, a near row of metal lawn chairs pushed to one bare living room wall. Lal Nun Puii leans against a leather couch and smiles easily up at her guest, Sivheng Ung.

Ung, a Home Visitor from the Healthy Families team at IRCO, sits primly upright with both stockinged feet flat on the carpet. She flips through a manila folder decorated edge-to-edge in penciled phrases in the Zomi dialect, words she learned in sessions with Lal Nun Puii during the previous two years. 

Often Lal Nun Puii invites other Burmese mothers to come to her home visits and learn the lesson Ung brings. Then Lal Nun Puii’s husband comes home from the Zomi Community Church, where he’s as much a social worker as he is a pastor. He reads the information packets Ung leaves behind, and later he uses the material to prepare lectures in Zomi for his congregation. 

Today it’s just the two of them, quietly talking and frequently laughing at the words Bethany has learned.

“Oh my God!” and “What happened?” are some of Bethany’s favorite English phrases. But for prayers, she slips into Zomi. She can count to 10, asks for “water” and says, “mom, I love you.”

“She likes to talk a lot?” Ung asks.

“Yes, she talks a lot now,”  Lal Nun Puii says. 

“Good job,” Ung says, and gives Lal Nun Puii’s hand an unconscious pat. “You’re a good mom. You are good parents.”

Stretching the Model

Healthy Families is a Multnomah County program funded by the state with federal grants and based on a national model; the program pairs families with advocates who help them navigate the first three years of their baby’s life. 

“Our biggest return on investment is in early childhood health. That matters,” said Charlene McGee, deputy refugee health coordinator for Multnomah County. “You’re learning how to bond, connect, engage, and sooth your child. It normalizes your fears as a new mom, especially a new mom in a new country. You know that cliche that knowledge is power, the more you know, it helps you be a better parent.”

The Healthy Families team at IRCO works with more than 100 immigrant and Refugee families

McGee should know; she had a home visitor when her son was born. McGee came here as a refugee from Liberia. But unlike many refugees, she spoke English and had family nearby. 

Healthy Families was developed to serve English and Spanish-speaking single, low-income parents, families with a history of child abuse, substance abuse and domestic violence. Those aren’t always the central problems for refugee families; many of whom have survived other kinds of trauma. 

“The screening tool doesn’t ask questions about, ‘have you survived a war?’ Or about cultural isolation,” said Lizzie Fussell, who leads the county's Healthy Families program.

Oregon has implemented the home visiting model for two decades. But that model hasn’t kept up with the changes in state demographics. In 1990, one-in-10 babies in Oregon were born to foreign-born mothers, according to data from the Centers for Disease Control and Prevention National Center for Health Statistics. By 2013, that ratio had jumped to more than one-in-five.

Multnomah County serves about 600 families through the Healthy Families program; one of three initiatives, including the Nurse-Family Partnership and the Healthy Birth Initiative, that support new parents.

More than 100 of those families are immigrants or refugees, served through a partnership with the Immigrant and Refugee Community Organization (IRCO).  

“That team has been so creative in how they implement a mainstream program,” Fussell said of the IRCO home visitors, all of whom immigrated to the United States. They are Somali and Thai, Cambodian, Bosnian, Romanian, and Vietnamese. 

“The piece I think is so inspiring  is the creativity and real dedication of that team,” she said. “The model gives them the tools, but that team has done a great job making the model stretch.”

Families are asked to set goals for themselves; a U.S. born parent might complete the task in 10 minutes. But for a refugee family, the concept of goals might be new, and the same exercise takes two entire visits. It’s the job of a home visitors to connect new mothers with primary care and social services. For a refugee family, that can extend to translating the week’s mail, giving someone a primer on public transportation, or teaching someone how to use the dishwasher.

The national model focuses on the relationship between a home visitor and an individual family, and it measures impact by how that individual family thrives.  

But when Sivheng Ung works with Lal Nun Puii and her husband, she’s also directly reaching their community.  

“In many immigrant communities, working with the family goes beyond the parents - there are aunts and grandmas and cousins all caring for that child.  And when we think about protective factors for immigrants and refugees, two big ones are social support and having a strong sense of cultural identity,” Fussell said. “So what makes Sivheng’s work so incredible is that she is doing the Healthy Families parent-child model, but she’s also supporting a community level approach with Lal Nun Puii’s friends and neighbors. Those parents are being empowered to be leaders. They’re sharing information, but they’re also strengthening their relationship with each other.”


A Visitor
Lal Nun Puii was alone - entirely alone - when she stepped off a plane at Portland International Airport in 2012, another refugee of Burma’s oppressive military regime. 

But a local pastor named Muana Khuptong was there to greet her.  

