Reducing refugee mental health disparities: a community-based intervention to address postmigration stressors with African adults

A Scoping Review of Instruments Used in Measuring Social Support among Refugees in Resettlement

This study aimed to systematically review current research on the application of existing social support scales in research with refugees in resettlement, assess their quality, and identify gaps in measurement to enhance research and practice. A scoping review was conducted on the extant literature published until March 2023. A team of researchers conducted search, sorting, and data extraction processes following best practices for scale development and validation. Of the 1185 studies collected from the search process, 41 articles were retained in the final analysis, from which 17 distinct social support instruments used in research with resettled refugees were identified. An assessment of all 17 instruments showed the presence of one or more limitations associated with construct, criterion, convergent, and/or discriminant validity. Test of reliability was assessed in all studies, with a range of 0.80 to 0.90. Our findings show that most of the research evaluating social support among resettled refugees is conducted without measurement instruments adequately validated in the resettlement context. This analysis highlights the need for rigorously developed social support scales that reflect the lived experiences, needs, and priorities of resettled refugees.

Place-based strengths and vulnerabilities for mental wellness among rural minority older adults: an intervention development study protocol

INTRODUCTION

Severe inequities in depression and its diagnosis and treatment among rural-dwelling, racial-minority and ethnic-minority older adults compared with their urban white counterparts result in cognitive impairment, comorbidities and increased mortality, presenting a growing public health concern as the United States (US) population ages. These inequities are often attributable to social and environmental factors, including economic insecurity, histories of trauma, gaps in transportation and safety-net services, and disparities in access to policy-making processes rooted in colonialism. This constellation of factors renders racial-minority and ethnic-minority older adults 'structurally vulnerable' to mental ill health. Fewer data exist on protective factors associated with social and environmental contexts, such as social support, community attachment and a meaningful sense of place. Scholarship on the social determinants of health widely recognises the importance of such place-based factors. However, little research has examined how they shape disparities in depression and treatment specifically, limiting the development of practical approaches addressing these factors and their effects on mental well-being for rural minority populations.

METHODS AND ANALYSIS

This community-driven mixed-method study uses quantitative surveys, qualitative interviews and ecological network research with 125 rural American Indian and Latinx older adults in New Mexico and 28 professional and non-professional social supporters to elucidate how place-based vulnerabilities and protective factors shape experiences of depression among older adults. Data will serve as the foundation of a community-driven plan for a multisystem intervention focused on the place-based causes of disparities in depression. Intervention Mapping will guide the intervention development process.

ETHICS AND DISSEMINATION

This study has been reviewed and approved by the University of New Mexico Health Sciences Center Institutional Review Board. All participants will provide informed consent. Study results will be disseminated within the community of study through community meetings and presentations, as well as broadly via peer-reviewed journals, conference presentations and social media.

The Correlates of Collective and Individual Trauma on Mental Health Outcomes Among Afghan Refugees: A Study of Sociodemographic Differences

Following the U.S. military's departure from Afghanistan, a significant number of Afghan refugees have resettled in the United States, presenting complex mental health challenges exacerbated by extensive traumatic exposure. This demographic is particularly affected by collective trauma due to war, genocide, and the loss of homeland. However, detailed investigations into the correlations between collective trauma and mental health outcomes among Afghan refugees are limited. This study sought to explore the relationship between collective trauma and mental health outcomes within the Afghan refugee population in the United States, paying particular attention to the influence of sociodemographic factors. Identifying subgroups at greater risk allows for the development of more targeted mental health interventions. The study surveyed 173 Afghan refugees employing snowball sampling, utilizing a cross-sectional design. Data collection was facilitated through online and in-person surveys in English, Dari, and Pashto. Key measures included the Harvard Trauma Questionnaire for individual trauma experiences, the Historical Loss Scale for collective trauma, the Historical Loss Associated Symptoms Scale for collective trauma symptoms, the Afghan Symptom Checklist-22 for mental health symptoms, and the Post-Migration Living Difficulties Scale for post-migration stressors. Statistical analyses involved Pearson's correlation for variable associations, with nonparametric Mann-Whitney U and Kruskal-Wallis tests conducted to assess sociodemographic impacts due to data's non-normal distribution. The analysis revealed significant variations in collective trauma and mental health outcomes across subgroups. Afghan women, minoritized ethnic groups, those who experienced extended displacement, and refugees with uncertain visa statuses reported higher collective trauma levels and worse mental health outcomes. Statistical significance was noted in the correlations between collective trauma and mental health symptoms (r = .53, p < .01) and between post-migration difficulties and mental health (r = .33, p < .01). The disparities in mental health outcomes based on sociodemographic characteristics were significant, with nonparametric tests showing clear distinctions across different groups (Kruskal-Wallis H = 14.76, p < .05 for trauma experience by visa status). This study emphasizes the critical need for mental health interventions that account for the complex experiences of collective trauma among Afghan refugees, especially among identified subgroups. Tailoring mental health services to address the specific needs highlighted through disaggregated data can enhance support for Afghan refugees in the United States. This research contributes to a deeper understanding of the relationship between collective trauma and refugee mental health, advocating for nuanced care strategies in resettlement environments.

Protocol of the study: Multilevel community-based mental health intervention to address structural inequities and adverse disparate consequences of COVID-19 pandemic on Latinx Immigrants and African refugees

The NIMH-funded Multilevel Community-Based Mental Health Intervention to Address Structural Inequities and Adverse Disparate Consequences of COVID-19 Pandemic on Latinx Immigrants and African Refugees study aims to advance the science of multilevel interventions to reduce the disparate, adverse mental health, behavioral, and socioeconomic consequences of the COVID-19 pandemic that are a result of complex interactions between underlying structural inequities and barriers to health care. The study tests three nested levels of intervention: 1) an efficacious 4-month advocacy and mutual learning model (Refugee and Immigrant Well-being Project, RIWP); 2) engagement with community-based organizations (CBOs); and 3) structural policy changes enacted in response to the pandemic. This community-based participatory research (CBPR) study builds on long-standing collaboration with five CBOs. By including 240 Latinx immigrants and 60 African refugees recruited from CBO partners who are randomly assigned to treatment-as-usual CBO involvement or the RIWP intervention and a comparison group comprised of a random sample of 300 Latinx immigrants, this mixed methods longitudinal waitlist control group design study with seven time points over 36 months tests the effectiveness of the RIWP intervention and engagement with CBOs to reduce psychological distress, daily stressors, and economic precarity and increase protective factors (social support, access to resources, English proficiency, cultural connectedness). The study also tests the ability of the RIWP intervention and engagement with CBOs to increase access to the direct benefits of structural interventions. This paper reports on the theoretical basis, design, qualitative and quantitative analysis plan, and power for the study.

Prevalence, comorbidities, and factors associated with prolonged grief disorder, posttraumatic stress disorder and complex posttraumatic stress disorder in refugees: a systematic review

BACKGROUND

The number of refugees worldwide is at an all-time high with many being exposed to potentially traumatic events and the loss of loved ones. The 11th revision of the International Statistical Classification of Diseases and Related Health Problems now includes prolonged grief disorder and complex posttraumatic stress disorder and revised criteria for posttraumatic stress disorder. An overview of these stress-related disorders among people who have become refugees is therefore needed. Consequently, we conducted a systematic review to determine prevalence rates, comorbidities, and associated factors for each of the disorders.

METHOD

We systematically searched PubMed, Web of Science, and PsycArticles to identify studies that reported prevalence rates, predictors or associated factors, and/or comorbid mental disorders for either (1) prolonged grief disorder, (2) posttraumatic stress disorder, or (3) complex posttraumatic stress disorder among refugees. The selection process followed the PRISMA guidelines.

