In or out? Barriers and facilitators to refugee-background young people accessing mental health services

Evaluating suicide prevention gatekeeper training designed to identify and support people from asylum-seeking and refugee backgrounds

BACKGROUND

Suicide-related behaviours and individual risk factors for suicide differ between ethnicities and demonstrate additional variation based on voluntary and forced migration. People forcibly displaced by violence and conflict, such as those seeking asylum and refugees, are likely to face stressors that can increase suicide risk. Research into evidenced-based suicide prevention strategies among people from asylum-seeking and refugee backgrounds is scarce. However, early, contextually-appropriate, identification and intervention may be a promising way to facilitate support for people in these groups. This research proposes that a contextually-responsive gatekeeper training is an appropriate strategy to increase the identification and support for people from asylum-seeking and refugee backgrounds.

METHODS

The present article relates to the statistical findings of a larger mixed-method study used to validate and refine a contextually-responsive gatekeeper training program. The qualitative results of this research will be published separately. The outcome measures - knowledge about suicide in multicultural contexts, attitudes towards suicide and prevention, and self-efficacy to intervene were measured quantitatively, adopting a similar pre- and post-training procedure used in previous training evaluations. Using Generalised Estimating Equations, statistical comparisons were made between three identical self-report surveys completed by participants across three consecutive time points - pre-training, immediately post-training, and three months following training completion - known in this investigation as time-point zero (T0), time-point one (T1), and time-point two (T2). Lastly, during the T2 follow-up, additional open-ended questions were included to understand which areas of training they feel prepared them effectively and how the program could have better prepared them to intervene.

RESULTS

A total of 28 participants took part in the study. Quantitative analysis indicated the program's capacity to exert a significant favourable and lasting influence on knowledge about suicide and self-efficacy to intervene. In addition, follow-up measurements suggest that the content delivered to participants transferred effectively into real-world suicide prevention behaviours.

CONCLUSIONS

Findings suggest that tailored suicide prevention training can have a significant influence on knowledge about suicide in multicultural contexts, self-efficacy to intervene in a crisis, and that course content translates effectively into real-world suicide prevention behaviour. Modifying training practices, based on feedback from contextually-experienced attendees, appears to be a pivotal factor in promoting the support of people from asylum-seeking and refugee backgrounds.

Inequalities in health literacy between European population and newly arrived male sub-Saharan migrants in Europe

Increases in migration pressure from sub-Saharan Africa to Europe have increased in recent years. Despite this trend, the health literacy needs of migrants in host communities have not been sufficiently studied. This research aims to explore the health literacy of migrants newly arriving in Europe and compare it with the health literacy levels of the European population, utilizing data obtained from the European health literacy survey. A convenience sampling cross-sectional study was conducted at the Temporary Immigrant Stay Center in Melilla (Spain) in June 2022 using a validated French and Arabic version of the 16-item European health literacy survey questionnaire. A total of 106 sub-Saharan migrants ≥ 18 years of age were surveyed. The general health literacy index of the migrants was 30.02 points (on a scale of 50), placing it in the 'problematic' level. Of the participants, 57.54% had a limited ability to obtain, understand and apply health information and make appropriate health-related decisions. The largest gap compared to European citizens was observed in skills to understand information related to disease prevention. These results reinforce that migrant status is a social determinant of low health literacy and suggest that health professionals should extend their educational role to this vulnerable group.

The Development and Validation of a Measure of Mental Health, Help-Seeking Beliefs in Arabic-Speaking Refugees

Despite reporting elevated rates of posttraumatic stress disorder (PTSD), refugees are less likely than other groups to seek psychological treatment. Relatively little attention has been paid to the role of negative help-seeking beliefs in influencing treatment uptake. The current study sought to develop and psychometrically validate a novel measure indexing negative help-seeking beliefs for refugees (Help-Seeking Beliefs Scale [HSBS]). In this study, 262 Arabic-speaking refugee participants completed an online survey consisting of the HSBS along with measures indexing similar constructs (self-stigma of PTSD and help-seeking, perceived stigma, negative help-seeking attitudes, and help-seeking intentions). Factor analysis revealed a three-factor structure aligning with key themes identified in the literature: (a) Fear of Negative Consequences, (b) Inappropriateness, and (c) Perceived Necessity. The scale demonstrated excellent internal consistency, convergent validity, and predicted reduced help-seeking intentions. Results support the utility of a novel measure capturing a prominent help-seeking barrier in a population with high psychopathology and low treatment uptake.

A qualitative study of negative sociocultural experiences of accessing primary health care services among Africans from refugee backgrounds in Australia: implications for organisational health literacy

BACKGROUND

Primary health care is the first point of contact for patients from refugee backgrounds in the Australian health system. Sociocultural factors, including beliefs and value systems, are salient determinants of health literacy and access to primary health care services. Although African refugees in Australia have diverse sociocultural backgrounds, little is known about the influence of sociocultural factors on their experiences of accessing primary health care services. Guided by the theoretical framework of access to health care, this study examined from the perspective of African refugees how culturally and religiously conditioned, constructed and bound health beliefs, knowledge and practices influence their experiences of access to, acceptance and use of primary health care services and information in Australia.

METHODS

This exploratory, qualitative study involved 19 African refugees from nine countries living in New South Wales, Australia. Semi-structured interviews were conducted and recorded using Zoom software. The interviews were transcribed verbatim and analysed using a bottom-up thematic analytical approach for theme generation.

RESULTS

Four main themes were identified. The themes included: participants' experiences of services as inaccessible and monocultural and providing information in a culturally unsafe and insensitive manner; the impact of the clinical care environment; meeting expectations and needs; and overcoming access challenges and reclaiming power and autonomy through familiar means. The findings generally support four dimensions in the access to health care framework, including approachability, acceptability, availability and accommodation and appropriateness.

CONCLUSION

African refugees experience significant social and cultural challenges in accessing primary health care services. These challenges could be due to a lack of literacy on the part of health services and their providers in servicing the needs of African refugees. This is an important finding that needs to be addressed by the Australian health care system and services. Enhancing organisational health literacy through evidence-informed strategies in primary health systems and services can help reduce disparities in health access and outcomes that may be exacerbated by cultural, linguistic and religious differences.

What Should Personalised Mental Health Support Involve? Views of Young People with Lived Experience and Professionals from Eight Countries

Research demonstrates that young people value mental health support that is tailored to their needs and preferences, rather than a "one size fits all" offer, which is often not equitably accessible (National Children's Bureau, 2021). Understanding young people's lived experiences across different sociocultural contexts is important. The aim of this research was to conduct an international qualitative study on the views of young people with lived experience and professionals, on proposed aspects of personalised support for anxiety and/or depression. Participatory action focus groups were conducted with N = 120 young people with lived experience of anxiety and/or depression (14-24 years) and with N = 63 professionals in Brazil, India, Kenya, Pakistan, Portugal, South Africa, Turkey, and the United Kingdom. Data were analysed using the rigorous and accelerated data reduction (RADaR) technique. Overall, although some country-specific differences were found in terms of what aspects of support young people found to be most important, individual preferences were considered stronger, furthering the view that support should be personalised to the needs of the individual young person. Young people experiencing anxiety and/or depression should be able to choose for themselves which aspects of support they would prefer in their own care and support plans, with families and mental health professionals providing guidance where appropriate, rather than removing the young person from the decision-making process altogether. It should also be ensured that the aspects of personalised support can be understood by young people and professionals from different contexts, including marginalised and minoritised groups and communities.

