Caring for Communities: Promoting Well-Being Among Refugees

Introduction

The health and well-being of the world’s refugees, many of them children and youth, is a rising concern in many communities and for medical professionals.  Evidence compiled over the last two decades suggests that refugee youth have complicated and in many cases, serious mental health issues, despite strengths and protective factors, due to traumatic events and social-economic disparities. At the same time, recent studies and scholars demonstrate that there is a lack of research and data that report on successful interventions (Fazel, 2018; Silove, Ventevogel & Rees, 2017; Hess et al., 2014; Miller & Rasmussen, 2016; Goodkind et al., 2014). Therefore, the topic of interventions supporting the mental health and well-being of refugees is important. Caring for Communities, by the Robert Wood Johnson Foundation, and the Refugee-Well-Being Project both show promising practices for urban refugee programs in the United States. 

Targeted Group

Silove et al. (2017), noted that there is a striking number of refugees in the world today (particularly in Syria), saying this is an “unprecedented upsurge” (p. 130). Their report relied on a United Nations estimate of 65 million people across the world who are “currently displaced by war, armed, conflict, or persecution” (Silove et al., 2017, p. 130). In 2016, over 3 million people were displaced, and the refugees are subject to “oscillations in public opinion and government policies” (Silove et al., 2017, p. 130) which continue to put them at risk for serious health and well-being challenges. 

Scholarly and humanitarian interests in the lives and health of refugees have increased over the years. Silove et al. note that The Adaption and Development After Persecution and Trauma (ADAPT) model rely on the following five areas which describe the nature of stability for human life and health. The authors explain that the ADAPT model shows the needs for programs and interventions that will help remediate these areas while increasing well-being. The five areas for stability are  “symptoms of safety and security, interpersonal bonds and networks, justice, roles, and identifies and existential meaning and coherence” (Silove et al., 2017, p. 134). When these are not present, people experience significant mental health issues. Therefore, the issue of mental health impacts this targeted group. For example, there is a combination of trauma, loss, and injustice, which lead to grief, anger, sadness, and depression in refugees, all of which great significant negative impacts.

Challenges and Barriers

The challenges and barriers to better care and treatment for mental health and well being are complex. Silove et al. evaluated recent trends in refugee health stats, including mental health status and access to care and services. They explain that treatment and support for mental health and well-being are “shared by a network of agencies” (Silove et al., 2017, p. 130), such as the World Health Organization, and the United Nations High Commissioner for Refugees (UNCHR) and but that the majority of refugees “will never receive appropriate services” (Silove et al., 2017, p. 130). The authors state that the primary reason for the challenges and barriers to tackle this issue is “scarcity and inequitable distribution fo services” (Silove et al., 2017, p. 130) as well as issues about coordinating national and international interventions, locating and transportation to care, as well as stigma that is associated with mental health problems. The authors explain that no one service provider or agency can provide all that is needs to address the “inter-related psychosocial and mental health needs for refugees” (Silove et al., 2017, p. 137). 

Miller and Rasmussen note that earlier research was placed on armed conflict and associated violence, grief, and loss, while nearly overlooking the mental health of refugees. The world is at a twenty-year high as far as millions of people displaced through a forced migration (Miller & Rasmussen, 2017) with few organized solutions to dealing with this complicated issue. Challenges and barriers to addressing this issue are the inter-related areas of exposure to violence before migrating (such as through war), as well as the stressors that are typical of migrating peoples, such as language barriers, financial struggle, and adequate housing and food. Tackling this issue is complicated due to mental health needs brought on by “social isolation…loss of social networks…unemployment”, as well as poverty, legal status, “discrimination…lack of safety in refugee camps, and difficulties navigating” new environments and settings (Miller & Rasmussen, 2017, p. 1). 

Literature Search

Hess et al. conducted a study on the impact of the Refugee Well-Being project (RWP) as a community-based intervention, which was designed to increase refugee well-being through social determinants. The research design featured methods including a six-month intervention that assessed the impact of the RWP on “English proficiency, enculturation, quality of life, social support, access to resources, and mental health,” as measured through structured qualitative interviews. The paired participants were comprised of 72 refugees (adults ages 18-71 and 36 children ages 7-17) from Africa and 53 American undergraduate students (Hess et al., 2014, p. 6). Statistical findings indicated that learning through social means was not identical for all participants. The undergraduate students gained an understanding of racism, and health and social disparities, while the refugees gained knowledge about access to healthcare, how to seek support and resources that may help them in their new homeland. The research results indicate that improving the lives of refugees “requires a comprehensive approach” (Hess et al., 2014, p. 15), such as building social health through lobbying efforts, and access to resources, and to strengthen relationships among individuals, based on the research results that there are key “social determinants of health” (Hess et al., 2014, 16). 