RESULTS

A total of 36 studies met the inclusion criteria. Most of the studies were of high quality. There was substantial variation in prevalence rates by disorder, with prolonged grief ranging from 6 to 54%, posttraumatic stress disorder ranging from 0.4 to 80%, and complex posttraumatic stress disorder ranging from 3 to 74.6%. Pooled prevalence for posttraumatic stress disorder was estimated at 29.8% in treatment seeking samples and 9.92% in population samples. For complex posttraumatic stress disorder, it was estimated at 57.4% in treatment seeking samples and 7.8% in population samples. Posttraumatic stress disorder was among the most frequent comorbidities for prolonged grief disorder while depressive symptoms were the most frequently occurring co-morbidity across all three disorders. Sociodemographic variables, trauma exposure, and loss characteristics were associated with higher symptom severity. Postmigration living difficulties played an important role in prolonged grief and complex posttraumatic stress disorder.

CONCLUSION

The review revealed substantial differences in prevalence rates between the three studied disorders but underscored a very high prevalence of ICD-11 stress-related disorders among refugees. The identified associated factors point to subgroups that may be particularly at risk and establishes a foundational basis for targeted interventions and potential policy changes. Future research should incorporate longitudinal investigations and emphasize culturally sensitive assessments.

Predictors of mental health outcomes of three refugee groups in an advocacy-based intervention: A precision medicine perspective

OBJECTIVE

Precision medicine is an area with great potential for mental health, but has made limited gains prognostically in predicting effective treatments. For refugees exposed to violence, culture may be a crucial factor in predicting treatment outcomes.

METHOD

For this study, 290 participants from three regions (Afghanistan, the Great Lakes region of Africa, and Iraq and Syria) participated in a randomized controlled trial of an advocacy-based intervention. Emotional distress symptoms were measured prior to intervention, midintervention (3 months), postintervention (6 months), and follow-up (6 months after the end of intervention). Number of traumatic events, resource access, social support, and English proficiency were tested for potential predictive effects on intervention outcome.

RESULTS

Multilevel generalized linear models revealed that Afghans' (B = -0.259, SE = 0.108, p = .013), and Great Lakes Africans' (B = -0.116, SE = 0.057, p = .042) emotional distress symptoms improved as a function of the intervention, while Iraqis and Syrians showed no intervention effects. For Afghans, English proficiency (B = -0.453, SE = 0.157, p < .01) and social support (B = -0.179, SE = 0.086, p = .037) were most strongly correlated to emotional distress, while for Africans, resource access (B = -0.483, SE = 0.082, p < .001) and social support (B = -0.100, SE = 0.048, p = .040) were the strongest predictors of emotional distress.

CONCLUSIONS

Response to advocacy-based interventions and active ingredients may be influenced by culture; findings have implications for refugees and precision medicine. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

A Helping Hand Out of the River: Refugee Perspectives for Provider Engagement

Purpose

A growing number of refugee groups are seeking care within the U.S. health care system for medical, psychological, and social needs. Research is limited in understanding refugee-specific conceptualizations of helping relationships and provider characteristics that improve interactions in health systems. This study aimed to identify provider characteristics that facilitate engagement and helpfulness in a refugee-specific population from refugee participant voices to inform future practices of health care clinics.

Methods

Semi-structured interviews with refugee participants were conducted to assess 1) experiences moving on from difficult experiences, 2) engagement with the health system, and 3) provider characteristics that facilitated engagement and healing. Qualitative data were analyzed using a grounded theory approach.

Results

An emergent theory was revealed on refugee-defined provider characteristics that facilitated healing and engagement in the health system. Providers who support an individual's story to be told, show awareness of barriers to accessing resources and prioritization of addressing barriers, maintain cultural humility, and demonstrate compassion, empathy, warmth, and openness toward patient engagement were the primary characteristics that facilitated engagement and healing.

Conclusions

Utilization of engagement strategies by providers at the onset of treatment is critical to providing culturally sensitive health care. Nonspecific but essential provider characteristics are thought to improve relational dynamics, trust-building, and overall engagement in the U.S. health care system from the perspective of refugee participants.

The impact of postresettlement stressors and access to health care on health outcomes in recently resettled refugees in the United States

This mixed-methods study examines mechanisms connecting the deployment of economic, social, and health care resources to emotional distress and physical health outcomes. Examining such mechanisms is critical for informing strategies, policies, and other interventions for reducing health disparities and improving refugee health in the United States and other resettlement contexts. Data for this study were collected as part of a randomized control trial in a mid-sized city in the Southwestern United States. Two-hundred ninety recently resettled (< 3 years) refugee adults from 143 households were enrolled in the study (36.2% Afghan, 32.8% Iraqi/Syrian, and 31.0% Great Lakes African; 52% women). Qualitative interview data were collected via semistructured interviews. A longitudinal structural equation path model of quantitative data from three time points over 12 months tested hypotheses that emerged from qualitative findings. In semistructured interviews, refugees in the United States (a) attributed the development of worse or new physical health problems to postresettlement stressors related to financial instability and limited social support that contributed to their emotional distress and (b) reported several barriers to accessing health care in the United States, including insufficient knowledge of health care resources, inadequate patient-provider communication, and navigating complex American health insurance systems, all of which exacerbated their physical health problems. Guided by these qualitative findings, longitudinal quantitative data revealed that: (a) postmigration stressors were associated with emotional distress and poor self-reported physical health, (b) emotional distress mediated the association between postmigration stressors and global health satisfaction, and (c) emotional distress was negatively associated with global health satisfaction. Findings document stressors refugees experience in the context of the unique environment created by the American health care system and how these stressors contribute to poor physical health through increased emotional distress. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

A conceptual study on the relationship between daily stressors, stressful life events, and mental health in refugees using network analysis

Introduction

There is growing recognition that daily stressors, such as social and material deficiencies, can be highly detrimental to the mental health of refugees. These stressors are in addition to stressful life events, which have been widely studied in the context of migration and forced displacement. Despite increasing evidence for an ecological model, there is still no consensus regarding the conceptualization of these highly influential factors. In particular, the demarcation of daily stressors from stressful life events and the categorization of daily stressors require further examination in order to develop usable and accurate tools for researchers, design effective interventions for practitioners and assist politicians in designing meaningful policies.

Methods

To address these challenges, we used data from a sample of 392 unaccompanied young refugees from diverse backgrounds and employed network analysis to examine the relationships between daily stressors, stressful life events, and symptoms of depression, anxiety, and post-traumatic stress.

Results

Our findings highlight the significant relationship between daily stressors and mental health, particularly depression. Meaningful clusters of daily stressors include material stressors, social stressors, and social exclusion stressors.

Conclusion

Our results demonstrate the importance of considering daily stressors in the mental health of refugees and suggest that using a network approach offers a viable way to study these complex interrelationships. These findings have implications for researchers, practitioners, and policymakers in understanding and addressing the mental health needs of refugees.

Refugee Family Health Brokers' (FHBs') Experiences with Health Care Providers: A Thematic Analysis

BACKGROUND

The resettlement and post-resettlement quality of life of refugees is often marred by chronic health/mental health conditions. To adequately care for refugees suffering these conditions, a promising strategy is the use of refugee Family Health Brokers (FHBs). FHBs are safe and trusted family members functioning as intermediaries between one's family and health care providers. Although FHBs are known to positively influence health care utilization in their families, little is known about them and this aspect of their family caregiving role and experiences, particularly with health care providers, necessitating further research.

METHODS

Fourteen Bhutanese and three Bosnian refugee FHBs participated in a 2-hr focus group discussing their experiences with health care providers after being surveyed about their FHB role.

RESULTS

Thematic analysis yielded five themes centered around perceptions, knowledge, communication, behavior, and responsibilities reflective of FHBs' experiences, which can be understood as symptoms of existing structural inequalities.

CONCLUSIONS

FHBs primarily conveyed problems, struggles, and dilemmas they experienced more so than rewarding aspects of being an FHB. Suggestions are provided on how to avert these negative experiences from occurring and becoming barriers to developing allyship with FHBs in the context of existing structural inequalities.