Starting conversations about mental health and wellbeing in Australian culturally and linguistically diverse communities

Australia is a multicultural nation with nearly 30% of the population born overseas. Migrants' mental health can be impacted by discrimination, racism and experiences relating to asylum and immigration. These can be compounded by low help-seeking caused by stigmatized beliefs and poor mental health literacy. My Mind, My Voice (MMMV) is a co-designed program aiming to promote awareness of mental health and wellbeing for people with a culturally and linguistically diverse (CALD) background. This research project explored the perceived impacts and value of MMMV and processes leading to those impacts. A mixture of internal quantitative and qualitative evaluation surveys (n = 32) and researcher-conducted semi-structured interviews (n = 9) were conducted with CALD organization and community members who attended training workshops, presented MMMV events or attended an event. Data were analysed using a reflexive thematic analysis approach. Five themes were developed: culturally relevant and respectful, cross-cultural connections, the importance of language, increasing confidence and literacy and the potential to change attitudes. Being involved with a co-produced program that was culturally relevant and respectful was a positive experience that enhanced people's confidence and literacy. Feeling respected, valued and validated helped participants feel empowered to develop and deliver mental health and wellbeing education in their community. Open, honest conversations are an important way to break down stigma and start conversations about mental health and wellbeing in CALD communities. Evaluation outcomes demonstrate the success of MMMV's collaborative approach, which can inform the development and evaluation of CALD mental health promotion interventions.

Culturally and Linguistically Diverse Community Access and Utilisation of the Mental Health Service: An Explanation Using Andersen's Behavioural Model

Andersen's Behavioural Model of Health Service Use (ABMHSU) is a multilevel model that helps understand the factors influencing health service access and utilisation. This framework is a widely used model for health service use in general, as well as in immigrant populations and vulnerable populations. ABMHSU, in this project, provided a framework to explain how the mental health nurses' cultural competence can influence the Victorian CALD community members' mental health care access and utilisation. A unique model of ABMHSU in the current multiple-method project provided a theoretical framework for examining the factors associated with people from the CALD community accessing mental health services in an Australian context to answer the research questions. The key findings of the research were discussed with reference to the extant literature and with triangulation of research results with the ABMHSU in the context of Victoria. The researchers argue that even though predisposing, enabling, and need factors are necessary to determine whether a person is selected for expert care for mental health issues, these factors alone are insufficient. Ongoing research is essential to ascertain the potential of mental health nurses' cultural competence education and cultural responsiveness in addressing the mental health service access and utilisation of the heterogeneous CALD communities. Additional research is advocated to identify the supplementary factors, as there is a dearth of research exploring the potential of ABMHSU worldwide.

New Brunswick's mental health action plan: A quantitative exploration of program efficacy in children and youth using the Canadian Community Health Survey

In 2011, the New Brunswick government released the New Brunswick Mental Health Action Plan 2011-2018 (Action Plan). Following the release of the Action Plan in 2011, two progress reports were released in 2013 and 2015, highlighting the implementation status of the Action Plan. While vague in their language, these reports indicated considerable progress in implementing the Action Plan, as various initiatives were undertaken to raise awareness and provide additional resources to facilitate early prevention and intervention in children and youth. However, whether these initiatives have yielded measurable improvements in population-level mental health outcomes in children and youth remains unclear. The current study explored the impact of the Action Plan by visualizing the trend in psychosocial outcomes and service utilization of vulnerable populations in New Brunswick before and after the implementation of the Action Plan using multiple datasets from the Canadian Community Health Survey. Survey-weighted ordinary least square regression analyses were performed to investigate measurable improvements in available mental health outcomes. The result revealed a declining trend in the mental wellness of vulnerable youth despite them consistently reporting higher frequencies of mental health service use. This study highlights the need for a concerted effort in providing effective mental health services to New Brunswick youth and, more broadly, Canadian youth, as well as ensuring rigorous routine outcome monitoring and evaluation plans are consistently implemented for future mental health strategies at the time of their initiation.

A scoping review into the service needs of people from culturally and linguistically diverse backgrounds living with disability to engage in meaningful occupations

INTRODUCTION

Although there is a large proportion of people from culturally and linguistically diverse backgrounds within Australia, their rate of access to disability services is disproportionately low. This review aims to understand the service needs of people from culturally and linguistically diverse backgrounds with disability to facilitate engagement in meaningful occupations.

METHODS

Arksey and O'Malley's scoping review framework was employed. Ten databases were searched for Australian studies. A deductive content analysis framework was applied in the synthesis.

RESULTS

Fourteen papers were included. Themes that emerged include language and cultural needs and considerations, which highlights the need for information sharing to take account of intergenerational, intercultural and sociolinguistic differences. It also identified the need for improved training and skills of existing interpreters. Culturally competent and responsive services was another theme identified, which emphasised the need to enhance the workforces' understanding of cultural practices. There is also a strong call for a more culturally diverse workforce to reduce the use of some interpreters and to build a more culturally competent workforce. The last theme was responsive service delivery, which requires the governance to support the development of a nurturing trusting therapeutic relationship.

CONCLUSIONS

Service providers should be trained on the inequities and intersectionality of this population. Further research is required to explore current disability policy in Australia with an intersectionality lens to ensure recommendations can be made to address barriers and ensure this population receives services in a manner that enhances their ability to engage in occupations meaningfully.

Developing a strategy to scale up place-based arts initiatives that support mental health and wellbeing: A realist evaluation of 'Arts for the Blues'

Place-based arts initiatives are regarded as rooted in local need and as having capacity to engage local assets. However, many place-based arts initiatives remain poorly funded and short-lived, receiving little attention on how to scale up and sustain their activities. In this study we make a unique contribution to knowledge about scaling up place-based arts initiatives that support mental health and wellbeing through focusing on the example of 'Arts for the Blues', an arts-based psychological group intervention designed to reduce depression and improve wellbeing amongst primary care mental health service users in deprived communities. Methodologically, we used realist evaluation to refine the study's theoretical assumptions about scaling up, drawing on the lived and professional experiences of 225 diverse stakeholders' and frontline staff through a series of focus groups and evaluation questions at two stakeholders' events and four training days. Based on our findings, we recommend that to scale up place-based arts initiatives which support mental health and wellbeing: (i) the initiative needs to be adaptable, clear, collaborative, evidence-based, personalised and transformative; (ii) the organisation has to have a relevant need, have an understanding of the arts, has to have resources, inspiration and commitment from staff members, relevant skillsets and help from outside the organisation; (iii) at a policy level it is important to pay attention to attitude shifts towards the arts, meet rules, guidelines and standards expected from services, highlight gaps in provision, seek out early intervention and treatment options, and consider service delivery changes. The presence of champions at a local level and buy-in from managers, local leaders and policy makers are also needed alongside actively seeking to implement arts initiatives in different settings across geographical spread. Our theoretically-based and experientially-refined study provides the first ever scaling up framework developed for place-based arts initiatives that support the mental health and wellbeing, offering opportunities for spread and adoption of such projects in different organisational contexts, locally, nationally and internationally.

Health literacy and cultural responsiveness of primary health care systems and services in Australia: reflections from service providers, stakeholders, and people from refugee backgrounds

BACKGROUND

Primary health care [PHC] services with general practitioners (GPs) as the first point of access to health care services for people from refugee backgrounds in Australia can play a crucial role in building health literacy and promoting access to culturally appropriate services. To achieve equitable access and engagement, services and systems must be responsive to diverse health literacy and cultural needs. This study aims to explore how primary health services respond as a system and organisation to the health literacy and cultural needs of people from refugee backgrounds in Australia.

METHODS

This exploratory qualitative study involved 52 semi-structured interviews among 19 Africans from refugee backgrounds, 14 service providers, including GPs and nurses, and 19 other stakeholders, such as service managers/directors. Participants resided in New South Wales, Victoria, and Queensland. Interviews were audio-recorded, transcribed, and coded into QSR NVivo 12. Data analysis was guided by reflexive thematic analysis.

FINDINGS

Three interrelated themes were identified from the data relating to the health literacy and cultural responsiveness of PHC systems and services. The first theme, 'variable and ad hoc organisational response to health literacy and culturally responsive care,' demonstrated that some organisations did not systematically address the inherent complexity of navigating the health system nor the capacity of services and providers to respond to the cultural needs of people from refugee backgrounds. The second theme, 'individual provider responsibility,' captured the individual providers' interpersonal and relational efforts in supporting the health literacy and cultural needs of people from refugee backgrounds based on their motivation and adaptation. The third theme, 'refugee patient responsibility,' encapsulated people from refugee backgrounds' adaptations to and learning of the health system to navigate and access services.