The purpose of the scientific study by Betancourt, Frounfelker, Mishra, Hussein, and Falzarano was to gain knowledge about the “problems, strengths, and help-seeking behaviors or Somali Bantu and Bhutanese refugees” (2015, p. 475) as well as how young people in these communities express mental health difficulties.  The research design utilized qualitative research methods in order to design assessments, which featured “local terms for child mental health problems” (Betancourt et al., 2015, p. 475) among new refugee in Massachusetts, USA. The study was conducted between 2011 and 2014 and included 56 refugees from Somali Bantu and 93 from Bhutan. The statistical findings included the fact that language barriers and lack of financial resources stopped families from seeking care. Specific difficulties that were not being treated included depression and anxiety (Betancourt et al., 2015). The findings included the recommendation to create methods and interventions that are at once culturally appropriate and rooted in preventions that are locally run. 

Betancourt et al.’s (2017) research purpose was to compare exposure to trauma, mental health needs, psychological distress, and how refugees and immigrants use mental health resources. This was accomplished through a research design that featured a concept of matching propensity scores within the National Child Traumatic Stress Network (NCTSN). The samples that were compared were 60 “refugee-origin youth”, 143 “immigrant-origin youth”, and 140 “USA-origin youth” with mean ages of  12 to 13. The research demonstrated that there was a greater range of type of trauma among refugees, with higher rates of exposure to violence, “dissociative symptoms, traumatic grief, and phobias a distinct pattern of trauma exposure” and “therefore differing service and health needs than other groups (Betancourt et al. 2017, p. 209). 

Next, Colucci, Szwarc, Minas, Paxton, and Guerra conducted a study to find out about mental health problems experienced by refugees, and their relatively low rates of treatment utilization. The research design was a systematic literature review completed through an analysis of at least ten major databases in nursing, psychiatry, and social sciences from 1960-2011. The final sample was eleven scientific studies, published between 2000-2010. The statistical findings noted an underutilization of mental health resources by “ethnic minorities” (Colucci et al., 2014, p. 98). Furthermore, the authors found a “paucity of research on barriers and facilitators to accessing” (Colucci et al., 2014, p. 99) of mental health services in resettlement communities across the world. The authors summarized that the main implication of their research is that even with existing policies designed to assist mental health service delivery, those policies have left gaps for the refugees. 

Goodkind et al. (2014) analyzed evidence for their purpose of developing a community intervention project that was designed to increase wellbeing of refugees. This was a pilot study conducted from 2006-2008 in the southwestern United States in which undergraduate students and refugees worked together for 6 hours per week for at least 6 months. The format was comprised of Learning Circles (LC) of 2-hour meetings, cultural exchange, and community advocacy. The research participants included 24 adult refugees who had settled in Arizona from 2002-2009, originally from the Democratic Republic of the Congo, Liberia, Burundi, or Rwanda. This was a “mixed-methods, within-group longitudinal design” (Goodkind et al., 2014, p. 8) that recorded data at 3-month interviews. Both samples featured a majority of female participants, but otherwise, the participants varied in age, education, sexual orientation, and religious affiliation. Statistical findings demonstrated that participants acquired skills that would help them in their new settlement such as “environmental mastery, self-sufficiency, self-confidence” (Goodkind et al., 2014, p. 10). An important implication is that the Refugee Well-Being model can be used as an intervention to increase English speaking as well as “quality of life and significant decreases in psychological distress,” and therefore this intervention “had positive impacts on participants’ mental health and well-being” (Goodkind et al., 2014, p.12).

Hudson, Adams, and Lauderdale studied trauma of refugees and mental health nurses’ practices as well. Their research purpose was to study intergenerational trauma after moving to the United States, and also to “determine culturally sensitive mental health care practice” (Hudson et al., 2016, p. 286) so that healthcare providers could be of service in this situation. The authors collected and evaluated scholarly articles of recent research, using computerized searches. The subjects of the study were the eight scholarly articles published between 2003 and 2013 that featured cultural expressions, such as theatrical plays and symbolism about refugee resettlement. a number of participants, sample characteristics. The statistical findings found six themes of communication in and about healthcare. They are: “silence, communication, adaptation, relationship, remembering, and national redress” (Hudson et al., 2016, p. 286). The findings have implications for nursing. For example, the authors showed that nurses and others in healthcare must be not only aware but also to “consider cultural influences of intergenerational trauma in processing grief related to loss” (Hudson et al., 2016, p. 301). 