Refugee mental health and the role of place in the Global North countries: A scoping review

Post-migration factors significantly influence refugee mental health. This scoping review looks at the role of place in refugee mental health. We included 34 studies in Global North high-income countries that elaborated on the place characteristics of facilities, neighbourhoods, urban and rural areas, and countries. While the role of place remains under-theorised, all studies reveal common characteristics that support a strong relationship between place of residence, refugee mental health and wellbeing outcomes in post-migration context. Given that refugees often have little or no choice of where they ultimately live, we suggest future research should focus on how characteristics of place co-constitute post-migration refugee mental health risks, protections, and outcomes.

Measuring Latinx/@ immigrant experiences and mental health: Adaptation of discrimination and historical loss scales

Migration processes encompass uncertainty, discrimination, racism, stigma, social isolation, lack of access to resources, fear of deportation, and family separation, having a critical impact on the health of Latinx/@ immigrants in the United States. It is essential to accurately measure the ways in which social, legal, economic, and political contexts impact mental health. This article discusses adaptation and use of discrimination and historical loss measures in a multilevel community-based advocacy, learning, and social support intervention (Immigrant Well-Being Project) with Latinx/@ immigrants in New Mexico, using participatory research approaches. Participants (n = 52) were recruited through community partner organizations and completed four qualitative and quantitative interviews over a 12-month period. The present analysis draws on the baseline quantitative data. Results show it is possible to adapt standardized measures of discrimination developed to assess the experiences of other racial/ethnic groups; however, the most common responses involved response options added by our research team. For the historical loss instrument, there was a high frequency of "never" answers for many items, suggesting that they were not relevant for participants or did not capture their experiences of loss. As with the discrimination measures, the items we added resonated the most with participants. The contexts of discrimination and loss for Latinx/@ immigrant populations are complex, thus the tools we use to measure these experiences and their impact on health must account for this complexity. This study contributes to these endeavors through involving community members in the conceptualization and measurement of discrimination and historical loss among Latinx/@ immigrants. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Geocultural variation in correlates of psychological distress among refugees resettled in the United States

Attention to cultural variability in mental health symptoms could inform intervention targets; however, this is currently a neglected area of study. This study examined whether the associations between common mental health disorder (CMD) symptoms and predictors of CMDs varied cross-culturally. Participants were 290 refugees from three geocultural regions (Afghanistan, Great Lakes region of Africa, and Iraq and Syria) who recently resettled in the United States and completed assessments of CMD symptoms and predictors. Multilevel generalized linear modeling was used to examine the interactions between correlates of depressive, anxiety, and posttraumatic stress disorder (PTSD) symptoms and each of the three cultural reference groups. Relative to refugees from other regions, Iraqi and Syrian participants demonstrated stronger associations between the number of reported traumatic experiences and both depressive, B = 0.01, SE = .003, p = .003, and anxiety symptoms, B = 0.01, SE = .003, p < .001; Afghan participants showed a stronger association between physical quality of life and PTSD symptoms, B = 0.02, SE = .011, p = .037; and African participants demonstrated stronger associations between gender and symptoms of all three CMDs, Bs = 0.11-.020, SEs = .04-.06, ps = .005-.008, and weaker associations between traumatic event exposure and CMD symptoms, Bs = -0.01--0.02, SEs = .003-.006, ps = .000-.002. CMD symptoms likely present differently across cultures, with various predictors more salient depending on cultural backgrounds and differential experiences that vary based on context. These findings have implications for cross-cultural assessment research and mental health.

The effects of social isolation stress and discrimination on mental health

Social isolation and discrimination are growing public health concerns associated with poor physical and mental health. They are risk factors for increased morbidity and mortality and reduced quality of life. Despite their detrimental effects on health, there is a lack of knowledge regarding translation across the domains of experimental research, clinical studies, and real-life applications. Here, we review and synthesize evidence from basic research in animals and humans to clinical translation and interventions. Animal models indicate that social separation stress, particularly in early life, activates the hypothalamic-pituitary-adrenal axis and interacts with monoaminergic, glutamatergic, and GABAergic neurotransmitter systems, inducing long-lasting reductions in serotonin turnover and alterations in dopamine receptor sensitivity. These findings are of particular importance for human social isolation stress, as effects of social isolation stress on the same neurotransmitter systems have been implicated in addictive, psychotic, and affective disorders. Children may be particularly vulnerable due to lasting effects of social isolation and discrimination stress on the developing brain. The effects of social isolation and loneliness are pronounced in the context of social exclusion due to discrimination and racism, during widespread infectious disease related containment strategies such as quarantine, and in older persons due to sociodemographic changes. This highlights the importance of new strategies for social inclusion and outreach, including gender, culture, and socially sensitive telemedicine and digital interventions for mental health care.

Mental health promotion among resettled Bhutanese adults in Massachusetts: Results of a peer-led family-centred Social and Emotional Well-being (SEW) intervention study

Family-centred interventions addressing sociocultural and emotional stressors promise to prevent mental health problems among refugees in the United States. Peer-led strategies are highly valued, as they engage communities and promote the sustainability of interventions. We assessed the effects of a peer-led family-centred Social and Emotional Well-being (SEW) intervention on preventive (coping, social networking and conflict resolution) and mental health outcomes (stress, anxiety and depression) among resettled Bhutanese adults in Massachusetts. We conducted a SEW intervention with a pre-intervention versus post-intervention (7-day) and follow-up (3-month) evaluation among 103 adults (50 families). The SEW is a culturally tailored 5-weekly session program that included health education, problem-solving and mind-body exercises to increase knowledge and skills regarding stress management and conflict resolution. We measured anxiety and depression using the Hopkins Symptom Checklist-25 and stress using Cohen Perceived Stress scales. Health-promoting behaviours were measured using validated scales. We used paired t-tests for continuous and McNemar tests for categorical variables. Mean scores significantly decreased from pre-intervention to post-intervention and follow-up for stress by 15% and 13.9%, anxiety by 20.9% and 25.1% and depression by 18.7% and 20.4% (all p's < 0.01). Mean scores increased from pre-intervention to post-intervention and follow-up for coping by 10% and 17.2%, and for community networking by 28% and 36.8% (all p's < 0.01). Generalised estimating equations showed a significant reduction in stress, anxiety, depression and improved coping, self-efficacy, family and community networking scored from baseline to follow-ups (all p's < 0.01). Our peer-led family-centred SEW intervention was associated with improved preventive and mental health outcomes among Bhutanese adults.

Refugee-related trauma patterns and mental health symptoms across three generations of Hmong Americans

Hmong adults who are Vietnam War refugees have been exposed to refugee-related trauma, but little is known about associations between patterns of trauma exposure and mental health outcomes in Hmong adults. We examined patterns of trauma exposure and mental health symptoms (i.e., somatization, depression, anxiety, and probable posttraumatic stress disorder [PTSD]) in three generations of Hmong adults (N = 219). Trauma exposure and probable PTSD were measured using the Harvard Trauma Questionnaire-Hmong Version. Somatization, depression, and anxiety symptoms were measured using the Brief Symptom Inventory. Latent class analysis (LCA) and auxiliary analysis of sociodemographic characteristics and mental health symptoms were performed. The best-fitting LCA model described three distinct classes: complex and pervasive trauma (60.3%), combat situation and deprivation trauma (26.0%), and low exposure to refugee-related trauma (13.7%). Participants in the complex and pervasive trauma class were the oldest, had the shortest U.S. residency, were the least proficient in English, and reported the most severe mental health symptoms; those in the combat situation and deprivation trauma class were the youngest, moderately proficient in English, and reported moderate mental health symptoms; and those in the low exposure to refugee-related trauma class were the most proficient in English, had the longest U.S. residency, and reported the least severe mental health symptoms. Our findings call for surveillance and a trauma-informed approach for Hmong elders with limited English proficiency, who have a high risk of experiencing accumulative effects of refugee-related trauma and are susceptible to poor mental health outcomes.

Innovative participatory bilingual data analysis with Latinx/@ immigrants: Language, power, and transformation

OBJECTIVE

The insights of Latinx/@ immigrants are essential to developing interventions that better address complex multilevel phenomena impacting mental health. Despite important advances in methods that genuinely embody participatory research practices, attention to collaborative data collection, analysis, and dissemination are limited. Our aim is to describe the development and implementation of research practices to address these gaps through an emphasis on and understanding of the centrality of language in collaborative research processes.