CONCLUSION

Health literacy and culturally responsive practices need to be systematised by PHC organisations to be implemented and sustained over time. There is a need for diversity in the organisational leadership and health care workforce, organisational commitment, health literacy and culturally responsive care policies, provider training, and auditing practice as essential components of the change process. Engaging with refugee communities would allow services to focus on people from refugee backgrounds' needs by design.

Do refugees with better mental health better integrate? Evidence from the Building a New Life in Australia longitudinal survey

Hardly any evidence exists on the effects of mental distress on refugee labor outcomes. We offer the first study on this topic in the context of Australia, one of the host countries with the largest number of refugees per capita in the world. Analyzing the Building a New Life in Australia longitudinal survey, we exploit the variations in traumatic experiences of refugees interacted with post-resettlement time periods to causally identify the impacts of refugee mental health. We find that worse mental health, as measured by a one-standard-deviation increase in the Kessler mental health score, reduces the probability of employment by 11.9% and labor income by 22.8%. These effects appear more pronounced for refugees that newly arrive or are without social networks, but they may be ameliorated with government support. These findings have significant implications for the development of health and labor policies, particularly regarding the integration of refugees within host countries.

Examining the relationship between non-suicidal self-injury and mental health among female Arab minority students: the role of identity conflict and acculturation stress

Background and objective

Research suggests that individuals from minority backgrounds, including immigrants and ethnic minorities, may be at a higher risk for non-suicidal self-injury (NSSI). The aim of the present research is to examine the relationship between non-suicidal self-injury (NSSI) and identity conflict and acculturation stress, depression, and risk behaviors among female Arab minority students.

Methods

The sample analyzed consisted of 1,529 female Arab students (85.8% B.A. students, 14% M.A. students) aged 21-54 (M = 23, SD = 4.17). The participants completed self-reported questionnaires assessing NSSI engagement, identity conflict and acculturation stress, depression, and risky substance use behavior.

Results

As expected, we found a significant positive association between NSSI and identity crisis. In addition, an identity conflict and acculturation stress impact the effect of depression and risky substance use behaviors in engaging in self-injury. Namely, participants were more likely to engage in NSSI when they also experienced identity conflict and acculturation stress and exhibited depressive symptoms and tended to display risky substance use behavior.

Conclusion

These findings provide evidence that the relationship between depression, risky substance use behavior, and NSSI may be stronger among individuals who experience higher levels of identity conflict and acculturation stress. Implications for intervention and future research are briefly presented.

Self-perceived problems of Afghan asylum seekers and refugees and their experiences with a short psychological intervention

BACKGROUND

The present study examined Afghan asylum seekers' and refugees' self-perceived problems, and their experiences of treatment with an adapted version of the brief transdiagnostic psychological intervention "Problem Management Plus" (aPM+). Specifically, the study explored which problems trouble them most and how these problems influence their daily functioning. Further, it examined how various standardized outcome measures correlate with these subjectively perceived problems.

METHOD

This study is part of a larger RCT study (PIAAS study) in which 88 Afghan asylum seekers and refugees were randomly allocated either to aPM + in addition to treatment as usual (aPM+/TAU) or TAU alone. The presented study uses a multi-method approach consisting of two parts: First, we investigated participants' self-identified problems and subjective functional impairment using quantitative and qualitative assessment in both the aPM+/TAU and TAU group (n = 88). Second, we conducted in-depth qualitative interviews with a subsample of the aPM+/TAU group (n = 24) to gain a deeper understanding of participants' personal experiences with aPM + and to obtain suggestions for improvement. Spearman correlations were applied for quantitative data, and deductive and inductive approaches of thematic analysis were used for qualitative data.

RESULTS

We identified six main themes of self-perceived problems (primary post-migration living difficulties, general mental health problems, interpersonal stressors, secondary post-migration living difficulties, mental health problems specifically associated with stress, and somatic problems) and their consequences, as well as subjective functional impairment. Standardized measures of general mental health, posttraumatic psychopathology, and quality of life did not correlate with the intensity of self-perceived problems. aPM + was mostly perceived positively, and few participants had recommendations for its improvement.

CONCLUSION

The study aimed at giving a voice to Afghan trauma survivors to inform service providers and policy makers about their needs. Based on their expertise, future interventions can be tailored to their actual needs and optimized in terms of practical use. aPM + proved to be a positively perceived intervention that reduces subjective symptom burden and facilitates daily functioning. Culture-sensitive treatments within (mental) health services should increase service utilization and improve (mental) health in the long term.

School-based Psychosocial Interventions' Effectiveness in Strengthening Refugee and Migrant Adolescents' Mental Health, Resilience, and Social Relations: A Four-country Cluster Randomized Study

School-based psychosocial interventions are increasingly put forward as a way to support young refugees' and migrants' well-being and mental health in resettlement. However, the evidence on these interventions' effectiveness remains scarce and scholars denounce particular gaps in the evidence to date, pointing to a lack of large-scale, controlled studies and studies including social outcome measures. This cluster randomized study aims to strengthen the evidence base on school-based psychosocial interventions for refugee and migrant youth by assessing the effect of two interventions, Classroom Drama and Welcome to School, on youth's mental health, resilience, and social relations in Belgium, Denmark, Norway, and the United Kingdom. Multilevel analyses were conducted separately for the two interventions (Classroom Drama, n = 307, ages 11-19; Welcome to School, n = 251, ages 11-23), using separate no-treatment control groups. Our analyses indicated a significant main, positive effect of Classroom Drama on perceived family support, and an effect on perceived support from friends that was moderated by country: in the United Kingdom, the intervention group reported an increase in perceived friend support, whereas the control group reported a decrease. Furthermore, baseline resilience moderated the effect of the Classroom Drama intervention on behavioral difficulties and well-being. No effects of Welcome to School on any of the outcome variables were found. Overall, this study provides novel, nuanced evidence on school-based psychosocial interventions for refugee and migrant adolescents.

School-Based Interventions for Child and Adolescent Victims of Interpersonal Violence

BACKGROUND

Interpersonal violence against children and adolescents can affect their mental health and functioning in the long term. To reduce mental health problems in children and adolescents, school-based mental health interventions have been shown to be beneficial. A review of school-based interventions designed to mitigate posttraumatic symptoms after interpersonal violence is lacking to date.

METHODS

We searched for original studies published in English or German until November 2019 in 6 electronic databases. Supplementary search strategies to reduce publication bias were implemented. Peer-reviewed original studies assessing school-based interventions for children and adolescents under the age of 21 after interpersonal violence were included. Relevant data was extracted, synthesised and assessed qualitatively. The methodological quality of included studies was assessed.

RESULTS

Of 5,021 unduplicated publications, 15 studies met eligibility criteria. The included studies were almost exclusively conducted in the USA; over half utilised a randomised-controlled design. Studies mainly focussed on Posttraumatic Stress Disorder (PTSD) or depression. In all studies, implemented interventions partially or fully mitigated posttraumatic symptoms. Nine school-based interventions, five of which were based on cognitive behavioural therapy (CBT), were identified. School staff were often involved in intervention implementation besides mental health professionals.

CONCLUSIONS

School-based interventions can be beneficial to reduce mental health problems in children and adolescents after interpersonal violence. Trained school staff aided by mental health professionals can implement trauma-informed practices at school. While school-based interventions may be a feasible way to provide children and adolescents with accessible mental health care, further research on school-based trauma interventions outside the USA is necessary.

"I can't describe how I could get better, but I would like to" - Conception of health and illness of refugee youth in Germany

Introduction and objective

Almost half of all the people displaced worldwide are children and adolescents. Many refugee children, adolescents, and young adults suffer from psychological stress. However, their utilization of (mental) health services is low, probably due to a lack of knowledge about (mental) health and (mental) health care. The current study aimed to explore concepts of (mental) health and illness of refugee youth as well as assess their mental health literacy (MHL) to arrive at conclusions for improving mental health care access and use.

