Family-based mental health interventions for refugees across the migration continuum: A systematic review

Home, School, and Community-based Services for Forcibly Displaced Youth and Their Families

Forced displacement can expose youth to unimaginable levels of traumatic life events. We discuss how home-based, school-based, and community-based services can be strategically situated to address the psychological sequelae of such events. Given the systemic challenges that refugee youth face when establishing trust in their new environments, are often from collectivist cultural backgrounds, espouse stigma towards professional help seeking, and must prioritize accessing services for their basic needs, these types of settings can be particularly relevant. In the administration of such services, we advocate for an intentional approach to addressing basic needs as well as using cultural brokers, validated measures, and family- and school-based interventions.

Myanmar migrants living along the Thailand-Myanmar border: Experiences related to pandemic and migration decisions

Importance

In Myanmar, amid political and civil unrest, droves of Burmese are displaced to neighboring countries including Thailand. Since the COVID-19 pandemic, little is known about the available healthcare services and health and well-being among refugees and migrant workers within resettlement areas along the Myanmar-Thailand border.

Objective

To explore the unmet needs of migrants along the Thailand-Myanmar border during the COVID-19 pandemic and their reasons for leaving Myanmar.

Design

A qualitative study that used focus groups with migrant schoolteachers and school masters was undertaken. An interpretative analysis approach was used to analyze the data from the focus group sessions. The study followed the COREQ (COnsolidated criteria for REporting Qualitative) checklist.

Setting

In July 2022, community stakeholders from migrant schools located in the vicinity of Mae Sot, Thailand were referred to the study team.

Participants

A purposive sample of 17 adult participants was recruited from 4 migrant schools. The participants were schoolteachers and schoolmasters who had traveled from Myanmar to Thailand 1 to 20 years ago.

Main Outcomes and Measures

Thematic analysis was used to scrutinize qualitative data for the outcomes of health and well-being, barriers, and reasons for migration.

Results

Three main themes were identified: "issues related to the pandemic", "teenage marriage and pregnancies" and "migration decisions". The issues related to the pandemic included behavior changes in children, a diminished quality of education, and barriers to receiving COVID-19 vaccines and accessing other health care. There were more dropouts due to teenage pregnancy/marriage during the shelter in place mandate. Migration decisions were affected by concerns over health, civil unrest, and military harassment.

Conclusions and Relevance

This study presented the difficulties experienced by Myanmar migrants currently living along the Thailand-Myanmar border. The reasons for leaving Myanmar included health and safety. Suspending education during the pandemic caused more school dropouts due to teenage pregnancy/marriage. Additionally, behavioral changes in children, a diminished quality of education, barriers to receiving COVID-19 vaccines and access to other health care services were reported. Future studies should focus on how migration stress and access to mental health care impact the migrant population.

Family Therapy for Kosovar Mothers Who Experienced Conflict-Related Sexual Violence and Their Children in Postwar Times: A Pilot Randomised Waitlist-Controlled Trial

Women who have experienced conflict-related sexual violence report significant long-term effects, including posttraumatic stress disorder (PTSD), depression and relationship difficulties. Research has demonstrated that maternal trauma is associated with children's behavioural difficulties and challenges in family functioning, such as impaired communication and harsh parenting. This pilot study is aimed at evaluating the preliminary effectiveness of family therapy for Kosovar mothers who experienced conflict-related sexual violence in 1998-1999 and later developed PTSD and their children in improving family functioning and reducing behavioural difficulties in postwar times. Sixty-four mothers were randomised to an intervention group or a waitlist control group. Data was collected during a screening phase, at baseline before intervention initiation, after the intervention group completed family therapy and once the waitlist control group received the intervention. Generalised linear mixed models were used to analyse group differences in family functioning and children's behaviours over time. At follow-up, mothers in the intervention group reported improved family functioning. However, mothers in the waitlist control group reported significantly fewer behavioural difficulties than mothers in the intervention group before the control group had started family therapy. There was no significant interaction between group condition and time for child-rated family functioning. Overall, this pilot study suggests that family therapy could be effective in reducing the effects of intergenerational trauma related to PTSD and conflict-related sexual violence. Future research should evaluate the long-term effects of family therapy to assess if immediate effects were maintained.

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

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

Assessing the mental health needs of Yazidi adolescents and young adults in an Iraqi Kurdi IDP Camp: a focus group study

BACKGROUND

Internally displaced people (IDP) in Iraq are 1.2 million (as March 2023). Protracted refugee status endangers the mental health, especially of minorities who survived persecution and conflict, such as the Yazidis. This study aims to identify the mental health needs of Yazidi adolescents and young adults (AYA) in the IDP camp of Bajed Kandala (Iraqi Kurdistan).

