'They first killed his heart (then) he took his own life'. Part 1: A review of the context and literature on mental health issues for refugees and asylum seekers

Journey to Health: (Re) Contextualizing the Health of Canada's Refugee Population

Existing literature on refugee health has often focused exclusively on either the post-arrival or pre-arrival experience. We believe the totality of each individual social identity should be acknowledged, including life prior to becoming a refugee. Thus, health status must be contextualized within pre-arrival health status and living conditions, health-care access, flight experiences, combined with post-arrival status: a fluid journey-to-health arc. The following article offers a holistic view of refugee health as an outcome of the entirety of this journey captured in a series of in-depth interviews with long-term, established service providers in Hamilton, Ontario. Our findings illustrate the importance of viewing health issues within the context of time and space. Refugees embark on fragmented journeys, leading to multiple challenges for providers, such as limited case histories, the absence of documentation and cultural (in)competence in terms of practice.

Lethal hopelessness: Understanding and responding to asylum seeker distress and mental deterioration

The mental deterioration of the so called 'legacy caseload' (asylum seekers who arrived in Australia by boat between August 2012-December 2013) has become a national concern and is garnering international attention. Prolonged uncertainty is contributing to mental deterioration and despair. There have been at least 11 deaths by suicide since June 2014. Social support services have been limited and legal assistance in short supply; this is associated with lengthy delays with visa applications. Thwarted belongingness, purpose and identity, a shortage of available services, and barriers to legal support for processes attendant upon Refugee Status Determination increase the likelihood that the mental health of asylum seekers will deteriorate further, potentially developing into worsening decline, which will lead to increased self-harm and suicide. This article summarises recent suicide deaths in Australia, positing practical assistance and support for asylum seekers living in the community. Therapeutic engagement should be trauma-informed wherever possible, helping asylum seekers to reframe their sense of lethal hopelessness.

An Investigation into Suicides Among Bhutanese Refugees Resettled in the United States Between 2008 and 2011

An increase of Bhutanese refugee suicides were reported in the US between 2009 and 2012. This investigation examined these reported suicides in depth to gain a better understanding of factors associated with suicide within this population. The study employed 14 psychological autopsies to elicit underlying motivations and circumstances for self-inflicted death and to identify potential future avenues for prevention and intervention among refugee communities. Disappointment with current (un)employment, lack of resettlement services and social support, and frustrations with separation from family were believed to contribute to suicidal acts. Suicide within refugee populations may be connected with experiences of family withdrawal, integration difficulties, and perceived lack of care. It is important to assess the effectiveness of improving refugee services on the mental health of migrants. More research is needed in order to better understand, and respond to, suicide in resettled populations.

Exploring physical activity engagement and barriers for asylum seekers in Australia coping with prolonged uncertainty and no right to work

This paper explores the engagement in physical activity as a potential coping strategy for asylum seekers living in the Australian community without the right to work and with prolonged uncertainty, and benefits or barriers to undertaking such activity. Semi-structured in-depth interviews were held with 29 asylum seekers who had arrived to Australia by boat and were living in the community in the cities of Perth, Sydney or Melbourne in July-October 2013 after their release from immigration detention. The ratio of the numbers of men and women interviewed (23 men and 6 women) was comparable to the ratio of men and women who came by boat to Australia seeking asylum in 2012-2013. Nine participants reported that they participated in physical activity as a coping strategy. Seven other participants were so worried about their future and their families that they did not have the mental or physical energy to engage in physical activity. A further six wanted to participate in physical activity but faced a number of barriers to doing so. The seven remaining participants were either not asked about their physical activity engagement because they focused their discussion on other challenges or did not elaborate on why they were not engaging in physical activity. The findings suggest that physical activity, coupled with other coping strategies, are important for some asylum seekers in trying to manage the distress of being denied the right to work and living with prolonged uncertainty. In addition, these findings highlight the critical barrier that government policy plays in disabling engagement in physical activity, which further compounds social exclusion. This includes the lack of welfare support provided, which hinders people's financial ability to access activities and support in the community.

