Mental health service utilization by Ethiopian immigrants and refugees in Toronto

Barriers to Accessing Mental Health Services That Impact Black Canadians: A Scoping Review and Thematic Analysis

Although experiencing lower levels of mental health compared to the general population of Canada, Black Canadians are less inclined to seek help from mental health services. Thus, the aim of this scoping review is to systematically document the current literature on the barriers in accessing mental health services among Black Canadians. Following PRISMA guidelines, a systematic search of the existing literature was conducted using PubMed, PsycINFO, Cumulative Index to Nursing and Allied Health, and Scopus on September 8, 2024. The final dataset consisted of 20 studies published between 1998 and 2023. Findings were synthesized using the sociobehavioural model of health service use to define the subtypes of barriers and the construct of Mental Health Literacy to guide the thematic analysis of the extracted data. Barriers impacting Black Canadians' access of mental health services included language barriers, difficulties in navigating the mental healthcare system, wait times, the quality of resources, and the lack of mental health services in their communities. Themes identified as barriers of use were Mental Health Literacy, Negative Perceptions of the Mental Healthcare System, and Discrimination. Challenges discussed in this review implicate the importance of a multitargeted approach to increasing the access and usage of mental health services among Black Canadians. This review also provides a foundation for research and practice that aims to investigate and develop strategies to promote the mental health of the Black population in Canada. Accordingly, we identify gaps in research-regarding the mental health perceptions, beliefs, and experiences of Black Canadians, required to properly develop interventions that increase mental health service access.

Utilization of Mental Health Counseling Services Among Refugees and Asylum-Seekers in Malaysia

This paper examines the frequency of post-traumatic stress disorder (PTSD) and factors associated with mental health counseling utilization among adult refugees and asylum-seekers in Malaysia. Participants (n = 286) were recruited using venue-based random sampling from three health clinics in 2018. Framed by Andersen's model of health care utilization, we used a multilevel logistic regression and hypothesized that predisposing factors (female, older age, not married, higher education, lived longer in Malaysia, registered refugee), greater enabling factors (easy access to healthcare, larger household income, not needing interpreter, health literacy, larger household), and greater need factors (higher PTSD symptoms) would be associated with counseling attendance. We found one-third (34.3%) of participants screened positive for PTSD and most (71.9%) never attended counseling services. Our hypothesis was partially supported. Older age was associated with counseling attendance [OR:1.03 (95% CI:1.00,1.06)]. Enabling factors associated with counseling attendance include easy access to a health facility [OR:9.82 (95% CI:3.15,30.59)] and not needing interpreter services [OR:4.43 (95% CI:1.34,14.63)]. Greater need factor/PC-PTSD score [OR:0.69 (95% CI:0.52,0.91)]; however, was associated with lower counseling attendance. Other predisposing/enabling/need factors did not show significant associations. Understanding factors associated to care can benefit health clinics address gaps in counseling utilization for refugees and asylum-seekers in Malaysia.

Why are African immigrants in Montreal reluctant to use mental health services?: a systematic inventory of reasons

PURPOSE

Previous research has shown that non-Caucasian immigrants in Western countries are less likely than native-born people to use mental health services. This study examined the reasons underlying reluctance to use mental health services among African immigrants in Montreal, Canada.

METHODS

The study participants were 280 African immigrants who had experienced symptoms suggesting depression but did not use formal mental health services. They were presented with a questionnaire that contained 65 statements referring to reasons for not using formal mental health services while experiencing those symptoms and were asked to indicate their degree of agreement with each of the statements on a scale of 0-10. Responses were then analyzed using factor analysis.

RESULTS

An eight-factor structure of reasons was found: "Minimizing symptoms and perceived self-efficacy" (61% of the sample), "Relying on spiritual care" (56% of the sample), "Cost and waiting time" (45% of the sample), "Influence of significant others" (34% of the sample), "Lack of cultural competence" (32% of the sample), "Fear of stigmatization" (23% of the sample), "Nature of the consultation" (10% of the sample) and "Social models" (8% of the sample). Scores on these factors were related to participants' demographics.

CONCLUSION

Effectively addressing the underutilization of mental health services among African immigrants requires a multifaceted approach rather than one focused on a single barrier. Our findings suggest critical points that could help develop tailored interventions to address the various barriers to care.