Reed, Fazel, Jones, Panter-Brick, and Stein’s research aim was to quantify minority populations through community organizations and evaluate the educational needs and mental health of refugee children that had resettled in low to mid-income cities. This research team conducted a two-part systematic review of mental health risk and protective factors among refugee children from around the world. Their final sample consisted of 27 studies published between 1985-2010, featuring about 5,765 research participants, under the 18, many from African or the Middle East.  Their statistical findings showed that locally based interventions can reduce the effects of depression as well as posttraumatic stress disorders (Reed et al., 2012). The findings indicate that there are “complex causal chains” (Reed et al., 2012, p. 260) that influence mental health symptoms, and that there is less research on low to middle-income settlements that high-income.  The implication of these findings, the author's stress, is that there needs to be a move towards assessing programs and their respective effectiveness of interventions (Reed et al., 2012). 

De Anstiss and Ziaian studied help-seeking behaviors by refugee adolescents. The research design was a mixed-methods investigation and thirteen focus groups conducted form 2000-2007 in Australia. 85 adolescent refugees aged 13-17 (of Middle-Eastern origin, primarily) made up the sample. The qualitative findings showed that the participants were reluctant to seek assistance beyond immediate friendships and a general mistrust of medical professionals coupled with stigma about mental illnesses. The findings imply that programs and interventions need to be culturally appropriate, and based on “planned, regular outreach (De Anstiss & Ziaian, 2010, p. 36). 

Potential Interventions

A number of important interventions have been developed in order to alleviate some of the difficulties with mental health for urban refugee youth. The Robert Wood Johnson Foundation’s Caring Across Communities and the Refugee Well-being Project are two examples of program-level interventions that address the mental health needs of this diverse population. The Caring for Communities program was successful in bringing mental health services to refugees (and immigrants) in eight states of the United States from 2007-2010. The main avenue was through the development of model programs which helped schools, families, and service providers, as well as local organizations in urban settings, to build culturally appropriate and accessible services for children and youth in fifteen communities. 

The program’s sites offered “culturally-informed, linguistically accessible, and readily available services”, which in some case included clothing, housing, and case management (Lear & Price, 2015, p. 2). All fifteen sites had mental health services in schools, language assistance, and also ached their interventions to meet the cultural groups being served. Overall, more than 9,000 students from 55 countries participated in Caring for Communities, plus over 4,600 parents or caregivers; the professionals involved also totaled about 4,500. The mental health supports included not only individual counseling but home visits as well as family counseling sessions. The program helped to solidify that there are four major components that are critical to program development for refugees. They are: “engaging with families”, “meeting basic needs” (such as winter clothing, bedding), “strengthening the ability to adapt to a new culture”, and “providing emotional and behavioral supports” (Lear & Price, 2015, p. 3).

Hess et al. (2014) developed a model centered around transformative learning in order to reduce mental health disparity for refugees living in urban areas, specifically in New Mexico. Their model, the Refuge Well-Being Project (RWP) is based on social aspects of life which have influence over mental health. Due to a “growing recognition that social inequities in education, housing, employment, healthcare, safety, resources, money, and power contribute to health disparities” (Hess et al., 2014, p. 2), a program such as this is developed as interventions to help close the gap for refugees. The  RWP demonstrated a community-based intervention that addresses a number of these social determinants of health with the purpose of reducing the “burden of mental illness” (Hess et al., 2014, p. 2) that refugees experience. The program’s interventions are based on ideas that learning may be transformative, may be collective, and can lead to not only empowerment but also can help the participants to understand the impact of broad worldwide contexts on individual lives. The program’s interventions were similar to the broad goals of the Caring for Communities.  

The Refuge Well-Being project was designed to increase access to mental health care and more general resources, to increase the safety of refugees’ new settlement environment, and to reduce the stress often involved in settling in a new homeland (for example, through better social support (Hess et al., 2014, p. 3-4). These were accomplished through advocacy as well as Learning Circles, both of which make the cultural exchange and shared learning top priorities. The advocacy component assigned the refugee’s learning partners (undergraduates) to help identify unmet needs while shoring up community resources to help meet those same needs. In addition, advocacy skills for refugees were also strengthened. The program leaders found that outcomes of these interventions increased in English proficiency, provided better social support, better access to resources, including medical and other care, and decreased psychological symptoms, such as distress. 