METHOD

Guided from the outset by community-based participatory research principles, our community-academic research partnership recognized the importance of developing and intentionally studying our collaborative processes. As part of an ethnographic interview study with 24 Latinx/@ immigrants, a community-university research team developed innovative methods, including practices related to research team meetings, data collection, analysis, and dissemination, which we documented through ongoing discussion and reflection.

RESULTS

The resulting participatory research processes were grounded in a theoretical framework of praxis and language and included six innovative and iterative stages: (a) Establishing the research team, (b) planning the interview process/data collection, (c) developing the data analysis methodology, (d) interpreting findings to adapt the intervention, (e) integrating results of the participatory process into the analysis, and (f) data analysis for dissemination.

CONCLUSIONS

A focus on praxis and language revealed how the language of research structures' power, meaning, feeling, collaboration, analysis, and transformation. We also found that bilingual participatory analytic processes have important implications with respect to achieving genuine inclusion in rigorous research that moves toward equity for Latinx/@ immigrants and other populations. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Peer-led family-centred problem management plus for immigrants (PMP-I) for mental health promotion among immigrants in USA: protocol for a pilot, randomised controlled feasibility trial

INTRODUCTION

Research is needed to investigate preventive strategies to reduce mental health burden and assess effective implementation among immigrants. Problem management plus (PMP) is a low-intensity multicomponent psychological intervention developed by the World Health Organization (WHO) that trained laypeople can deliver. PMP has been adapted as a prevention intervention and developed as PMP for immigrants (PMP-I), including psychoeducation, problem-solving, behavioural activations and mind-body exercise, to address immigrants' multiple stressors. This pilot trial aims to assess the feasibility and acceptability of PMP-I and provide a preliminary estimate of the difference between PMP-I versus community support services pamphlets on the primary outcomes of interest (stress, anxiety and depressive symptoms) to inform the design of a large-scale intervention.

METHODS AND ANALYSIS

The feasibility and acceptability of PMP-I will be assessed by measuring recruitment, session attendance, retention rates, programme acceptability and the fidelity of intervention delivery. This pilot trial will test preliminary effects of PMP-I vs community support services pamphlets in a randomised controlled trial (N=232 participants from 116 families (2 members/family); 58 families randomised to condition intervention or control) on stress, anxiety and depressive symptoms (primary outcomes), chronic physiological stress assessed in hair cortisol (secondary outcomes), and coping, family conflict resolution, and social networking (targets), with assessment at baseline, postintervention and 3-month postintervention. Eligibility criteria for the primary study participants include Bhutanese ≥18 years resettled in Massachusetts with a score of ≤14 on the Patient Health Questionnaire-9. All family members will be invited to participate in the family-based intervention (one session/week for 5 weeks). Multilevel modelling will compare the longitudinal change in outcomes for each treatment arm.

ETHICS AND DISSEMINATION

The Institutional Review Board of the University of Massachusetts Amherst approved this study (Protocol: 1837). Written informed consent will be obtained from all participants. The study results will be used to inform the design of a large-scale intervention and will be disseminated in peer-reviewed journals and conferences.

TRIAL REGISTRATION NUMBER

NCT04453709.

“Watching my family being killed by terrorists made me really depressed”: Mental health experiences, challenges and needed support of young internally displaced persons in northern Nigeria

Background

Over 3.9 million people have been displaced in Nigeria as a result of the over one-decade-long Boko Haram insurgency and about 2.1 million of this population are internally displaced within the country. Young internally displaced persons (IDPs) are at higher risk of mental illness such as depression, anxiety, post-traumatic stress disorder (PTSD) among others, however, there are sparse studies on this population. Therefore, this study explored the mental health experiences, challenges, and needed support for young internally displaced persons in Durumi and New Kuchingoro Internally Displaced Persons Camps in Nigeria.

Methods

This qualitative study was conducted among young IDPs in Durumi and New Kuchingoro IDP camps in Northern Nigeria. Fourteen (14) focus group discussions comprising 89 participants and 30 in-depth interviews with 30 participants were conducted with young IDPs. The interviews were in Hausa and Pidgin English, audio-recorded, transcribed, translated into English, and applied thematic analysis was done using MAXQDA Analytics Pro 2020

Results

A total of 89 participants consisting of 47 males and 42 females participated in the FGDs and IDIs. Five key themes emerged from the FGDs and IDI: (1) knowledge about mental health, (2) mental Health Experiences, (3) coping strategies, (4) availability of mental health and other health Support, and (5) needed support. Young IDPs had fair knowledge about mental healthcare. Participants reported their experience before displacement as being peaceful with members of the family together in a good environment while they experienced stress, trauma, shock, sadness, and symptoms of anxiety, depression, and PTSD during and post displacement. Personal coping strategies such as listening to music, engaging in sports, reading books, farming, and other economic activities were reported by participants. Participants reported the absence of structured and specialized mental health support in the IDP camps and solicited mental health, physical health, economic and educational support.

Conclusion

Young IDPs had negative experiences that led to symptoms of mental health disorders such as depression, anxiety disorders, PTSD among others with little or no access to quality mental healthcare. Hence, they require specialized and structured mental health support to lead healthy and productive lives. Policy and programs aimed at increasing access to mental health information and services for forced migrants are recommended.

A Scoping Review of Social Support Research among Refugees in Resettlement: Implications for Conceptual and Empirical Research

This study reviewed social support research with refugees in resettlement by assessing the scope of scholarship and examining methodological approaches, definitions, theoretical frameworks, domains, and sources of support. The scoping review followed a systematic approach that retained 41 articles for analysis. The findings indicate that refugee resettlement studies seldom conceptualizes social support as a central focus, defines the concept, draws from related theory, or examines multifaceted components of the construct. The review nevertheless yielded promising findings for future conceptual and empirical research. The analysis identified a wide range of relevant domains and sources of social support, laying the foundation for a socio-ecological model of social support specific to refugee experiences in resettlement. The findings also indicate an imperative to examine and theorize social support vis-à-vis diverse groups as a main outcome of interest, in connection to a range of relevant outcomes, and longitudinally in recognition of the temporal processes in resettlement.

Trauma Healing Club: Utilizing Culturally Responsive Processes in the Implementation of an After-School Group Intervention to Address Trauma Among African Refugees

The State of Tennessee granted appropriations to an urban university in the West Tennessee region to address the needs of at-risk African refugee children and families who have experienced Adverse Childhood Experiences (ACEs). Action oriented research efforts were conducted to address the needs of youth in the local region by developing, implementing, and evaluating a community-based intervention that was not only trauma responsive but culturally competent. The Trauma Healing Club was a treatment package developed and researched for this purpose and offered in an after school support program. This identified intervention utilized an existing evidence-based trauma intervention framework that was adapted to include more culturally responsive processes such as pyramid mentoring and African drumming. This work aimed to evaluate the effectiveness of an integrated trauma-informed practice model for community-based programming and the effectiveness of adapting an existing intervention to better fit the community needs. Results indicated that the adaptation of the trauma-responsive intervention was effective and supportive of the child-participant and his/her family needs -both culturally and as it relates to improved participant functioning post intervention.

The Community as the Unit of Healing: Conceptualizing Social Determinants of Health and Well-Being for Older American Indian Adults

Background and Objectives

Multiple racial and social inequities shape health and access to health care for American Indian Elders, who have a lower life expectancy than all other aging populations in the United States. This qualitative study examines how upstream social determinants of health influence Elders’ ability to access and use health care.

Research Design and Methods

Between June 2016 and March 2017, we conducted individual, semistructured interviews with 96 American Indian Elders, aged 55 and older, and 47 professionals involved in planning or delivering care to Elders in 2 states in the U.S. Southwest. Transcripts were analyzed iteratively using grounded theory approaches, including open and focused coding. A group of American Indian Elders and allies called the Seasons of Care Community Action Board guided interpretation and prioritization of findings.