Method

From April 2019 to October 2020, we conducted 24 face-to-face interviews with refugee children and adolescents in an outpatient clinic (n = 8), in youth welfare facilities (n = 10), and at a middle school (n = 6). A semi-structured interview was used to assess knowledge about mental and somatic health and illness as well as corresponding health strategies and care options. The material was evaluated using qualitative content analysis.

Results

Participants (N = 24) were between 11 and 21 years old (M = 17.9, SD = 2.4). The coded material was assigned to four thematic main areas: (1) conception of illness, (2) conception of health, (3) knowledge about health care structures in their country of origin, and (4) perceptions of mental health care structures in Germany. Compared to somatic health, the interviewed refugee children and adolescents knew little about mental health. Furthermore, respondents were more aware of opportunities of somatic health promotion, but almost none knew how to promote their mental health. In our group-comparative analysis we observed that younger children possess little knowledge about mental health-related topics.

Conclusion

Our results show that refugee youth have more knowledge about somatic health and somatic health care than about mental health (care). Accordingly, interventions to promote the MHL of refugee youth are necessary to improve their utilization of mental health services and to provide adequate mental health care.

A Mixed-Methods Investigation of Facilitators to Accessing and Utilising Mental Health Services amongst Sri Lankan Australians

Many individuals with mental health conditions avoid, delay, discontinue, or do not seek mental health services and treatments, despite the existence of evidence-based treatments and support methods. Little is known about the barriers to mental health service utilisation for Sri Lankan Australians, and there is no research on factors that facilitate access for this group. Using quantitative and qualitative methods, this study explored the perspectives of Sri Lankan Australians (N = 262) on the facilitators of mental health service utilisation. Participants rated a set of 18-items (Facilitator Set) and 7 public health interventions (Intervention Set) in relation to their capacity to improve the uptake of mental health services. Participants also completed two open-ended questions about the enablers to seeking professional mental health care. Descriptive statistics were used to summarise quantitative findings, while open-text responses were analysed using reflexive thematic analysis. The Facilitator Set demonstrated that trust in the provider and their confidentiality processes, positive relationships with mental health professionals, and the community having positive attitudes towards seeking help were the primary facilitators to seeking professional help. The Intervention Set suggested that raising community awareness of mental health conditions and providing public stigma reduction interventions may increase access to care. Themes identified in the open-ended responses included access to culturally safe and responsive services and clinicians, improved accessibility and affordability of services, trust, and a community-based approach to increasing mental health literacy and addressing stigma beliefs. Within its limitations, the present study's findings suggest that providing culturally safe and responsive care, dispelling mental health stigma, and increasing knowledge of mental health conditions within Sri Lankan Australian communities are potential facilitating factors that would enable Sri Lankan Australians to seek and use mental health services. Implications for clinical care and future research are discussed.

Perspectives of culturally and linguistically diverse (CALD) community members regarding mental health services: A qualitative analysis

WHAT IS KNOWN ABOUT THE SUBJECT?: Immigrant, refugee and asylum seeker populations worldwide are at high risk of mental health issues National mental health policies call for recognising Australian society's multicultural characteristics to ensure adequate mental health services to CALD communities Several barriers exist for people from CALD communities in Victoria to access and utilise mental health services Improving mental health professionals' knowledge of mental health service provision and cultural responsiveness can enhance CALD community access to services. WHAT DOES THIS PAPER ADD TO EXISTING KNOWLEDGE?: We analysed the perspectives of people from CALD communities in Victoria regarding their needs and experiences with mental health services. Participants reported diverse perceptions and understanding of mental health issues and services Various challenges were identified regarding health service utilisation for the CALD community in Victoria, including language barriers, stigma towards mental health issues, mental health illiteracy, distrust and lack of familiarity with mainstream mental health services. These challenges were acknowledged by community members even after a long residence in Australia The data generated on the beliefs about mental health issues and consequent help-seeking behaviours highlight the importance of culturally sensitive targeted prevention and early intervention strategies and ongoing commitment to building mental health literacy in the wider community WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The information from the study can be adapted for quality improvement and culturally responsive practices The strategies for effective service delivery drawn by this paper can be a comprehensive resource tool for mental health professionals, organisations and policymakers The findings imply that CALD mental health service users and their families will likely benefit from improved service assessment and quality of mental health care and equity when MHNs undertake cultural competence training and bring that into their practice.

ABSTRACT

INTRODUCTION: Victoria is one of the most multicultural states in Australia. Many CALD communities in Victoria may have encountered complicated migration journeys and complex life stressors during their initial settlement, leading to adverse mental health concerns. This diversity necessitates public policy settings to ensure equity and access in health services planning and delivery. While the MH policies and services take cultural diversity into account, there needs to be more implementation of those components of MH policies that relate to the particular needs of various CALD communities in Victoria. Even though mental health services prevent and address mental health issues, many barriers can impair CALD community access and utilisation of mental health services. Furthermore, the recent Royal Commission inquiry into the Victorian Mental Health system drives a renewed policy imperative to ensure meaningful engagement and cultural safety of all people accessing and utilising mental health services (Department of Health, 2023).

AIM

This study focused on the perspectives of people from CALD communities in Victoria regarding their mental health service needs, understandings of and experiences with mental health services to prepare an education package for mental health nurses as part of a larger multi-method research project.

METHOD

A qualitative descriptive design was used to collect and analyse the perspectives of 21 participants in Victoria, using telephone interviews, followed by thematic analysis.

RESULTS

The themes and sub-themes identified were: Settling issues; Perceptions of understanding of mental health issues (help-seeking attitudes toward mental health issues; the need for CALD community education); perceived barriers to accessing and utilising mental health services in Victoria (socio-cultural and language barriers; stigma, labelling and discrimination; knowledge and experience of accessing health facilities); experience with mental health services and professionals.

DISCUSSION

Community participation, mental health professional education and robust research regarding the mental health needs of CALD people are some of the recommended strategies to improve access and utilisation of mental health services in Victoria.

IMPLICATIONS FOR PRACTICE

The current study can contribute to the existing knowledge, understanding, practice and quality improvement as it vividly portrays the issues of various CALD communities in Victoria. The findings of this study imply that CALD MH service users and their families are likely to benefit in terms of improved service assessment and quality of MH care and equity when MHNs undertake CC training and bring that into their practice.

A perspective on mental health literacy and mental health issues among Australian youth: Cultural, social, and environmental evidence!

Mental health literacy (MHL) helps improve mental health outcomes and reduce the impacts of mental illness. This study aims to reflect on scientific evidence on MHL levels, barriers to MHL, their impacts on mental health among Australian youth and interventions to overcome these barriers. The factors explored in the Perspective included; influence of social determinants, culturally and linguistically diverse (CALD) communities, help-seeking attitudes and behaviors. MHL intervention programs and MHL for improving mental health outcomes due to the recent COVID-19 pandemic were also explored. Adequate levels of youth MHL significantly improved one's ability to recognize own mental health status as well as provide peer support. Practical considerations such as designing more gender and culturally specific youth MHL programs are proposed.

What works? Lessons from a pretrial qualitative study to inform a multi-component intervention for refugees and asylum seekers: Learning Through Play and EMDR Group Traumatic Episode Protocol

Almost half of the trials failed to recruit their targeted sample size of which 89% could be preventable. Successful implementation of mental health trials in a context of forcibly displaced individuals can be even more challenging. Mental health difficulties have the potential to impact parenting skills, which are linked to poor development in children, while parenting interventions can improve parents' mental health and parenting behaviors. However, the evidence on parenting interventions for refugees is limited. A parenting intervention, Learning Through Play Plus Eye Movement Desensitization and Reprocessing Group Treatment Protocol, has been designed to address parental mental health. This pretrial qualitative study, conducted with refugees, asylum seekers and professionals, aimed to explore their perceptions of the intervention and to identify barriers and recommendations for better engagement, recruitment, and delivery. Three themes were generated from thematic analysis: the content of the intervention, suggestions for improvement and implementation, and understanding the role of the facilitator. These themes provided insights into the issues that might predict the barriers for delivery of the intervention and offered several changes, including destigmatization strategies to improve engagement.