METHODS

A focus group discussion (FGD) study was conducted between April and August 2022. The FGDs involved AYAs, as well as the staff of the clinic of the Bajed Kandala camp. An inductive approach was adopted referring to the 'theme' as the unit of content analysis of the text. All FGDs were recorded and transcribed. The analysis was carried out independently by two researchers. The inter-rater agreement was assessed through the Cohen's k.

RESULTS

A total of 6 FGDs were conducted. The participants were 34 of whom 21 (61.8%) females with a median age of 18.5 years (IQR 17.0-21.0). A total of 156 themes were found as relevant to the objective of this study. Four main areas and twelve subareas of needs in mental health were identified. The interrater agreement over the main area and subareas was good (κ = 0.78 [0.95CI 0.69-0.88], κ = 0.82 [0.95CI 0.73-0.91], respectively). The four areas had a similar frequency: Activities (28.2%), Individual (27.6%), Social relationships (22.4%) and Places/setting (21.8%). The subareas 'community' and 'internal resources' were labelled as negative 85.7% and 61.9% of the time, respectively. These sub-areas referred to stigma and self-stigma towards mental health. The subarea 'female condition' was always considered as negative, as well as the subareas 'camp' and 'tent' referring to housing as an important social determinant of mental health.

CONCLUSIONS

Community stigma and self-stigma are two still important factors preventing the achievement of mental well-being. Alongside these, a gender gap in mental health was identified in the FGDs. These factors should be taken into account in order to guide future mental health interventions in refugee camps.

Coparenting, mental health, and the pursuit of dignity: A systems-level analysis of refugee father-mother narratives

Research on coparenting is virtually absent from the refugee literature, despite its importance for family systems, children's bio-behavioural and emotional development, and intergenerational responses to social change. In 2022, we conducted 30 semi-structured interviews with Syrian refugees in Jordan and used thematic analysis to examine how fathers and mothers (n = 15 dyads) enacted parenting together. We identified four approaches characterising how couples navigated coparenting interactions, family cohesion, and intergenerational change. These were negotiation, mirroring, anchoring, and transformation. Specifically, Syrian couples negotiated how to balance responsibilities, sought emotions and behaviours that reflected calm and respect, prioritised family togetherness over education or resettlement opportunities, and, strikingly, adopted gentler parenting approaches to transform intergenerational experiences. Underpinning these four themes were efforts to uphold family dignity. Syrians described themselves as ordinary parents, eschewing the label of refugee parents and building a normal life for their families after war and displacement. Our thematic analysis offers methodological and conceptual advances in exemplifying how to capture a dyadic understanding of coparenting and why refugees strive to parent in ways that sustain mental health and dignity. This systems-level analysis of coparenting in dignity is specifically relevant to strengthening the processes of family-level communication and to designing integrated programs that support caregiving, wellness, and family unity. Our findings lay the groundwork for developing a relational, agentic model of family caregiving systems in the context of precarity and forced displacement.

Promoting positive development among refugee adolescents

Of the estimated 35.3 million refugees around the world (UNHCR, Figures at a Glance, 2022), approximately 50% are children under the age of 18. Refugee adolescents represent a unique group as they navigate developmental tasks in an unstable and often threatening environment or in resettlement contexts in which they often face marginalization. In addition to physiological, social, and psychological changes that mark adolescence, refugee youth often face traumatic experiences, acculturative stress, discrimination, and a lack of basic resources. In this consensus statement, we examine research on refugee adolescents' developmental tasks, acculturative tasks, and psychological adjustment using Suárez-Orozco and colleague's integrative risk and resilience model for immigrant-origin children and youth proposed by Suárez-Orozco et al. Finally, we discuss recommendations-moving from proximal to more distal contexts.

Evaluation of the Early Adolescent Skills for Emotions (EASE) intervention in Lebanon: A randomized controlled trial

BACKGROUND

There is a need for scalable evidence-based psychological interventions for young adolescents experiencing high levels of psychological distress in humanitarian settings and low- and middle-income countries. Poor mental health during adolescence presents a serious public health concern as it is a known predictor of persistent mental disorders in adulthood. This study evaluates the effectiveness of a new group-based intervention developed by the World Health Organization (Early Adolescent Skills for Emotions; EASE), implemented by non-specialists, to reduce young adolescents' psychological distress among mostly Syrian refugees in Lebanon.