Living with the Choice: A Grounded Theory of Iraqi Refugee Resettlement to the U.S

Though the United States has become a place of increasing resettlement for refugees, particularly Iraqi refugees who have been forced to flee their homeland due to violence, persecution and civil unrest, little is known about Iraqi refugee resettlement in the United States, or the way in which resettlement impacts health and adjustment. A grounded theory study was conducted to develop a substantive theory of Iraqi refugee resettlement. Participants in the qualitative study included 29 Iraqi refugees and 2 community partners who participated in face-to face interviews. Data analysis and interpretation revealed fundamental concepts related to Iraqi refugee resettlement. Results of analysis showed that for Iraqis choosing to resettle here, the outcome is dichotomous: satisfaction or regret. The outcome is influenced by contextual factors as well as facilitating and hindering intervening conditions during the basic social process of resettlement transition. Each refugee's story is unique, yet all share common threads. This study allowed Iraqi refugees the opportunity to voice their personal experiences of resettling in America, and revealed life stories that inspire and illuminate a process that can guide health care delivery as they cope with the stresses of their journey. As a result, an in-depth storyline was established to explain the process of resettlement for Iraqi refugees. The development of this resettlement theory, grounded in Iraqi refugee experience, has the potential to guide nursing education, enhance the efficacy of practice, inform policy development and form the basis for research.

The mental health needs of refugee children: a review of literature and implications for nurse practitioners

PURPOSE

To review the current literature regarding the mental health needs of refugee children resettled in the United States and provide recommendations for clinicians working with refugee children and their families.

DATA SOURCES

An extensive review of journal articles published from research conducted in first-world countries such as the United States, the United Kingdom, Australia, the Netherlands, and Canada.

CONCLUSIONS

Review of the current literature suggests that while some refugee children will suffer poor mental health outcomes, such as post-traumatic stress disorder, depression, and anxiety, others may not. Several groups of researchers concluded that refugee children are actually a high functioning group. Many coping and protective factors as well as risk factors for poor outcomes have been identified by the research.

IMPLICATIONS FOR PRACTICE

Because many refugee children will experience adverse psychosocial outcomes during the resettlement period, it is essential that the mental health screenings be performed during each primary care visit. Nurse practitioners have the unique opportunity to make a difference in the lives of refugee children because they play a pivotal role in the assessment, screening, and referral of children for mental health services.

Participatory action research: practical strategies for actively engaging and maintaining participation in immigrant and refugee communities

In this research we examined the processes involved in implementing and maintaining a participatory action research (PAR) project by uncovering how theoretical PAR tenets hold up in the reality of a community-based project addressing immigrants' and refugees' mental health needs. Qualitative data from focus groups with these newcomers were analyzed for thematic content. Findings reveal that active participation is seen as the gateway into a PAR project, whereas knowledge attainment and empowerment are the stimuli for continued participation. The data also suggest that newcomers' motivations to participate in a PAR-oriented project might vary across ethno-cultural groups. Practitioners working in community-based initiatives would do well to appeal to the diversity of motivational factors, while endorsing individual and group strengths.

A Phenomenological Study on the Experience of North Korean Refugees

The purpose of this phenomenological study was to explore the experience of North Korean refugees living in South Korea. From the analysis of the participants' comments, six essences were identified: entrance to a new world after struggling for survival, unexpected shock and chaos, reconsidering the reasons for leaving North Korea, recovery from trauma, rebuilding meaning, and posttraumatic growth.

'They first killed his heart (then) he took his own life'. Part 2: Practice implications

This paper is the second in a two-part series dedicated to mental health needs of refugees and asylum seekers. Against a background of selective review of literature and context in paper 1, this paper describes practical steps in meeting the mental health needs of refugees and asylum seekers. Nurses see refugees and asylum seekers at the very point of their distress--often outside of or external to immigration detention facilities. Practical strategies are presented for the generation of trust and supportive counselling with implications drawn for nurses working across a range of practice settings, such as in accident and emergency departments, psychiatric clinics, community-health centres and as general practice nurses. Continuity and integration of mental health care is achieved by bridging discrete elements in the asylum seeker journey through legal reviews, news from home and ongoing psychosocial stressors, in the context of different episodes, interventions by different providers or changes in illness status. Also important will be actions that build resilience intrinsically over time, such as the asylum seeker's values, sustained supportive interpersonal relationships and therapeutic care plans.