Advocating for Change: Policy Recommendations

At the policy level, experts, such as Fazel (2018), Silove et al., (2017), and Goodkind et al. (2014) emphasize that program level effectiveness needs to be measured. For example, the Robert Wood Johnson not only provided direct support, such as mental health counseling, and clothing but also provided grants in order to help “build capacity for school-based mental health programs” (Lear & Price, 2015, p. 4). When advocating for change, it is essential to identify and review any and all federal, state or local policies and regulations in order to learn how to manage and finance programs in schools that support mental health. This may include webinars on best practices, and learning how to best support children of all diverse backgrounds. Furthermore, the agency called Root Cause was contracted in order to help the programs with longer-term financial health. Caring for Communities advocates that all school children should be included in mental health and associated wellness programs. 

Summary and Conclusions

The topic of interventions supporting the mental health and well-being of refugees is important as there is currently a great increase in the number of refugees worldwide. Since the mental health of refugee youth is often based on complicated causes and events, the need for effective programs is also needed. Furthermore, there is a documented need for policy changes so that refugee programs can be developed and evaluated for effectiveness, as advocated by Fazel (2018) and Silove et al. (2017). The Caring for Communities Project was notable for providing greatly needed mental health interventions, but also for its program-level measurements. The concern for the well-being of the world’s refugees needs to be matched with effective interventions, as advocated by Fazel (2018) as well as Hess et al. (2014), such as the Caring for Communities Project and the Refugee Well-Being Project, as this population, especially those resettling in low and mid-income urban areas, has significant trauma histories and face burdens due to social-economic disparities.

References

Betancourt, T. S., Frounfelker, R., Mishra, T., Hussein, A., & Falzarano, R. (2015). Addressing health disparities in the mental health of refugee children and adolescents through community-based participatory research: a study in 2 communities. American Journal of Public Health, 105(S3), S475-S482.

Betancourt, T. S., Newnham, E. A., Birman, D., Lee, R., Ellis, B. H., & Layne, C. M. (2017). Comparing trauma exposure, mental health needs, and service utilization across clinical samples of refugee, immigrant, and US‐origin children. Journal of traumatic stress, 30(3), 209-218.

Colucci, E., Szwarc, J., Minas, H., Paxton, G., & Guerra, C. (2014). The utilization of mental health services by children and young people from a refugee background: A systematic literature review. International Journal of Culture and Mental Health, 7(1), 86-108.

De Anstiss, H., and Ziaian, T. (2010). Mental health help-seeking and refugee adolescents: Qualitative findings from a mixed-methods investigation. Australian Psychologist, 45(1), 29-37.

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Goodkind, J. R., Hess, J. M., Isakson, B., LaNoue, M., Githinji, A., Roche, N., ... & Parker, D. P. (2014). Reducing refugee mental health disparities: A community-based intervention to address post migration stressors with African adults. Psychological Services, 11(3), 333.

Hess, J. M., Isakson, B., Githinji, A., Roche, N., Vadnais, K., Parker, D. P., & Goodkind, J. R. (2014). Reducing mental health disparities through transformative learning: A social change model with refugees and students. Psychological services, 11(3), 347.

Hudson, C. C., Adams, S., & Lauderdale, J. (2016). Cultural expressions of intergenerational trauma and mental health nursing implications for US health care delivery following refugee resettlement: An integrative review of the literature. Journal of Transcultural Nursing, 27(3), 286-301.

Lear, J. G., & Price, O. A. (2015). Executive summary. Robert Wood Johnson Foundation National Program Executive Summary Report—Caring Across Communities: Addressing Mental Health Needs of Diverse Children and Youth.

Miller, K. E., & Rasmussen, A. (2017). The mental health of civilians displaced by armed conflict: An ecological model of refugee distress. Epidemiology and psychiatric sciences, 26(2), 129-138.

Reed, R. V., Fazel, M., Jones, L., Panter-Brick, C., & Stein, A. (2012). Mental health of displaced and refugee children resettled in low-income and middle-income countries: Risk and protective factors. The Lancet, 379(9812), 250-265.

Silove, D., Ventevogel, P., & Rees, S. (2017). The contemporary refugee crisis: An overview of mental health challenges. World Psychiatry, 16(2), 130-139.

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