METHODS

We conducted a two-arm, single-blind, individually randomized group treatment trial. Adolescents aged 10 to 14 years who screened positive for psychological distress using the Pediatric Symptom Checklist (PSC) were randomly allocated to EASE or enhanced treatment as usual (ETAU) (1:1.6). ETAU consisted of a single scripted psycho-education home-visit session with the adolescent and their caregivers. EASE consists of seven group sessions with adolescents and three sessions with caregivers. The primary outcome was adolescent-reported psychological distress as measured with the PSC (internalizing, externalizing, and attentional symptoms). Secondary outcomes included depression, posttraumatic stress, well-being, functioning, and caregivers' parenting and distress. All outcomes were assessed at baseline, endline, and 3 months (primary time point) and 12 months follow-up.

RESULTS

Due to the COVID-19 pandemic and other adversities in Lebanon at the time of this research, the study was prematurely terminated, resulting in an under-powered trial sample (n = 198 enrolled compared to n = 445 targeted). We screened 604 children for eligibility. The 198 enrolled adolescents were assigned to EASE (n = 80) and ETAU (n = 118), with retention rates between 76.1 and 88.4% across all timepoints. Intent-to-treat analyses demonstrated no between-group differences on any of the outcome measures between the EASE and ETAU. We did observe a significant improvement on the primary outcome equally in the EASE and ETAU groups (-0.90, 95% CI: -3.6, 1.8; p = .52), - a trend that was sustained at three months follow-up. Sub-group analyses, for those with higher depression symptoms at baseline, showed ETAU outperformed EASE on reducing depression symptoms (difference in mean change = 2.7, 95% CI: 0.1, 5.3; p = .04; d = 0.59) and internalizing problems (difference in mean change 1.0, 95% CI: 0.08, 1.9; p = .03; d = 0.56) .

CONCLUSION

No conclusions can be drawn about the comparative effectiveness of the intervention given that the sample was underpowered as a result of early termination. Both EASE and single session psycho-education home visits resulted in meaningful improvements in reducing psychological distress. We did not identify any indications in the data suggesting that EASE was more effective than a single session family intervention in the context of the COVID-19 pandemic and other crises in Lebanon. Fully powered research is needed to evaluate the effectiveness of EASE.

A study on the influencing factors and response strategies for young teachers from Taiwan to teach in universities in China: a push-pull-mooring model perspective

Introduction

A growing number of Taiwanese teachers are choosing to teach at universities in mainland China, but their jobs are not always stable. Therefore, this study aims to investigate the factors infuencing young teachers from Taiwan to teach in universities in China.

Methods

Twenty-seven young teachers from Taiwan with master's or doctoral degrees who were willing to apply to work at universities in China and who were already teaching in China were invited to conduct in-depth interviews to collect research data.The interview data were coded and analyzed according to the Push-Pull-Mooring (PPM) Model.

Results and discussion

The results showed that the understanding of mainland Chinese universities among young Taiwanese teachers is not entirely consistent. Taiwanese teachers who previously studied in mainland China have a more comprehensive understanding of mainland Chinese universities, and some teachers have gained a superfcial understanding through academic exchanges between the two sides and information shared by friends.However,still,7% of the teachers have no understanding at all. Most young Taiwanese teachers indicate that they do not understand the talent recruitment policies of mainland Chinese universities. The push factors that infuence young teachers from Taiwan to teach at mainland universities are: Oversupply of teachers in Taiwan, poor environment for higher education in Taiwan, poor articulation of the cross-strait academic system, and four aspects of teacher retirement and re-employment in Taiwan. The pull factors are: Benefcial policies, salary, living environment, educational advantages and cultural dissemination in 5 areas. Mooring factors are divided into 3 aspects: personal factors, environmental factors and social factors.

Global Mental Health: Where We Are and Where We Are Going

PURPOSE OF REVIEW

To summarize recent findings in global mental health along several domains including socioeconomic determinants, inequities, funding, and inclusion in global mental health research and practice.

RECENT FINDINGS

Mental illness continues to disproportionately impact vulnerable populations and treatment coverage continues to be low globally. Advances in integrating mental health care and adopting task-shifting are accompanied by implementation challenges. The mental health impact of recent global events such as the COVID-19 pandemic, geo-political events, and environmental change is likely to persist and require coordinated care approaches for those in need of psychosocial support. Inequities also exist in funding for global mental health and there has been gradual progress in terms of building local capacity for mental health care programs and research. Lastly, there is an increasing effort to include people with lived experiences of mental health in research and policy shaping efforts. The field of global mental health will likely continue to be informed by evidence and perspectives originating increasingly from low- and middle-income countries along with ongoing global events and centering of relevant stakeholders.

