Important considerations when providing mental health first aid to Iraqi refugees in Australia: a Delphi study

Conceptualisations of mental illness and stigma in Congolese, Arabic-speaking and Mandarin-speaking communities: a qualitative study

BACKGROUND

Australia is an ethnically diverse nation. Research has demonstrated an elevated risk of developing a mental illness in culturally and linguistically diverse (CaLD) communities yet uptake of mental health services is low. To improve mental health treatment seeking and outcomes for CaLD individuals in Australia there is an urgent need to deeply understand barriers to treatment such as stigma. Using an exploratory qualitative approach, the aim of the study was to explore how CaLD communities' conceptualise and interpret mental illness and associated beliefs and experiences of stigma.

METHODS

The study focused on three key CaLD groups: the Congolese, Arabic-speaking and Mandarin-speaking communities residing in Sydney, Australia. A series of eight focus group discussions (n = 51) and 26 key informant interviews were undertaken online using Zoom during the period of November to December 2021. Focus group discussions and key informant interviews were digitally recorded, transcribed, and analysed using NVivo software.

RESULTS

Three major themes were identified. The first theme related to mental illness terminology used in the three communities. Despite variation in the terms used to refer to 'mental illness' all three communities generally distinguished between 'mental illness', a more severe condition and 'mental health problems', considered to arise due to stressors. The second theme centred on beliefs about mental illness; with all three communities identifying migration-related stressors as contributing to mental illness. Culturally related beliefs were noted for the Congolese participants with the perception of a link between mental illness and supernatural factors, whereas Mandarin-speaking participants highlighted lack of inter and intrapersonal harmony and failure to adhere to values such as filial piety as contributing to mental illness. The final theme related to mental illness related stigma and the various ways it manifested in the three communities including presence of collectivist public stigma felt across all three groups and affiliate (family) stigma reported by the Arabic and Mandarin-speaking groups.

CONCLUSIONS

We found rich diversity in how these communities view and respond to mental illness. Our findings provide some possible insights on both service provision and the mental health system with a view to building effective engagement and pathways to care.

Mental Illness Stigma and Associated Factors among Arabic-Speaking Religious and Community Leaders

Evidence suggests that Arabic-speaking refugees in Australia seek help from informal sources, including religious and community leaders, when experiencing mental health issues. Despite their significant influence, there is scarce research exploring attitudes of Arabic-speaking leaders toward mental illness. The current exploratory study explored mental illness stigma and various factors among Arabic-speaking religious and community leaders. This study uses a subset of data from an evaluation trial of mental health literacy training for Arabic-speaking religious and community leaders. Our dataset contains the pre-intervention survey responses for 52 Arabic-speaking leaders (69.2% female; mean age = 47.1, SD = 15.3) on the ability to recognise a mental disorder, beliefs about causes for developing mental illness, and two stigma measures, personal stigma, and social distance. Being female was associated with a decrease in personal stigma. An increase in age was associated with an increase in personal stigma. Correct recognition of a mental disorder was associated with decreased personal stigma, and after adjusting for age and gender, significance was retained for the I-would-not-tell-anyone subscale. Endorsing the cause “being a person of weak character” was associated with an increase in personal stigma. There is an urgent need for future research to elucidate stigma to develop effective educational initiatives for stigma reduction among Arabic-speaking leaders.

Guidelines for the public on how to provide mental health first aid: narrative review

BACKGROUND

Expert-consensus guidelines have been developed for how members of the public should assist a person with a mental health problem or in a mental health crisis.

AIMS

This review aimed to examine the range of guidelines that have been developed and how these have been implemented in practice.

METHOD

A narrative review was carried out based on a systematic search for literature on the development or implementation of the guidelines.

RESULTS

The Delphi method has been used to develop a wide range of guidelines for English-speaking countries, Asian countries and a number of other cultural groups. The primary implementation has been through informing the content of training courses.

CONCLUSION

Further work is needed on guidelines for low- and middle-income countries.

DECLARATION OF INTEREST

A.F.J. is an unpaid member of the Board of Mental Health First Aid International (trading as Mental Health First Aid Australia), which is a not-for-profit organisation.