Results

Participants described multiple barriers that hindered Elders’ ability to access health care services and providers, which were largely tied to funding shortages and bureaucratic complexities associated with health care and insurance systems. Where available, community resources bridged service gaps and helped Elders navigate systems.

Discussion and Implications

Longstanding structural inequities for American Indians manifest in barriers to health equity, many of which are situated at the community level. These are compounded by additional disparities affecting older adults, rural residents, and marginalized citizens in general. Findings underscore the importance of health and policy initiatives for American Indian Elders that emphasize the community as the focus of intervention.

Health professionals' experiences of and attitudes towards mental healthcare for migrants and refugees in Europe: A qualitative systematic review

Migrants living in Europe constitute over half of the world's international migrants and are at higher risk of poor mental health than non-migrants, yet also face more barriers in accessing and engaging with services. Furthermore, the quality of care received is shaped by the experiences and attitudes of health professionals. The aim of this review was to identify professionals' attitudes towards migrants receiving mental healthcare and their perceptions of barriers and facilitators to service provision. Four electronic databases were searched, and 23 studies met the inclusion criteria. Using thematic synthesis, we identified three themes: 1) the management of multifaceted and complex challenges associated with the migrant status; 2) professionals' emotional responses to working with migrants; and 3) delivering care in the context of cultural difference. Professionals employed multiple strategies to overcome challenges in providing care yet attitudes towards this patient group were polarized. Professionals described mental health issues as being inseparable from material and social disadvantage, highlighting a need for effective collaboration between health services and voluntary organizations, and partnerships with migrant communities. Specialist supervision, reflective practice, increased training for professionals, and the adoption of a person-centered approach are also needed to overcome the current challenges in meeting migrants' needs. The challenges experienced by health professionals in attempting to meet migrant needs reflect frustrations in being part of a system with insufficient resources and without universal access to care that effectively stigmatizes the migrant status.

Social and Emotional Wellbeing (SEW) Intervention for Mental Health Promotion Among Resettled Bhutanese Adults in Massachusetts

Preventative behavioral interventions aimed at reducing mental problems among refugees are limited. We assessed the effect of a Social and Emotional Wellbeing (SEW) intervention on health-promoting behaviors (coping, social-networking, and conflict-resolution) and health-outcomes (stress, anxiety, and depression) among resettled Bhutanese adults in Western Massachusetts. The study was a community-based SEW intervention with pre-posttest evaluation among 44 Bhutanese adults in Western Massachusetts. The SEW is a culturally tailored 5-week, once-weekly health-education, problem solving, and mind-body exercise program to promote stress management skills. We used validated scales to measure outcomes. Mean scores of mental problems decreased by 5.9 for depression, 9.0 for anxiety, and 5.0 for stress post-intervention (p < 0.01). Mean scores increased by 27.3 for coping, 10.6 for social support, and 20.4 for conflict-resolution. Mean social-network scores increased by 4.6 for family, 4.7 for friends, and 1.8 for community networks (p < 0.01). Our Bhutanese participants reported improvement in their mental health after attending SEW intervention.

Protocol for a caregiver psychosocial support intervention for populations affected by displacement in Uganda

BACKGROUND

Child psychological distress in refugee settings is a significant public health concern, which is exacerbated by poor caregiver mental health and functioning. However, there are limited studies about effective interventions to improve caregiver mental health in support of child wellbeing. The objective of the current study is to evaluate the effectiveness and implementation of the Journey of Life (JoL) intervention to improve caregiver mental health in a refugee camp in Western Uganda.

METHODS

A waitlist-control quasi-experimental design is being implemented in the Kiryandongo refugee settlement (intervention n = 600, control n = 600). Caregiver mental distress, measured using the Kessler-6, was selected as the primary outcome. Secondary outcomes include (a) functioning measured by the World Health Organization Disability Assessment Schedule, (b) social support measured by the Medical Outcomes Study Social Support Survey, and (c) caregiving behaviors according to the Parental Acceptance and Rejection Questionnaire and the Child Protection Index. The study aims to examine the implementation of the JoL intervention through qualitative assessments of intervention feasibility, adaptations, and reach.

DISCUSSION

This trial will add much-needed evidence for the implementation of caregiver psychosocial programming within the humanitarian community. Findings will be disseminated amongst local, regional, and global actors in order to guide potential scale up within humanitarian settings.

TRIAL REGISTRATION

Clinical Trials NCT04817098 (Registered: 3/24/21).

Latinx/@ immigrant inclusion trajectories: Individual agency, structural constraints, and the role of community-based organizations in immigrant mobilities

Immigration is at the forefront of national, state, and local policy struggles in the United States, and Latinx/@ immigrants have experienced increased deportations, detention, and individual threats. A mobilities perspective allows analysis to extend our view of migration beyond frameworks confined to pre- and postmigration, examining trajectories of social inclusion and exclusion that are influenced by multiple factors in the receiving country. The Immigrant Well-being Project, a community-based participatory research project involving university faculty, students, staff, and representatives from 4 community-based organizations (CBOs), was initiated in New Mexico in 2017 to better understand and promote Latinx/@ immigrant mental health and integration by creating change at multiple levels. We began these efforts by conducting an in-depth study of the mental health needs, stressors, current socioeconomic, legal, and political context, and local solutions as experienced by 24 Latinx/@ immigrants and their mixed status families. Five trajectories of immigrant integration emerged: continuous exclusion, simultaneous exclusion and inclusion, continuous inclusion, movement from exclusion to inclusion, and movement from inclusion to exclusion. These diverse mobilities were shaped by participants' social locations, agency, and experiences with CBOs, which played critical roles in creating, maintaining, and/or transforming immigrants' trajectories. However, CBOs could not completely buffer immigrants from the current hostile climate and related stressors that resulted in experiences of exclusion or movement from inclusion to exclusion. These findings add to understandings of immigrant mental health, complex ongoing mobility, and mechanisms of resilience and resistance within the United States and have important implications for policy and practice. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Reducing loneliness among migrant and ethnic minority people: a participatory evidence synthesis

Background

To date, there has been little research into the causes of, and solutions to, loneliness among migrant and ethnic minority people.

Objectives

The objectives were to synthesise available evidence and produce new insights relating to initiatives that aim to address loneliness among these populations, plus the logic, functioning and effects of such initiatives.

Data sources

Electronic database searches (MEDLINE, Applied Social Sciences Index and Abstracts and Social Science Citation Index via Web of Science – no date restrictions were applied), grey literature searches, and citation and reference searching were conducted. Data were generated via nine workshops with three consultation panels involving 34 public contributors, and one practitioner workshop involving 50 participants.

Review methods

Guided by ‘systems thinking’, a theory-driven synthesis was combined with an effectiveness review to integrate evidence on the nature and causes of loneliness, interventional types and programme theory, and intervention implementation and effectiveness.

Results

The theory review indicated that common conceptualisations of ‘loneliness’ can be usefully extended to recognise four proximate determinants when focusing on migrant and ethnic minority populations: positive social ties and interactions, negative social ties and interactions, self-worth, and appraisal of existing ties. A total of 170 interventions were included. A typology of eight interventions was developed. Detailed logic models were developed for three common types of intervention: befriending, shared-identity social support groups and intercultural encounters. The models for the first two types were generally well supported by empirical data; the third was more tentative. Evaluation of intervention processes and outcomes was limited by study content and quality. Evidence from 19 qualitative and six quantitative studies suggested that social support groups have a positive impact on dimensions of loneliness for participants. Evidence from nine qualitative and three quantitative studies suggested that befriending can have positive impacts on loneliness. However, inconsistent achievements of the befriending model meant that some initiatives were ineffective. Few studies on intercultural encounters reported relevant outcomes, although four provided some qualitative evidence and three provided quantitative evidence of improvement. Looking across intervention types, evidence suggests that initiatives targeting the proximate determinants – particularly boosting self-worth – are more effective than those that do not. No evidence was available on the long-term effects of any initiatives. UK intervention (n = 41) and non-intervention (n = 65) studies, together with consultation panel workshop data, contributed to a narrative synthesis of system processes. Interlocking factors operating at individual, family, community, organisational and wider societal levels increase risk of loneliness, and undermine access to, and the impact of, interventions. Racism operates in various ways throughout the system to increase risk of loneliness.