Rebuilding life after migration: Research protocol of a mixed methods study on settlement experiences of refugee and migrant youth

Internationally, there is an urgent need to understand factors promoting successful settlement and integration of people with forced or voluntary migration experiences (i.e., refugee and non-refugee migrants). This paper provides a protocol of a mixed-methods investigation of contextual factors of successful settlement and service utilization of youth and their families, as young people could be at higher risk due to stressors associated with pre-migration trauma, post-migration settlement stressors, and adolescent development. This large-scale mixed-methods study will be conducted across three countries. A questionnaire survey will seek responses from 1200 youth aged 15-24 years residing in South Australia, Ontario, Canada, and California, United States of America. The qualitative component of the study will comprise 54 focus groups (324 participants) with youth and their parents/caregivers. The study design allows a range of important phenomena (e.g., different migration pathways and settlement countries) and key questions (e.g., regarding the intersection of migration, settlement, and wellbeing) to be addressed. It also allows for generalizability of findings to be tested across different communities and countries. Findings will support recommendations for policy and practice and may be generalized to advance research with youth and their families. This study is one of the largest, most comprehensive studies of youth settlement.

Non-European immigrants' self-described strategies for mental health promotion and perceptions of Finnish mental health services: A qualitative descriptive analysis

PURPOSE

This study aims to describe non-European immigrants' perceptions toward mental health care in Finland and the factors that support their mental health.

DESIGN AND METHODS

Participants (N = 17) were interviewed through semistructured interviews, after which interview transcripts were analyzed using a six-phase thematic analysis process.

FINDINGS

The participants reported that developing self-help strategies benefitted their mental health. The participants primarily preferred unprofessional help over professional mental health care. Several structural and cultural barriers to help-seeking were identified.

PRACTICAL IMPLICATION

Health care staff working with immigrants need proper education and knowledge to provide sufficient, holistic care; for this reason, information about the cultural differences among immigrants and cultural sensitivity should be included in basic as well as post-graduate nursing education.

Barriers to Accessing Mental Health Services by Migrant Youth

The purpose of the study was to identify barriers to accessing mental health services by migrant youth in a middle-sized central Canadian city. We asked participants, "What would stop you from talking to someone about mental health stress?". We interviewed 30 youth aged 16 to 22 who migrated from 10 different countries and lived in Canada for an average of 29 months. The data was analyzed using group concept mapping. The participants identified five concepts: fear of being misunderstood or ignored, desire for confidentiality, lack of trust and understanding, talking about it as not appropriate, and fear of the disclosure process. We compare these results with the literature.

A brief transdiagnostic psychological intervention for Afghan asylum seekers and refugees in Austria: a randomized controlled trial

Background

Afghan refugees often face hardship and traumatic experiences before, during, and after migration and frequently suffer from mental health burdens. Evidence based psychological treatments for refugees mostly focus on symptoms of posttraumatic stress disorder (PTSD), however, refugees often suffer from a variety of general health problems as well as depression and anxiety. We thus aimed to evaluate the effectiveness of a transdiagnostic psychological intervention.

Objective

To investigate the effectiveness of an adapted version of Problem Management Plus (aPM+) delivered by mental health professionals to adult Afghan refugees and asylum seekers.

Methods

We randomly allocated 88 Afghan refugees either to aPM+ in addition to treatment as usual (aPM+/TAU) or TAU alone. APM+ comprises of six weekly 90-minute individual sessions including strategies of stress management, problem solving, behavioural activation, strengthening social support and either anger regulation or increasing self-efficacy. The primary outcome was general health (GHQ-28) post intervention. Secondary outcome measures included distress by PMLD, Complex PTSD symptoms, quality of life, self-identified problems, and integration.

Results

Attrition was high: 42% of the randomized participants did not participate in the post-treatment assessment. A repeated measures per-protocol (completers only) ANCOVA evidenced a significant group × timepoint interaction for GHQ total scores [F(1, 47) =  14.80, p < .001, partial η2 = 0.24]. Post-hoc analyses showed significantly lower symptoms in the aPM+/TAU arm (n = 26) as compared to the TAU arm (n = 25) for the GHQ total scores (dz  = 1.04). Most secondary outcomes significantly improved in the aPM+/TAU arm, but not in the TAU arm.

Conclusion

APM+ was effective in reducing general health problems in Afghan refugees and might be considered as a first-line intervention. High drop-out rate limit the interpretations of our results, where future investigations should focus on possibilities to reduce these rates.Trial registration: Uniform Trial Number identifier: U1111-1226-3285.

HIGHLIGHTS

Refugees' mental health can be strengthened with a brief psychological intervention that also focuses on skills in the context of post-migration stressors.High drop-out rates are a major challenge for future research and delivery of psychological interventions as part of health care systems to refugees and asylum seekers.

Barriers and facilitators to access mental health services among refugee women in high-income countries: a systematic review

BACKGROUND

Based on the Global Trends report from the United Nations High Commissioner for Refugee, in high-income countries, there are 2.7 refuges per 1000 national population, girls and women account for nearly 50% of this refuge population. In these high-income countries, compared with the general population refuge women have higher prevalence of mental illness. Thus, this review was conducted to examine the barriers to and facilitators of access to mental health services for refugee women in high-income countries for refugee resettlement.

METHODS

We searched MEDLINE, EMBASE, PsycINFO, and CINAHL databases for research articles written in English with qualitative component. The last search date was on March 14, 2020. A narrative synthesis was conducted to gather key synthesis evidence. Refugee women (aged 18 and older) that could receive mental health services were included. Men and women under non-refugee migrant legal status were excluded. Studies were evaluated studies using the Critical Appraisal Skills Programme (CASP) qualitative checklist.

RESULTS

Of the four databases searched, 1258 studies were identified with 12 meeting the inclusion criteria. Three studies were cross-sectional by design, eight studies used a qualitative approach and one studies used mixed approach. The major barriers identified were language barriers, stigmatization, and the need for culturally sensitive practices to encourage accessing mental health care within a religious and cultural context. There were several studies that indicated how gender roles and biological factors played a role in challenges relating to accessing mental health services. The major facilitators identified were service availability and awareness in resettlement countries, social support, and the resilience of refugee women to gain access to mental health services.

CONCLUSION

This review revealed that socio-economic factors contributed to barriers and facilitators to accessing mental health among women refugees and asylum seekers. Addressing those social determinants of health can reduce barriers and enhance facilitators of access to mental health care for vulnerable populations like refugee women. A key limitation of the evidence in this review is that some data may be underreported or misreported due to the sensitive and highly stigmatizing nature of mental health issues among refugee populations.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020180369.

Working With the Encounter: A Descriptive Account and Case Analysis of School-Based Collaborative Mental Health Care for Refugee Children in Leuven, Belgium

Scholars increasingly point toward schools as meaningful contexts in which to provide psychosocial care for refugee children. Collaborative mental health care in school forms a particular practice of school-based mental health care provision. Developed in Canada and inspired by systemic intervention approaches, collaborative mental health care in schools involves the formation of an interdisciplinary care network, in which mental health care providers and school partners collaborate with each other and the refugee family in a joint assessment of child development and mental health, as well as joint intervention planning and provision. It aims to move away from an individual perspective on refugee children's development, toward an engagement with refugee families' perspectives on their migration histories, cultural background and social condition in shaping assessment and intervention, as such fostering refugee empowerment, equality, and participation in the host society. Relating to the first stage of van Yperen's four-stage model for establishing evidence-based youth care, this article aims to engage in an initial exploration of the effectiveness of a developing school-based collaborative mental health care practice in Leuven, Belgium. First, we propose a detailed description, co-developed through reflection on case documents, written process reflections, intervision, an initial identification of intervention themes, and articulating interconnections with scholarly literature on transcultural and systemic refugee trauma care. Second, we engage in an in-depth exploration of processes and working mechanisms, obtained through co-constructed clinical case analysis of case work collected through our practice in schools in Leuven, Belgium. Our descriptive analysis indicates the role of central processes that may operate as working mechanisms in school-based collaborative mental health care and points to how collaborative mental health care may mobilize the school and the family-school interaction as a vehicle of restoring safety and stability in the aftermath of cumulative traumatization. Our analysis furthermore forms an important starting point for reflections on future research opportunities, and central clinical dynamics touching upon power disparities and low-threshold access to mental health care for refugee families.