Kurdish Refugee Beliefs about Mental Health and Help-Seeking: A Community-Engaged Research Study in Tennessee

Refugee populations exhibit high rates of PTSD, anxiety, depression, and psychological distress, but are less likely to receive care than the general population. Perceptions among the Kurdish refugee community about causes and consequences of mental illness symptoms and perceived barriers to help-seeking are understudied. This community-engaged research study conducted in-depth interviews with Kurdish refugees from Iraq to explore their beliefs about drivers of mental illness and seeking help for mental health. Iterative thematic analysis of transcripts from ten participants indicated four key themes: (1) social network loss due to resettlement causes poor mental health; (2) socioeconomic status loss due to unrecognized professional qualifications puts strain on mental health; (3) social stigma about mental health and fears about disclosure of mental health issues within community and subsequent negative gossip prevent help-seeking; and (4) social interaction may alleviate mental illness symptoms. Overall, Kurdish refugees perceived social factors as major drivers of mental illness symptoms and barriers to help-seeking in their community. However, while participants believed that the general community attitude was against help-seeking, most participants personally expressed support of anyone in their community needing to see a mental health professional. Future research should assess the extent to which perceived community norms differ from aggregated personal help-seeking attitudes and behaviors among Kurdish refugees from Iraq in the United States.

For the Parent, by the Parent: Creating a Program to Empower Parents of Refugee Background in Canada Using Novel Participatory Approaches

BACKGROUND

Families of refugee background have complex, multigenerational mental health and developmental needs that are not accounted for in current programming frameworks in Canada. Providing appropriate support services and educational resources that address the unique concerns of families of refugee background will allow for improved family cohesion and developmental outcomes for children. Parenting programs have been shown to be successful in improving parental stress, parental efficacy, and children's mental health and well-being. This study gathers data about the experiences of caregivers of refugee background in order to develop a novel, multi-dimensional parenting program model using Community-Based Participatory Research (CBPR) principles.

METHODOLOGY

This was a qualitative, CBPR study using a formative research framework. In-depth interviews (IDIs) were conducted with caregivers of refugee background and service providers that work closely with this population. Data were recorded, transcribed, and coded using deductive and inductive coding methods by two independent coders.

RESULTS

A total of 20 IDIs were conducted (7 caregivers and 13 service providers). The main topics that were identified to be incorporated into the program include: features of child development, how to address resettlement issues, child advocacy, and parenting after resettlement. Participants felt that tackling language barriers, addressing the overlapping responsibilities of caregivers attending the sessions, providing incentives, increasing awareness of the program, and using an anti-racist and anti-oppressive approach was key to the program's success. Participants emphasized the need for trauma-informed mental health supports within the program model.

CONCLUSION

This study describes the key considerations for a novel parenting program for families of refugee background, by engaging them as key stakeholders in the program design process. Future iterations of this project would involve a pilot and evaluation of the program.

Investigating Outcomes of a Family Strengthening Intervention for Resettled Somali Bantu and Bhutanese Refugees: An Explanatory Sequential Mixed Methods Study

Pre- and post-migration stressors can put resettled refugee children at risk of poor mental health outcomes. The Family Strengthening Intervention for Refugees (FSI-R) is a peer-delivered preventative home visiting program for resettled refugees that aims to draw upon families' strengths to foster improved family communication, positive parenting, and caregiver-child relationships, with the ultimate goal of reducing children's risk of mental health problems. Using an explanatory sequential mixed methods design, this study draws upon qualitative interviews with caregivers (n = 19) and children (n = 17) who participated in a pilot study of the FSI-R intervention in New England, as well as interventionists (n = 4), to unpack quantitative findings on mental health and family functioning from a randomized pilot study (n = 80 families). Most patterns observed in the quantitative data as published in the pilot trial were triangulated by qualitative data. Bhutanese caregivers and children noted that children were less shy or scared to speak up after participating in the FSI-R. Somali Bantu families spoke less about child mental health and underscored feasibility challenges like language barriers between caregivers and children. Interventionists suggested that families with higher levels of education were more open to implementing behavior change. In both groups, families appreciated the intervention and found it to be feasible and acceptable, but also desired additional help in addressing broader family and community needs such as jobs and literacy programs.