Limitations

There was a lack of high-quality quantitative studies, and there were no studies with longer-term follow-up. UK evidence was very limited. Studies addressing upstream determinants operating at the community and societal levels did not link through to individual outcome measures. Some elements of the search approach may mean that relevant literature was overlooked.

Conclusions

Theory regarding the causes of loneliness, and functioning of interventions, among migrant and ethnic minority populations was usefully developed. Evidence of positive impact on loneliness was strongest for shared-identity social support groups. Quantitative evidence was inadequate. The UK evidence base was extremely limited.

Future work

UK research in this area is desperately needed. Co-production of interventional approaches with migrant and ethnic minority people and evaluation of existing community-based initiatives are priorities.

Study registration

This study is registered as PROSPERO CRD42017077378.

Funding

This project was funded by the National Institute for Health Research Public Health Research programme and will be published in full in Public Health Research; Vol. 8, No. 10. See the NIHR Journals Library website for further project information.

Randomized Controlled Trial of a Multilevel Intervention to Address Social Determinants of Refugee Mental Health

Understanding processes that support the well-being of the unprecedented numbers of forcibly displaced people throughout the world is essential. Growing evidence documents post-migration stressors related to marginalization as key social determinants of refugee mental health. The goal of this RCT was to rigorously test a social justice approach to reducing high rates of distress among refugees in the United States. The 6-month multilevel, strengths-based Refugee Well-being Project (RWP) intervention brought together university students enrolled in a 2-semester course and recently resettled refugees to engage in mutual learning and collaborative efforts to mobilize community resources and improve community and systems responsiveness to refugees. Data collected from 290 Afghan, Great Lakes African, Iraqi, and Syrian refugees at four time points over 12 months were used to test the effectiveness of RWP to reduce distress (depression and anxiety symptoms) and increase protective factors (English proficiency, social support, connection to home and American cultures). Intention-to-treat analyses using multilevel modeling revealed significant intervention effects for all hypothesized outcomes. Results provide evidence to support social justice approaches to improving refugee mental health. Findings have implications for refugees worldwide, and for other immigrant and marginalized populations who experience inequities in resources and disproportionate exposure to trauma/stress.

Community-Based Healthcare for Migrants and Refugees: A Scoping Literature Review of Best Practices

BACKGROUND

Strengthening community-based healthcare is a valuable strategy to reduce health inequalities and improve the integration of migrants and refugees into local communities in the European Union. However, little is known about how to effectively develop and run community-based healthcare models for migrants and refugees. Aiming at identifying the most-promising best practices, we performed a scoping review of the international academic literature into effective community-based healthcare models and interventions for migrants and refugees as part of the Mig-HealthCare project.

METHODS

A systematic search in PubMed, EMBASE, and Scopus databases was conducted in March 2018 following the PRISMA methodology. Data extraction from eligible publications included information on general study characteristics, a brief description of the intervention/model, and reported outcomes in terms of effectiveness and challenges. Subsequently, we critically assessed the available evidence per type of healthcare service according to specific criteria to establish a shortlist of the most promising best practices.

RESULTS

In total, 118 academic publications were critically reviewed and categorized in the thematic areas of mental health (n = 53), general health services (n = 36), noncommunicable diseases (n = 13), primary healthcare (n = 9), and women's maternal and child health (n = 7).

CONCLUSION

A set of 15 of the most-promising best practices and tools in community-based healthcare for migrants and refugees were identified that include several intervention approaches per thematic category. The elements of good communication, the linguistic barriers and the cultural differences, played crucial roles in the effective application of the interventions. The close collaboration of the various stakeholders, the local communities, the migrant/refugee communities, and the partnerships is a key element in the successful implementation of primary healthcare provision.

Improving Mental Health in Refugee Populations: A Review of Intervention Studies Conducted in the United States

Mental health is one of the most pervasive health concerns in the refugee population due to the combined effects of traumatic experiences prior to migration and post-migration stressors related to resettlement. The objectives of this systematic search were to synthesize evidence on the effectiveness and identify gaps of mental health interventions on mental health outcomes for refugees resettled in the United States. This review search identified a combination of quasi-experimental (7 studies) and qualitative research studies (5 studies). Twelve papers, published between 2003-2017, evaluating twelve different interventions, were selected for review. Studies were conducted in a variety of refugee populations: Africans (8), Southeast Asians (2), Bhutanese (1), and multicultural (1). Interventions included groups/workshops (10) and individual counseling (2). The results from the mental health interventions showed increases in health confidence, health seeking behaviors, consistency with treatment course, English proficiency, quality of life, and level of enculturation. Results also showed decreases in depression and psychological distress. Also identified from this review were different methods for interventions including linguistic and ethnically-matched facilitators versus non-matched facilitators, as well as group interventions versus non-group interventions. These differences were identified in the review and discovered to be areas for further research as these items were not often addressed in the literature.

Maternal perceptions of father involvement among refugee and disadvantaged families in Beirut, Lebanon

The role of fathers in (co-)parenting their children among refugee and disadvantaged families in low and middle-income countries (LMICs) remains poorly understood. This study sought to examine the associations among mothers' perceptions of their husband's involvement (hereafter referred to as paternal involvement), and her perceptions of her own well-being and a number of other variables, as well as observed mother-child interactions in families living in refugee and disadvantaged communities in Beirut, Lebanon. We analyzed baseline data from 104 mother-child dyads (mean age of children = 4.34 years; range = 2.05 to 7.93 years of age) who participated in a randomized controlled trial aimed at evaluating the impact of the Mother-Child Education Program in Beirut. In addition to the mother's perception of paternal involvement and the videotaped mother-child interactions, data were collected concerning the mother's well-being and her level of social support, as well as her level of stress as a parent and the way her children were disciplined in the family. Mother-child pairs were videotaped while completing a puzzle together and dyadic interactions were coded. Path analysis showed that paternal involvement was significantly associated with a higher level of maternal well-being and lower distress levels. In addition, higher levels of maternal distress were associated with higher levels of harsh discipline and parenting stress. Correlation analysis showed that higher perceptions of paternal involvement were associated with more positive affect displayed by the child, more positive regard for the child, and better mother-child synchrony during the dyadic interactions. Limitations include the cross-sectional design and the modest sample size, which hinder causal inferences and generalizability of the findings. These preliminary findings suggest that higher levels of paternal involvement may have an impact on markers of maternal mental health and positive mother-child interactions in families living in disadvantaged communities or humanitarian settings. Paternal involvement should be considered when designing and implementing parenting programs in LMICs.

A Review of Mental Health and Mental Health Care Disparities Research: 2011-2014

Racial/ethnic minorities in the United States are more likely than Whites to have severe and persistent mental disorders and less likely to access mental health care. This comprehensive review evaluates studies of mental health and mental health care disparities funded by the National Institute of Mental Health (NIMH) to provide a benchmark for the 2015 NIMH revised strategic plan. A total of 615 articles were categorized into five pathways underlying mental health care and three pathways underlying mental health disparities. Identified studies demonstrate that socioeconomic mechanisms and demographic moderators of disparities in mental health status and treatment are well described, as are treatment options that support diverse patient needs. In contrast, there is a need for studies that focus on community- and policy-level predictors of mental health care disparities, link discrimination- and trauma-induced neurobiological pathways to disparities in mental illness, assess the cost effectiveness of disparities reduction programs, and scale up culturally adapted interventions.