A comparative analysis of psychological trauma experienced by children and young adults in two scenarios: evacuation after a natural disaster vs forced migration to escape armed conflict

OBJECTIVES

Little is known about the psychological trauma experienced by children and young adults (CYAs) following displacement after natural disasters vs migration from conflict zones. In both instances, the decision to leave is usually cast by the family, and the life of CYAs is suddenly disrupted by external circumstances.

STUDY DESIGN

An anonymous survey.

METHODS

The same survey instrument, provided by the National Child Traumatic Stress Network (NCTSN), was used to survey self-reported health needs among CYAs during the aftermath of Hurricane Katrina (Health Survey for Children and Adolescents After Katrina) in October 2005-February 2006 and again during the peak of refugee arrivals in Berlin between October 2015 and March 2016. A weighted index to measure cumulative exposure to traumatic stresses during migration was developed along with an unweighted psychological impact score based on the 22-item NCTS psychological impact questionnaire. Spearman's correlation coefficient (rho) was used to assess the correlation between age and the two psychological impact indices. The two-tailed t-test was used to investigate differences in trauma experienced and psychological impact by gender. Logistic regression was used to investigate differences in types of traumatic stress experienced and psychological impact among CYAs displaced because of Hurricane Katrina and those seeking asylum in Berlin.

RESULTS

The Katrina cohort included a total of 1133 CYAs, the Berlin cohort, a total of 405 CYAs. The median age in the Katrina cohort was 6.73 years (standard deviation [SD] 5.67, range 0-24; 50.13% males) compared with 17.64 years (SD, range 0-24; 83% males) in the Berlin cohort. Comparative analyses were adjusted to age and gender and revealed significant differences between the two cohorts, both with regards to the amount of trauma experienced and the psychological impact. A statistically significant and moderate positive correlation was observed between trauma experienced and psychological impact of migration in the refugee population (rho = 0.4955, P < 0.001); the correlation was less pronounced but still significant in the Katrina cohort (rho = 0.0942, P = 0.0015). Free-text responses revealed that in addition to common concerns about health, housing and safety, refugees were also pre-occupied with language acquisition and the adaptation to a new culture.

CONCLUSIONS

The observed differences in the experience and the consequences of trauma in displaced CYAs warrant additional investigation. It was replicated that human-made disaster seems to show more traumatising potential than natural disaster. Stakeholders need to be aware of the potential medium and long-term consequences of migration/evacuation and allocate resources accordingly.

Cross-cultural generalizability of suicide first aid actions: an analysis of agreement across expert consensus studies from a range of countries and cultures

BACKGROUND

A number of Delphi expert consensus studies have been carried out with different countries and cultural groups to develop guidelines on how a member of the public should provide assistance to a person who is suicidal. The present study aimed to determine whether cross-culturally generalizable suicide first aid actions are possible by comparing agreement across these Delphi studies.

METHODS

Data on endorsement rates for items were compared across six Delphi studies. These studies involved panels of professionals and consumer advocates from English-speaking countries, professionals from Sri Lanka, professionals from Japan, professionals from India, professionals from the Philippines, and professionals and consumer advocates in refugee and immigrant mental health. Correlations were calculated between item endorsement rates across panels.

RESULTS

There were 18 items that were highly endorsed across all eight of the Delphi panels and an additional 15 items highly endorsed across the panels from the three lower middle-income countries (India, Philippines and Sri Lanka). Correlations across panels in item endorsement rates were all 0.60 or above, but were higher between panels from countries that are socioeconomically similar.

CONCLUSIONS

There is broad agreement across the diverse expert panels about what are appropriate suicide first aid actions for members of the public, indicating that cross-cultural generalizability is possible. However, there is also some cultural specificity, indicating the need for local tailoring.

Improving the capacity of community-based workers in Australia to provide initial assistance to Iraqi refugees with mental health problems: an uncontrolled evaluation of a Mental Health Literacy Course

BACKGROUND

Australia is a multicultural nation with a humanitarian program that welcomes a large number of Iraqi refugees. Despite the high prevalence of trauma related disorders, professional help-seeking in this group is very low. This study sought to evaluate a face-to-face mental health literacy (MHL) Course that teaches community-based workers how to provide initial help to Iraqi refugees with depression and post-traumatic stress disorder (PTSD) related problems.

METHODS

An uncontrolled pre, post and follow-up design was used to measure improvement in MHL in community-based workers assisting Iraqi refugees.