Khuptong, who grew up in India and spoke several dialects, including Lusei and Zomi, had come to Oregon on a student visa in 2005. He earned a bachelor of theology at the Portland Bible College, then a master of arts in pastoral studies from Multnomah University. 

Because there are few English-speaking advocates who also speak  Zomi, he acted as a kind of volunteer social worker to that small but growing refugee community. Later he launched a Zomi-language Christian fellowship at the Glenfair Church is Northeast Portland. When Lal Nun Puii arrived in 2012, he offered her rides to doctor and social service appointments, and introduced her to other Zomi refugees. They became friends, and the next year, he asked her to marry him. Six months after that they were expecting their baby girl. 

Muana Khuptong and his wife Lal Nun Puii share the lessons they've learned from the Healthy Families program with members of their Zomi-speaking community

“I was a little nervous, but it was a blessing,” Khuptong said. 

Lala Nun Puii was taking English classes at IRCO, where staff told her about the Health Families program and introduced her to Sivheng Ung.

Ung also came to the United States, as a refugee from Cambodia, in 1979. She was lucky to bring with her a college degree and a command of English. She came with her younger brother and a friend who would later become her husband. Still, she said, it took her years to adjust. 

“When I came here there was no IRCO. I didn’t even know how to take a bus,” she said. “I spoke English, but it was still hard for me because of what I had been through.”

Ung launched a successful janitorial company, which she managed until 1997. That’s when she was recruited as a parent educator for IRCO. She later moved over to the Healthy Families team. The national trainers instruct new home visitors like Ung not to get emotionally involved; but for refugees serving other refugees, detachment is a foreign concept.

“You share your story and you show you care,” she said. “This is important because it helps people who get lost. You pluck someone from one place and put them in another country, a whole other culture, where you have a new system. You’re confused and really scared.”

Ung has 16 clients, and they come from all over the world, including Iraq, Tibet, China and Russia. She visits a family each week for six months, then twice a month until the child turns 3. Each of her manila case files becomes increasingly marked with common phrases and keywords in the family’s native language.

She rarely speaks the same language as her clients, and her heavily accented greetings in their own language makes them laugh. They do often share the trauma of war, violence, fleeing dictatorship. It gives her an insight into how to better communicate lessons. She doesn’t say, for example, you must make sure your kids brush their teeth.

“They escaped an authority that told them what to do, so you have to find another way to do it,” she said. “I talk about myself, my own experience. My kids had a lot of cavities. I talk about the cost of fillings, braces. It’s not that I’m telling you what to do. I’m sharing my experience with you.” 

The first time Ung visited Lal Nun Puii, she brought along an interpreter. Then Lal Nan Puii’s husband Khuptong interpreted for them. But after the first few visits, Kuptong and his wife decided they no longer wanted to use an interpreter; it would force Lal Nun Puii to learn English.

And so she did. During the next two years, Ung and her grew close.

“I had no experience with children,” Lal Nun Puii said. The way she was raised, children were reprimanded with a harsh tone and the swat of a hand. But Ung cautioned her about the United States system of child protection and gave her alternative ideas for discipline. They have discussed everything, from birth control and health insurance, to ways of preparing a squash.

One more year
This week they talk about encouraging Bethany to explore with her words and play.

Bethany wears pink polka dot pajamas, but she’s already changed twice, her mother says. When she wakes up, she’s sure to go back to her drawers and pull out some new outfit, like a dress from the Disney movie Frozen.

Ung smiles. “It’s good for her imagination,” she says. Then Ung brings out a clear container filled with bright plastic pieces - a game of assembling and disassembling parts. It’s tricky, and they laugh as they try it themselves.

IRCO's Sivheng Ung and her client Lal Nun Puii finish a Healthy Families session by trying out a new toy intended for 2-year-old Bethany.

“Talk to her as she plays,” Ung tells Lal Nun Puii, who nods. “And remember to thank her when you’re all done. You’ll play this with her every day, ok?” Lal Nun Puii nods again. The conversation turns to family planning. Ung asks when they think they’ll start trying for their second child, and that raises an uncomfortable topic.

“You know I can’t help you with your second,” Ung explains.  If she’s done a good job, Lal Nun Puii won’t have the same risk factors that qualified her for the program two years earlier. Lal Nun Puii looks up, and knits her brow. She opens her mouth, then closes it again. “Oh, you can’t?” 

“The program lets me help you for three years,” Ung says.

“Can I request you again?” She asks. It’s a conversation for another day; and they have another year before they must say good-bye. It won’t be easy. Ung has become like a mother to her. In fact, Lal Nun Puii says, she had a hard time when Ung went on a vacation to Cambodia for a month. Then she laughs at herself. They both stand; Ung has two more appointments this evening.

“I love you,” Lal Nun Puii says.

“I love you too,” Ung says and pulls mother and the still-sleeping Bethany into her arms. “See you in two weeks.”