REFUGEE MENTAL HEALTH AND HEALING: UNDERSTANDING THE IMPACT OF POLICIES OF RAPID ECONOMIC SELF-SUFFICIENCY AND THE IMPORTANCE OF MEANINGFUL WORK

Although refugees who are accepted for resettlement in a third country are guaranteed certain rights and experience safety from war and persecution, they face many mental health challenges. Using qualitative methods and constructivist grounded theory, we explored culturally-specific perspectives on trauma and recovery among Burundian, Congolese and Iraqi refugees resettled in the United States. Eighteen semi-structured interviews provided extensive data on the meaning of productivity and work, the ways in which they index normalcy and self-sufficiency, and how they create security that facilitates the healing process. Our inductive analyses revealed that participants emphasized the relationship between productivity and healing when they described recovery from trauma. Participants also discussed individual and structural facilitators and barriers to work. Finally, prominent themes emerged around gendered roles and expectations and the ways these function in refugee resettlement contexts that are shaped by policies that demand rapid economic self-sufficiency. Taken together, these findings suggest that policies that promote underemployment and foreclose opportunities for education and professional development may contribute negatively to refugee mental health, as well as keep refugees in poverty.

A house is not a home: Modeling the effects of social support and connection within resettled refugee populations

AIM

The U.S. resettlement program currently resettles refugees in communities of similar or the same ethnic background known as like-ethnic communities. This practice provides resettled refugees with a familiar community who may be able to provide support through the difficult resettlement process. However, by associating with a like-ethnic community, resettled refugees may limit interaction with the host community, which may have subsequent adverse effects on well-being.

METHODS

This study examined whether satisfaction with community support is moderated by a premigration factor (trauma history) or a postmigration factor (English fluency) in predicting depressive symptoms in a resettled refugee community (N = 179). Four moderation models were analyzed and compared.

RESULTS

The model in which English fluency moderated the relationship between satisfaction with community support and depressive symptoms had the best overall model fit. In addition, trauma history was found to also be a meaningful but secondary moderator within this relationship. English fluency and trauma history within this study did not significantly interact.

CONCLUSION

These results highlight the importance of early English language lessons and community support during resettlement. Further, they emphasize the need to integrate refugees with individuals from similar backgrounds, as well as with host communities throughout resettlement.

Undocumented migrants' life situations: An exploratory analysis of quality of life and living conditions in a sample of undocumented migrants living in Norway

AIMS AND OBJECTIVES

To gather insight in conditions important to an understanding of undocumented migrants' life situations and more specifically to explore undocumented migrants' quality of life and how we can understand the various domains of quality of life related to demographics, living conditions, migration history and inflicted burden.

BACKGROUND

Undocumented migrants suffer from economic hardship and acculturative stress, limited psychological and social support and at the same time restricted access to health care and social welfare.

DESIGN

An exploratory mixed methods design using primarily quantitative data with a qualitative component was implemented.

METHODS

Sociodemographic data on 90 undocumented migrants were collected, and self-report questionnaires on quality of life and psychological distress were completed, supplemented by qualitative data obtained through interviews and additional qualitative questions. The STROBE checklist for cross-sectional studies was used for reporting this study.

RESULTS

Quality of life in our group of undocumented migrants was poor. Leaving their home country because of war or persecution, hunger, having experienced abuse, homelessness and higher age were statistically significantly associated with poorer quality of life. Having membership in a local association and having a partner were statistically significantly associated with better quality of life. Qualitative data indicate that marginal living conditions, fear of death and suffering and conditions associated with dependency were the main components comprising the burden to our respondents, reflecting their precarious juridical status as undocumented migrants.

CONCLUSION

Our respondents' poor quality of life was related to the complex interplay between possible exposures to traumatic experiences before and during flight and post-migration traumatisation in relation to our respondents' experiences of economic, social and acculturative hardship in Norway.

RELEVANCE TO CLINICAL PRACTICE

Responses called for to improve undocumented migrants' quality of life and eliminate barriers to their health care appeal more to nurses as a professional group and to those in positions of authority than each individual nurse on duty.

Immigrants Psychopathology: Emerging Phenomena and Adaptation of Mental Health Care Setting by Native Language

Mental health of immigrants is an important social and clinical issue. Immigrants may report higher rates of mental disorders and lower levels of use of mental health service with respect to natives. The aim of the present work is to review recent findings of the psychopathology of immigrants and analyze how to adapt the mental care settings through the use of mother tongues. We searched the literature to individuate and review the most recent scientific articles focused on the psychopathology of immigrants realized in Europe. Moreover, we summarized the guidelines about immigrants mental health care and we focused on the barriers caused by language. We individuated 15 papers reporting data about mental disorders among immigrants and the related risk and protective factors. The articles reported information about psychosis, depression, anxiety, post-traumatic stress disorder, somatization and suicide rates. Risk and protective factors are individuated mainly among social factors (e.g. ethnic density effect, hosting countries' policies). Furthermore, immigrants encounter language barriers in the use of mental care services. The realization of cross-cultural training and the development of a working alliance between clinicians and interpreters resulted to be effective solutions even if these interventions are not frequently implemented. The extent of migratory flows and the related difficulties experienced by immigrants require attention and well-informed interventions. The high rates of incidence of mental disorder and the strict number of services who implement interventions taking into accounts fundamental aspect as language show that there is still a lot to do.

The Psychological Consequences of Pre-Emigration Trauma and Post-Migration Stress in Refugees and Immigrants from Africa

Over 50 million people have been displaced, some as a result of conflict, which exposure can lead to psychiatric sequelae. The aims of this study were to provide estimates of pre-emigration trauma, post-migration stress, and psychological sequelae of immigrants and refugees from predominantly Sub-Saharan Africa who immigrated to Sweden. We also examined the predictors of the psychiatric sequelae as well as acculturation within the host country. A total of 420 refugees and immigrants were enrolled using stratified quota sampling. A battery of questionnaires including the Harvard Trauma Questionnaire, Post-Migration Living Difficulties Scale, the Cultural Lifestyle Questionnaire; and the Hopkins Checklist were administered. Descriptive statistics, Chi square analyses, Pearson correlations, analysis of variance, and logistic and linear regression were performed to test the aims of the study. Eighty-nine percent of participants reported at least one traumatic experience prior to emigration. Forty-seven percent of refugees reported clinically significant PTSD and 20 % reported clinically significant depressive symptoms. Males reported a significantly greater number of traumatic events [F(1, 198) = 14.5, p < 0.001] and post-migration stress than females [F(1, 414) = 5.3, p = 0.02], particularly on the financial, discrimination, and healthcare subscales. Females reported a higher prevalence of depressive symptoms when compared to males [F(1, 419) = 3.9, p = 0.05]. Those with a shorter duration in Sweden reported higher rates of PTSD [F(63, 419) = 1.7, p < 0.001]. The greater number of traumatic events was found to be significantly associated with the severity of PTSD symptoms [F(34, 419) = 9.6, p < 0.001]. Using regression analysis, 82 and 83 % of the variances associated with anxiety and depression, respectively, was explained by gender, education, religion, PTSD and post-migration stress. Sixty-nine percent of the variance associated with PTSD included education, number of traumatic events, depressive symptoms and post-migration stress. Forty-seven percent of the variance for acculturation was accounted for by a model that included age, education, duration in Sweden, anxiety, depression, and post-migration stress. These predictors were also significant for employment status with the exception of depressive symptoms. Multidimensional interventions that provide treatments to improve psychiatric symptoms in combination with advocacy and support to reduce stress (e.g., financial, access to health care) are recommended. The focus of the intervention may also be modified based on the gender of the participants.

"My World is Upside Down": Transnational Iraqi Youth and Parent Perspectives on Resettlement in the United States

The U.S. war with Iraq led to the displacement of millions of Iraqis, many of whom have resettled in the United States as refugees. We explore the challenges Iraqi families face after resettlement, with a particular focus on the agency of refugees and challenges/opportunities of familial social reproduction in a transnational context. We conducted 181 qualitative interviews with 38 Iraqis (11 youth, 27 adults) and 5 service providers. Our findings highlight the importance of exploring refugee agency and illuminate how the interplay between structure and agency in transnational contexts is a useful framework for understanding transformations around social roles.