‘We do not talk about it’: Engaging youth in Malawi to inform adaptation of a mental health literacy intervention

Purpose

There is limited knowledge on how to tackle mental health problems among youth in Africa. Literature describing community engagement (CE) approaches in low/middle-income countries (LMICs) health research is sparse. CE with youth from LMICS can help steer and shape culturally relevant interventions for stigmatised topics like mental health, resulting in better healthcare experiences. We share our experience of engaging youth in Malawi through advocacy organisations to inform cultural adaptation of a mental health literacy intervention.

Methods

Young people were recruited using social media from universities and community youth organisations in Malawi to participate in focus group discussions to help culturally adapt content of an existing mental health literacy intervention. Nine online focus groups with 44 individuals were conducted. Discussions involved views and experiences of mental health, including impact of the coronavirus pandemic. Discussions were recorded, transcribed verbatim and analysed using content analysis.

Results

Transcript analyses revealed a vicious cycle of poverty and mental health problems for youth in Malawi. Four key themes were identified, 1) poverty-related socioeconomic and health challenges, 2) no one talks about mental health, 3) lacking mental health support and 4) relationship issues. These themes fed into one another within this vicious cycle which perpetually and negatively impacted their lives. The coronavirus pandemic worsened socioeconomic issues, health challenges, mental health and substance use issues, and burden on Malawi’s already weak mental health system.

Conclusion

Findings suggest increasing untreated mental health burden among Malawi’s youth. It highlights great need to address mental health literacy using existing community structures like educational settings to minimise burden on a weak health system. Online focus groups are an effective way of acquiring views from various young people in Malawi on mental health. This CE approach has grown our stakeholder network, strengthening potential for future CE activities and broader research dissemination.

"Everything was stuck in my inside and I just wanted to get it out": Psychological distress, coping, and help-seeking for young adult Australian Hazaras from refugee backgrounds

Hazaras form an Afghan ethnic minority group in Australia who arrived as refugees and through humanitarian resettlement schemes over the past three decades. This qualitative study explored psychological distress in a community sample of young adult Hazaras with a refugee background. The aim was to contribute to a more detailed understanding of their mental health, coping, and help-seeking in Australia. Eighteen Hazaras, nine males and nine females aged 18-30 years (M  =  22.39, SD  =  3.35), in Perth, Melbourne, or Sydney, who had been living in Australia on average 7.17 years (range 1 to 16 years), participated in a semi-structured interview based on Kleinman's explanatory model framework. Participants described mental and physical health as interconnected and their explanatory models for psychological distress focused on their current difficult life experiences as refugees. Findings indicated noteworthy gender differences, with young women reporting less distress associated with adaptation than did young men. Some young people used positive coping strategies in the community, while others engaged with a variety of mental health services. Level of satisfaction with these services varied considerably, with satisfaction highest for services provided by multicultural centers. Generally, respondents were not focused on their past traumas, but more interested in planning for their futures in Australia. Key implications for culturally appropriate training and specialized interventions for use with young adult Hazaras from refugee backgrounds are discussed.

Are we on the same page? Mental health literacy and access to care: a qualitative study in young Hazara refugees in Melbourne

Hazaras, mostly aged <30 years, constituted the greatest number of people resettled under Australia's migration resettlement between 2009 and 2013. This group is at high risk of mental health issues due to pre- and post-forced migration experiences. This study explored the understanding of mental health and barriers to accessing primary mental health care in young Hazara refugees in Melbourne. Seventeen Hazaras aged 18-30 years were recruited for two sex-segregated focus groups; two individual semistructured interviews were also conducted (with one male and one female participant). Discussions were audiotaped, transcribed and analysed thematically. Participants had varied perspectives on mental health issues stemming from historical and current beliefs. Lack of knowledge and concerns over confidentiality within Hazaras were considered major barriers to seeking help. Community education through existing community groups and through the women could potentially help overcome barriers to mental health access by young Hazaras.

Working towards Culturally Responsive Trauma-Informed Care in the Refugee Resettlement Process: Qualitative Inquiry with Refugee-Serving Professionals in the United States

Trauma-informed care (TIC) approaches have gained popularity in various contexts of human services over the past decades. However, relatively little has been explored about how it is applicable and built into services for refugee populations in resettlement programs. This study explores the current status of the application of TIC in refugee-serving agencies and identifies perceived and experienced challenges and opportunities for culturally responsive TIC in the United States. As designed as part of the evaluation of state-wide refugee health promotion programs, this study conducted individual interviews with 78 refugee service providers from five resettlement sites. Despite the burgeoning interest and attempt to embrace TIC, our findings show that there is clear inconsistency and inexperience in TIC adaptation in resettlement programs. This study highlights that TIC that is culturally responsive and relevant to refugee trauma and acculturation experiences is a vital way to address the chasms between refugee-specific programs and mainstream services including mental health care systems. This study also discusses community resources and opportunities to bridge the deep divide and substantial gaps between mental health services and refugee resettlement services and to address comprehensive needs around mental health and wellness in the refugee community.

Working towards Culturally Responsive Trauma-Informed Care in the Refugee Resettlement Process: Qualitative Inquiry with Refugee-Serving Professionals in the United States

Trauma-informed care (TIC) approaches have gained popularity in various contexts of human services over the past decades. However, relatively little has been explored about how it is applicable and built into services for refugee populations in resettlement programs. This study explores the current status of the application of TIC in refugee-serving agencies and identifies perceived and experienced challenges and opportunities for culturally responsive TIC in the United States. As designed as part of the evaluation of state-wide refugee health promotion programs, this study conducted individual interviews with 78 refugee service providers from five resettlement sites. Despite the burgeoning interest and attempt to embrace TIC, our findings show that there is clear inconsistency and inexperience in TIC adaptation in resettlement programs. This study highlights that TIC that is culturally responsive and relevant to refugee trauma and acculturation experiences is a vital way to address the chasms between refugee-specific programs and mainstream services including mental health care systems. This study also discusses community resources and opportunities to bridge the deep divide and substantial gaps between mental health services and refugee resettlement services and to address comprehensive needs around mental health and wellness in the refugee community.

Professional mental health support seeking in Women of Refugee Background resettled in Australia: An exploratory study of facilitators and barriers

The present study is the first to investigate factors influencing professional mental health support seeking in Women of Refugee Background (WoRB) in Australia. WoRB are a vulnerable population with a range of complex mental health needs. Despite this, research has indicated that WoRB are an underrepresented population in the utilisation of mental health support services. This is a particular concern in Australia, due to an increasing number of WoRB being resettled. A multivariate logistical regression was conducted on a sample of 450 WoRB resettled in Australia from the Building a New Life in Australia (BNLA) data set to investigate factors associated with seeking professional mental health support. Several factors were identified as being significantly associated with professional mental health support seeking in WoRB resettled in Australia, including age, resettlement location, marital status, prearrival trauma involving violence against women, language barriers and health-related variables, including mental distress and long-term disability. The current study provides a unique insight into professional mental health support seeking from a gendered perspective in WoRB resettled in Australia. Insights into factors that influence seeking professional mental health support in this highly vulnerable population must inform mental health practice, service delivery and policies.

From Formative Research to Cultural Adaptation of a Face-to-Face and Internet-Based Cognitive-Behavioural Intervention for Arabic-Speaking Refugees in Germany

Background

This study aims to provide a transparent and replicable documentation approach for the cultural adaptation of a cognitive-behavioural transdiagnostic intervention (Common Elements Treatment Approach, CETA) for Arabic-speaking refugees with common mental disorders in Germany.

Method

A mixed-methods approach was used, including literature review, interviews, expert decisions and questionnaires, in order to adapt the original CETA as well as an internet-based guided version (eCETA). The process of cultural adaptation was based on a conceptual framework and was facilitated by an adaptation monitoring form as well as guidelines which facilitate the reporting of cultural adaptation in psychological trials (RECAPT).