RESULTS

Eighty-six participants completed the pre- and post-training questionnaires. Forty-five (52%) completed all 3-time point questionnaires. Fifty-six percent (48/86) of participants were able to correctly recognise 'PTSD' as the problem depicted in a vignette before the training. This increased to 77% (66/86) after training and was maintained at follow-up with 82% (37/45) correctly recognising the problem (p = 0.032). Recognition of depression also increased from 69% (59/86) at pre-training to 83% (71/86) after training and to 82% (37/45) at follow-up. There was a significant increase in perceived helpfulness of professional treatments for depression after training (p < 0.001 at post-training, p = 0.010 at follow-up). Significant changes were reported in confidence of participants when helping an Iraqi refugee with PSTD (p < 0.001 at post-training, p < 0.001 at follow-up) and depression (p < 0.001 at post-training, p = 0.003 at follow-up). A decrease were also found on social distance mean scores associated with PTSD (p = 0.006 at post-training, p < 0.001 at follow-up) and depression (p = 0.007 at follow-up). Changes were not significant following training for offering help and helping behaviours in both PSTD and depression vignettes and, the 'dangerous/unpredictable' subscale in the depression vignette.

CONCLUSION

This training is a recommendable way to improve and better equip staff on how to respond to mental health crises and offer Mental Health First Aid in a culturally sensitive manner to Iraqi refugees.

The mental health and help-seeking behaviour of resettled Afghan refugees in Australia

Background

Psychological trauma, in particular, posttraumatic stress disorder (PTSD) and depression, are highly prevalent among resettled refugees. However, little is known regarding the mental health status and associated help-seeking behaviour of resettled Afghan refugees in Australia.

Methods

A sample of 150 resettled Afghan refugees (74 males; mean age 32.8 years, SD = 12.2) living in Adelaide, South Australia were recruited. Self-reported measures of PTSD, depression, exposure to traumatic events, functional impairment, self-recognition of PTSD symptomatology and help-seeking behaviours were completed. Multivariate analysis of variables associated with help-seeking was conducted.

Results

Forty-four percent of participants met criteria for clinically significant PTSD symptoms and all but one participant reported being exposed to 1 or more traumatic and/or conflict related events, such as ‘losing your property and wealth’. Moreover, 14.7% of participants had symptoms suggestive of clinically significant depression. General practitioners were the most common source of help in relation to mental health problems, with very few participants (4.6%) seeking help from specialist trauma and torture mental health services. Self-recognition of having a PTSD related mental health problem and functional impairment levels were both found to be independent predictors of help-seeking (p ≤ .05).

Conclusions

The findings provide further evidence for high rates of PTSD symptomatology and low uptake of mental care among resettled refugees. Poor self-recognition of the presence and/or adverse impact of PTSD symptoms may need to be targeted in mental health promotion programs designed to improve “mental health literacy” and thereby promote early and appropriate help-seeking where this is needed.

Causes of and risk factors for posttraumatic stress disorder: the beliefs of Iraqi and Afghan refugees resettled in Australia

BACKGROUND

Resettled refugees are a vulnerable group for mental health problems and in particular, trauma-related disorders. Evidence suggests that poor 'mental health literacy' (MHL) is a major factor in low or inappropriate treatment-seeking among individuals with mental health problems. This study sought to determine the beliefs regarding the causes of and risk factors for post-traumatic stress disorder (PTSD) amongst two resettled refugee groups in Australia.

METHODS

Utilising a culturally adapted MHL survey method, 225 Iraqis and 150 Afghans of refugee background were surveyed.

RESULTS

Approximately 52% of the Iraqi participants selected 'experiencing a traumatic event' as the 'most likely' cause for the clinical vignette, whereas 31.3% of the Afghan sample selected 'coming from a war torn country' as their top cause. While both groups identified being 'born in war torn country' as the most likely risk, at 34.4 and 48% of the Iraqis and Afghans respectively, differences regarding other risk factors selected were noted.

CONCLUSIONS

The results of this study indicate the need for culturally sensitive health promotion and early intervention programs seeking to improve MHL relating to PTSD in resettled refugee populations. There is also a need for mental health services to recognise that variation in MHL may be a function of both the cultural origin of a refugee population and their resettlement experiences. Such recognition is needed in order to bridge the gap between Western, biomedical models for mental health care and the knowledge and beliefs of resettled refugee populations.