Posttraumatic stress disorder and comorbid depression among refugees: Assessment of a sample from a German refugee reception center

In 2015, a large number of refugees arrived in Germany, mostly driven to emigrate by devastating circumstances in their countries of origin. Arriving refugees are distributed to reception centers within the German federal states, frequently facing marginal conditions in terms of overcrowding or waiting time of several months until their application for asylum is processed. Most of these refugees underwent numerous traumatizing experiences-both in their country of origin and while fleeing from their country of origin. Furthermore, they faced and will likely continue to face various access barriers to mental health care. In this study, we assessed a sample of 85 refugees from a reception center in Germany selected due to their observed psychological strain. Results showed that the majority suffered from posttraumatic stress disorder, mostly with symptoms of intrusion, hyperarousal, avoidance, and dissociation. Most refugees also suffered from comorbid depression. We discuss implications of these findings for reception services and the need for more preventive psychiatric care.

Exploring the relationship between postmigratory stressors and mental health for asylum seekers and refused asylum seekers in the UK

Numerous studies have linked the high rates of traumatic events experienced by refugees to the elevated rate of mental health problems in these populations. A growing body of evidence has also highlighted the importance of considering postmigratory stressors when making sense of displaced person distress. This study explored the relationship between mental health and postmigratory stress for asylum seekers and refused asylum seekers in Britain. The study further examined if those refused asylum experienced elevated distress and postmigratory stress compared to those awaiting the outcome of asylum applications. Results indicated that participants ( N = 97) had endured a range of pre- and postmigratory stressors and had high scores on measures of anxiety, depression, and PTSD. A postmigratory factor comprising items associated with isolation, restrictive policies, and stressors associated with having an insecure immigration status, was significantly associated with PTSD scores. This relationship remained when controlling for the variance accounted for by premigratory trauma predictors. Being refused asylum was the strongest predictor of depression and anxiety. Those refused asylum scored higher on a factor associated with barriers to accessing services. Social materialist theories of distress are drawn upon to contextualise the heightened vulnerability of those refused asylum. The paper concludes by emphasising the problems associated with taking an exclusively trauma-focussed approach when working with asylum seekers and argues for community orientated interventions to support displaced people to cope with the various stressors endured in exile.

A saúde mental dos refugiados: um olhar sobre estudos qualitativos

As experiências que levam pessoas a solicitarem refúgio envolvem fatores com potencial de desencadear desordens mentais. O objetivo desta revisão de literatura é apresentar o estado da arte sobre a saúde mental dos refugiados. O levantamento dos artigos foi realizado na coleção Social Science Citation Index® na Web of Science™. Foram identificados 35 estudos qualitativos em periódicos internacionais de 1993 a janeiro de 2016. A análise focou na saúde mental de refugiados adultos, na saúde mental de refugiados na infância e adolescência, e nos cuidados em saúde de refugiados. Houve um aumento desta produção nos últimos anos, e os estudos evidenciaram temas como: a diversidade cultural, a importância da família e das redes de apoio, a atuação dos profissionais envolvidos com estes grupos, a presença ou não de doença mental, as intervenções e o comprometimento com os direitos humanos.

The mental health of civilians displaced by armed conflict: an ecological model of refugee distress

Early research on the mental health of civilians displaced by armed conflict focused primarily on the direct effects of exposure to war-related violence and loss. Largely overlooked in this war exposure model were the powerful effects of ongoing stressors related to the experience of displacement itself. An ecological model of refugee distress is proposed, drawing on research demonstrating that mental health among refugees and asylum seekers stems not only from prior war exposure, but also from a host of ongoing stressors in their social ecology, or displacement-related stressors. Implications of this model for addressing the mental health and psychosocial needs of refugees and other displaced populations are considered.

Gendered Sources of Distress and Resilience among Afghan Refugees in Northern California: A Cross-Sectional Study

Recent studies have emphasized the influence of resettlement factors on the mental health of refugees resettling in developed countries. However, little research has addressed gender differences in the nature and influence of resettlement stressors and sources of resilience. We address this gap in knowledge by investigating how gender moderates and mediates the influence of several sources of distress and resilience among 259 Afghan refugees residing in Northern California (USA). Gender moderated the effects of four factors on levels of distress. Intimate and extended family ties have little correlation with men’s distress levels, but are strongly associated with lower distress for women. English ability is positively associated with lower distress for women, but not men. In terms of gender ideology, traditionally oriented women and egalitarian men have lower levels of distress. And experiencing greater dissonant acculturation increases distress for men, but not women. The influence of gender interaction terms is substantial and patterns may reflect difficulty adapting to a different gender order. Future studies of similar populations should investigate gender differences in sources of distress and resilience, and efforts to assist new arrivals might inform them of changes in gender roles they may experience, and facilitate opportunities to renegotiate gender roles.

Challenges and Innovations in a Community-Based Participatory Randomized Controlled Trial

Randomized controlled trials (RCTs) are a long-standing and important design for conducting rigorous tests of the effectiveness of health interventions. However, many questions have been raised about the external validity of RCTs, their utility in explicating mechanisms of intervention and participants' intervention experiences, and their feasibility and acceptability. In the current mixed-methods study, academic and community partners developed and implemented an RCT to test the effectiveness of a collaboratively developed community-based advocacy, learning, and social support intervention. The goals of the intervention were to address social determinants of health and build trust and connections with other mental health services in order to reduce mental health disparities among Afghan, Great Lakes Region African, and Iraqi refugee adults and to engage and retain refugees in trauma-focused treatment, if needed. Two cohorts completed the intervention between 2013 and 2015. Ninety-three adult refugees were randomly assigned to intervention or control group and completed four research interviews (pre-, mid-, and postintervention, and follow-up). Several challenges to conducting a community-based RCT emerged, including issues related to interviewer intervention to assist participants in the control group, diffusion of intervention resources throughout the small refugee communities, and staff and community concerns about the RCT design and what evidence is meaningful to demonstrate intervention effectiveness. These findings highlight important epistemological, methodological, and ethical challenges that should be considered when conducting community-based RCTs and interpreting results from them. In addition, several innovations were developed to address these challenges, which may be useful for other community-academic partnerships engaged in RCTs.

Afghan Refugee Explanatory Models of Depression: Exploring Core Cultural Beliefs and Gender Variations

Relatively little empirical attention has been paid to understanding how refugees conceptualize depression and how this concept varies between genders. The purpose of this study was to explore beliefs about depression among Afghans residing in San Diego County, California, using cultural consensus analysis. Using the prescribed mixed-method approach, we employed results from in-depth interviews to develop a culturally meaningful questionnaire about depression. Consensus analysis of responses to questionnaire items from 93 Afghans (50 men, 43 women) indicates shared beliefs that associates depression causality with mild traumatic experiences and post-resettlement stressors, symptomatology to include culturally salient idioms of distress, and treatment selections ranging from lay techniques to professional care. Divergence between genders occurred most in the symptoms subdomain, with women associating depression with more somatic items. This study contributes to understanding the etiology of and cultural responses to depression among this population, which is critical to improving culturally sensitive intervention for Afghan refugees.

"Seeing the Life": Redefining self-worth and family roles among Iraqi refugee families resettled in the United States

Social and geographic displacement is a global phenomenon that precipitates novel stressors and disruptions that intersect with longstanding familial and social roles. Among the displaced are war-torn Iraqi refugee families, who must address these new obstacles in unconventional ways. This study explores how such disruptions have influenced associations between gender and apparent self-worth experienced by Iraqi refugee families upon relocation to the United States. Further, the psychosocial mechanisms requisite of any novel approach to a new social construct are explored and reveal that production in the family is at the core of instability and shifting power dynamics during resettlement, preventing family members from "seeing the life" in the United States that they had envisioned prior to immigration. Over 200 semi-structured qualitative interviews with Iraqi participants and mental health providers were conducted over the course of the study, and demonstrate a plasticity among social roles in the family and community that transcends the notion of a simple role reversal, and illustrate the complex positionalities that families under stress must approximate during such physical and social displacement.