Results

Consistent with this form and the guidelines, the decision-making process of adaptation proved to be coherent and stringent. All specific CETA treatment components seem to be suitable for the treatment of Arabic-speaking refugees in Germany. Adaptations were made to three different elements: 1) Cultural concepts of distress: a culturally appropriate explanatory model of symptoms was added; socially accepted terms for expressing symptoms (for eCETA only) and assessing suicidal ideation were adapted; 2) Treatment components: no adaptations for theoretically/empirically based components of the intervention, two adaptations for elements used by the therapist to engage the patient or implement the intervention (nonspecific elements), seven adaptations for skills implemented during sessions (therapeutic techniques; two for eCETA only) and 3) Treatment delivery: 21 surface adaptations (10 for eCETA only), two eCETA-only adaptations regarding the format.

Conclusion

The conceptual framework and the RECAPT guidelines simplify, standardise and clarify the cultural adaptation process.

Perceived barriers to care for migrant children and young people with mental health problems and/or neurodevelopmental differences in high-income countries: a meta-ethnography

OBJECTIVES

To develop conceptual understanding of perceived barriers to seeking care for migrant children and young people (aged 0-25 years) with mental health problems and/or neurodevelopmental differences in high-income countries.

DESIGN

Qualitative evidence synthesis using meta-ethnography methodology. We searched four electronic databases (Medline, PsycINFO, Global Health and Web of Science) from inception to July 2019 for qualitative studies exploring barriers to care (as perceived by migrant communities and service providers) for migrant children and young people in high-income countries with neurodevelopmental differences and/or mental health problems. The quality of included studies was explored systematically using a quality assessment tool.

RESULTS

We screened 753 unique citations and 101 full texts, and 30 studies met our inclusion criteria. We developed 16 themes representing perceived barriers to care on the supply and demand side of the care-seeking process. Barriers included: stigma; fear and mistrust of services; lack of information on mental health and service providers lacking cultural responsiveness. Themes were incorporated into Levesque et al's conceptual framework of patient-centred access to healthcare, creating a version of the framework specific to migrant children and young people's mental health and neurodevelopmental differences.

CONCLUSIONS

This is the first qualitative evidence synthesis on barriers to care for mental health problems and/or neurodevelopmental differences in migrant children and young people in high-income countries. We present an adapted conceptual framework that will help professionals and policy-makers to visualise the complex nature of barriers to care, and assist in improving practice and designing interventions to overcome them. Similar barriers were identified across study participants and migrant populations. While many barriers were also similar to those for children and young people in general populations, migrant families faced further, specific barriers to care. Interventions targeting multiple barriers may be required to ensure migrant families reach care.

A Systematic Review of the Protective and Risk Factors Influencing the Mental Health of Forced Migrants: Implications for Sustainable Intercultural Mental Health Practice

This systematic review followed the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. The primary aim of this research was to identify risks and protective factors for the mental health of forced migrants. The secondary aim was to suggest an alternative, more comprehensive approach in social work that surpasses usual diagnoses and intrinsically contradicts the medicalization of mental health issues of forced migrants. The search was conducted between January 2015 and January 2021. As a result, 29 studies met inclusion criteria. Medicalizing mental health issues by relying solely on the effectiveness of medicine was a controversial risk factor that negatively affected daily life activities of refugees and reduced their willingness for seeking professional mental health services. Empowering vulnerable minorities by giving them back their power and agency to be able to speak for themselves and raise voices of trauma and recovery was the missing protective factor for a sustainable mental health practice. The benefits of group-based interventions were highlighted in which communities and individuals address mental health issues as well as isolation through building collective identities and support networks. Information and communication technologies (ICTs) can add more strength to any kind of mental health interventions. Finally, the benefits of applying an ecological perspective for the study of the mental health of refugees, and its implications for a sustainable intercultural practice, were discussed. Social workers in this model are the representatives of at-risk groups, and thus require more agency and creativity in reflecting client’s concrete needs.

Migrants and Service Providers' Perspectives of Barriers to Accessing Mental Health Services in South Australia: A Case of African Migrants with a Refugee Background in South Australia

International mobility has increased steadily in recent times, bringing along a myriad of health, social and health system challenges to migrants themselves and the host nations. Mental health issues have been identified as a significant problem among migrants, with poor accessibility and underutilisation of the available mental health services (MHSs) repeatedly reported, including in Australia. Using a qualitative inquiry and one-on-one in-depth interviews, this study explored perspectives of African migrants and service providers on barriers to accessing MHSs among African migrants in South Australia. The data collection took place during the COVID-19 pandemic with lockdown and other measures to combat the pandemic restricting face to face meetings with potential participants. Online platforms including Zoom and/or WhatsApp video calls were used to interview 20 African migrants and 10 service providers. Participants were recruited from community groups and/or associations, and organisations providing services for migrants and/or refugees in South Australia using the snowball sampling technique. Thematic framework analysis was used to guide the data analysis. Key themes centred on personal factors (health literacy including knowledge and the understanding of the health system, and poor financial condition), structural factors related to difficulties in navigating the complexity of the health system and a lack of culturally aware service provision, sociocultural and religious factors, mental health stigma and discrimination. The findings provide an insight into the experiences of African migrants of service provision to them and offer suggestions on how to improve these migrants’ mental health outcomes in Australia. Overcoming barriers to accessing mental health services would need a wide range of strategies including education on mental health, recognising variations in cultures for effective service provision, and addressing mental health stigma and discrimination which strongly deter service access by these migrants. These strategies will facilitate help-seeking behaviours as well as effective provision of culturally safe MHSs and improvement in access to MHSs among African migrants.

Reflections on researching vulnerable populations: Lessons from a study with Bhutanese refugee women

This paper explores the critical roles of researchers in research involving vulnerable populations. Its purpose is to reflect on the complex nature of vulnerability of Bhutanese refugee women who had resettled in Australia involved in research looking at the barriers to accessing preventive cancer screening. First, we describe the vulnerabilities considered prior to the research study and the actions taken to protect participants while the study was conducted. Second, we discuss those vulnerabilities that we did not anticipate, but were subsequently revealed during the study and consequently included in the study findings. These vulnerabilities should be considered for future research involving similar populations. It is important for researchers to use appropriate research designs that enable the voice of vulnerable people to be heard and to use research strategies that ensure findings are robust and participants are protected and empowered. Potential implications include the development of research practices that take account of the sources of vulnerabilities and consideration of how different vulnerabilities can evolve and affect findings and research recommendations.

Exploring presentation differences in multi-cultural youth seeking assistance for mental health problems

Background

Mental ill-health can impact an individual’s capacity to interact with others, make decisions, and cope with social challenges. This is of particular importance for many Culturally and linguistically diverse (CALD) individuals who may be at various stages of the acculturation process. The increasing diversity of the Australian population necessitates informed and culturally relevant services that meet the needs of a changing demographic. However the extant research on the mental health needs of CALD Australians is limited. This study aimed to further our understanding of the mental health needs of young CALD Australians by exploring the mental health concerns and social factors exhibited by CALD individuals accessing community based youth mental health services in two major cities.

Methods

We performed a series of logistic regression models to ascertain if a concert of factors (i.e., clinical, socio-economic, criminal justice system involvement, child maltreatment, social support) were associated with CALD status

Results

Comparisons across factors revealed no significant differences between groups. A small number of correlates differentiated between CALD and non-CALD participants (mental illness diagnosis during childhood, family history of mental illness/suicide, sensation seeking, sensitivity to punishment, maternal overprotection) however these factors were no longer meaningful after adjustment for multiple comparisons.

Conclusions

In help-seeking mainstream youth populations, cultural differences across clinical and environmental factors appear to be minimal.

Resettlement Stressors for Women of Refugee Background Resettled in Regional Australia

Women of Refugee Background (WoRB) have been repeatedly identified as an extremely vulnerable population. Within an Australian context, WoRB are increasingly resettled to non-metropolitan locations, otherwise known as regional locations. Despite this, to date, no research has focused on the lived experience and challenges associated with the resettlement of WoRB to regional contexts. This study aimed to address this gap in the literature by investigating the resettlement experience of WoRB resettled in Tasmania-a state in Australia classified as a rural and regional location. Qualitative interviews were conducted with a group of 21 individuals (nine WoRB and 12 service providers). Thematic analysis identified four overarching themes-Communication Barriers and Lack of Fluency in English, Challenges Accessing Everyday Basic Needs, Loss of Connection to Culture of Origin and Inability to Access Mainstream Mental Health Services for Help. Participants also highlighted a number of unique gender-related vulnerabilities experienced during resettlement, which were exacerbated in regional locations due to health services being overstretched and under-resourced. Results of the current study are discussed in regard to policy and practical implications, taking into consideration the unique vulnerabilities experienced by WoRB, which, to date, are often overlooked.

The Costs of Institutional Racism and its Ethical Implications for Healthcare

This paper discusses the ethical implications of racism and some of the various costs associated with racism occurring at the institutional level. We argue that, in many ways, the laws, social structures, and institutions in Western society have operated to perpetuate the continuation of historical legacies of racial inequities with or without the intention of individuals and groups in society. By merely maintaining existing structures, laws, and social norms, society can impose social, economic, and health costs on racial minorities that impinge on their well-being and human dignity. Based on a review of multidisciplinary research on racism, particularly focusing on healthcare, we demonstrate how institutional racism leads to social and economic inequalities in society. By positing institutional racism as the inherent cause of avoidable disparities in healthcare, this paper draws attention to the ethical significance of racism, which remains a relatively neglected issue in bioethics research.

A Walk-In Clinic for Newly Arrived Mentally Burdened Refugees: The Patient Perspective

Providing refugees with psychosocial support is particularly important considering the high level of mental health problems prevalent in this population. A psychosocial walk-in clinic operating within a state reception and registration center in Germany has been supporting mentally burdened refugees since 2016. This study focused on patients' perspectives on their mental health burden, the psychosocial walk-in clinic, and future help seeking. We conducted interviews with n = 22 refugees attending the walk-in clinic from March to May 2019. Qualitative analysis focused on the following four topics: (1) mental burden from the patients' perspective, (2) access to the psychosocial walk-in clinic, (3) perception of counseling sessions, and (4) perception of follow-up treatment. The results show that the majority of interviewees were burdened by psychological and somatic complaints, mostly attributed to past experiences and post-migratory stress. Therapeutic counseling and psychiatric medication were found to be particularly helpful. Most of the participants felt motivated to seek further psychosocial support. Key barriers to seeking psychosocial help included shame, fear of stigma, and lack of information. Overall, the psychosocial walk-in clinic is a highly valued support service for newly arrived refugees with mental health issues.

Health care provided to recent asylum-seeking and non-asylum-seeking pediatric patients in 2016 and 2017 at a Swiss tertiary hospital - a retrospective study

Background

Asylum-seeking children represent an increasing and vulnerable group of patients whose health needs are largely unmet. Data on the health care provision to asylum-seeking children in European contexts is scarce. In this study we compare the health care provided to recent asylum-seeking and non-asylum-seeking children at a Swiss tertiary hospital.

Methods

We performed a cross-sectional retrospective study in a pediatric tertiary care hospital in Basel, Switzerland. All patients and visits from January 2016 to December 2017 were identified, using administrative and medical electronic health records. The asylum-seeking status was systematically assessed and the patients were allocated accordingly in the two study groups.

Results

A total of 202,316 visits by 55,789 patients were included, of which asylum-seeking patients accounted for 1674 (1%) visits by 439 (1%) individuals. The emergency department recorded the highest number of visits in both groups with a lower proportion in asylum-seeking compared to non-asylum-seeking children: 19% (317/1674) and 32% (64,315/200,642) respectively. The median number of visits per patient was 1 (IQR 1–2) in the asylum-seeking and 2 (IQR 1–4) in the non-asylum-seeking children. Hospital admissions were more common in asylum-seeking compared to non-asylum-seeking patients with 11% (184/1674) and 7% (14,692/200,642). Frequent visits (> 15 visits per patient) accounted for 48% (807/1674) of total visits in asylum-seeking and 25% (49,886/200,642) of total visits in non-asylum-seeking patients.

Conclusions

Hospital visits by asylum-seeking children represented a small proportion of all visits. The emergency department had the highest number of visits in all patients but was less frequently used by asylum-seeking children. Frequent care suggests that asylum-seeking patients also present with more complex diseases. Further studies are needed, focusing on asylum-seeking children with medical complexity.

Psychological trauma and access to primary healthcare for people from refugee and asylum-seeker backgrounds: a mixed methods systematic review

Background

Several reviews have found that psychological trauma affects access to health care services, including mental health care, in the general population. People from refugee and asylum seeker backgrounds are more likely to have a mental illness than the general population, and experience a broad range of barriers and facilitators to service access. However, to date there has been no comprehensive consideration of the potential effect of psychological trauma on access to primary health care within this population.

Methods

This paper provides a mixed-methods systematic review of literature which included any consideration of the relationship between psychological trauma and access to primary health care. A systematic search of Medline, PsychInfo, Scopus, Web of Science, Embase, CINAHL and Cochrane Library was conducted. Study eligibility criteria were empirical, peer-reviewed studies that considered the relationship between psychological trauma and access to, or use of, primary healthcare in resettlement countries for refugees (including asylum seekers). Papers were required to be written in English and published between 1998 and August 2019. Quality was assessed using the Multi-Methods Appraisal Tool. The search identified a total of 14 eligible studies (11 quantitative and 3 qualitative) which had explored this relationship in refugee and asylum seeker populations.

Results

Overall, synthesis of findings indicated variable results with respect to the impact of psychological trauma on service access. Specifically, the review found that while rates of psychological trauma were high. Key themes were that while general health care access was comparable or greater than the general population, rates of mental healthcare specifically were low. In addition, included papers identified a range of barriers to service access-particularly somatisation, stigma and healthcare provide knowledge about psychological trauma.

Conclusions

While there is a critical need for more research in this area, the study points to several key recommendations including training of general practitioners in relation to psychological trauma, ensuring culturally responsive services, and the use of interpreters. Finally, due to the levels of somatisation found in some studies, ensuring general practitioners understand the somatic element of psychological trauma-particularly within some groups of people from refugee backgrounds-is important.

Barriers and facilitators to access mental health services among refugee women in high-income countries: study protocol for a systematic review

BACKGROUND

According to the United Nation High Commissioner for Refugee Global Trends report in 2019, on average, there are 2.7 refugees per 1000 national population in high-income countries, where girls and women attributed to 48% of the refugee population. Evidence shows high prevalence of mental health disorder among women refugees in comparison to the general population. To our knowledge, no systematic reviews have addressed access to mental health services for refugee women. The aim of this study will be to examine existing barriers and facilitators to accessing mental health services for refugee women in leading high-income countries for refugee resettlement.

METHODS

We designed and registered a study protocol for a systematic review. We will conduct a literature search (from inception onwards) in MEDLINE, EMBASE, PsycINFO, and CINAHL. Research articles having a qualitative component (i.e., qualitative, mixed, or multi-method) will be eligible. Study populations of interest will be refugee women at any age that can receive mental health services in leading high-income countries for refugee resettlement (e.g., 14 countries from North America, Europe, and Oceania). Eligibility will be restricted to studies published in English. The primary outcome will be all barriers and facilitators related to accessing mental health services. Two reviewers will independently screen all citations, full-text articles, and abstract data. Potential conflicts will be resolved through discussion. The study methodological quality (or bias) will be appraised using appropriate tools. Reporting will follow the Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) statement. A narrative synthesis will be conducted, and summary of findings tables will be produced. As it will be a systematic review, without human participants' involvement, there will be no requirement for ethical approval.

DISCUSSION

The systematic review will present key evidence on barriers and facilitators to access mental health services among refugee women in leading resettlement countries. The findings will be used to inform program developers, policymakers, and other stakeholders to enhance mental health services for refugee women. The final manuscript will be disseminated through a peer-reviewed journal and scientific conferences.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020180369.