Food Related Challenges and Mental Health Among U.S. African Migrants: A Narrative Review

The United States' (US) African immigrant (AI) population is growing, yet they are underrepresented in health and nutrition research. This population experiences difficulties finding culturally appropriate foods and navigating the US food environment (FE), is highly food insecure (FI), and vulnerable to mental disorders. This review examined the current evidence for AIs' food and mental health outcomes and connections; and identified gaps in the literature and future research opportunities. A literature search was conducted using Google Scholar, PubMed, CINAHL, MEDLINE, and SCOPUS. Twenty-one studies were identified, reporting high (37-85%) FI rates, poor diet quality, and increased risk of mental disorders among participants. Challenges in the FE, lack of transportation, limited access to ethnic foods, low SES, and language barriers were associated with FI and poor diet quality. Similarly, discrimination, substance use, and immigration status were associated with depression and anxiety. However, studies examining the connection between AI's food experience and mental health are lacking. AIs are at a higher risk for FI, poor diet quality, and mental disorders. Ethnic-specific research to understand the connection between their food and mental health is needed to reduce nutrition and mental health disparities.

Perceived Need for a Faith-Based Trauma-Focused Treatment in a Sample of Forcibly Displaced Muslims

Forcibly displaced Muslims, including refugees, internally displaced persons, and asylum seekers who have fled their homes to escape violence, conflict, and persecution, often have inequitable access to quality mental health services, despite substantial trauma exposure and high rates of posttraumatic stress disorder (PTSD). Understanding factors associated with domains of perceived need (i.e., community, individual, friends/family) for culturally-responsive, trauma-focused mental health interventions among forcibly displaced Muslims may provide insight into those most likely to seek psychological treatment. A sample of 108 forcibly displaced Muslims endorsed moderate to high perceived need across all three domains for a trauma healing group tailored for Muslim refugees. PTSD severity related to perceived individual need, regardless of locus of displacement. Among participants with minimal PTSD symptoms, those who were externally displaced had higher perceived community and friends or family need than those who were internally displaced. Findings highlight a need for culturally responsive, trauma-focused mental health services to facilitate access to mental health care for forcibly displaced Muslims.

Uses of Andersen health services utilization framework to determine healthcare utilization for mental health among migrants-a scoping review

Background

Migration is a worldwide occurrence that carries significant implications for healthcare systems, and it entails challenges to mental healthcare. The Andersen Behavioral Model is widely used by researchers to determine healthcare service utilization among many populations, including migrants. Our study aimed to explore the ways of using the Andersen Health System Utilization Framework in the literature to discover the utilization of mental healthcare by migrants.

Methods

This scoping review was based on Arksey and O'Malley's framework. A comprehensive search was performed across five electronic databases.

Results

A total of 12 articles from January 1992 to July 2023 identified various versions of the Andersen Behavioral Model to provide an overview of mental health services utilization among migrants. The analysis identified four significant trends in the literature. First, there is a predominant focus on individual characteristics over contextual factors. Second, researchers tend to integrate multiple versions of the Andersen Behavioral Model, and the most is the version from 1995. Third, additional factors specific to migrant populations are incorporated into the model, but the categorization is sometimes unclear. Finally, the majority of studies have used a quantitative approach and are based in North America, suggesting a focus on the significance of mental health in migrant communities in that context.

Conclusion

In summary, our scoping review calls for further research using the Andersen Behavioral Model to study mental healthcare utilization among migrants. Notable findings include the adaptation of the model to migrant populations, a focus on individual characteristics, a need for more diverse research methods, and the proposal of a new conceptual model to guide research and policy development in this field.

Perceived racial discrimination, psychosomatic symptoms, and resilience among Black individuals in Canada: A moderated mediation model

OBJECTIVE

Although no study has explored psychosomatic symptoms in Black communities in Canada, several studies in the United States showed that psychological distress is often express as physical pain among African Americans. Using a cross-sectional design, the present study documents the frequency of psychosomatic symptoms and its association to racial discrimination, and resilience among Black individuals aged 15 to 40 in Canada.

METHOD

A total of 860 participants (M_age = 25.0 years, SD = 6.3), predominantly born in Canada (79.1%) and women (75.6%), completed the Symptom Checklist-90-Revised (somatization subscale), the Everyday Discrimination Scale, and the Resilience Scale-14.

RESULTS

Findings revealed that 81.7% of participants experienced psychosomatic symptoms, with higher prevalence among women (84.2%) compared to men (70.7%;), ꭓ² = 21.5, p < .001; participants aged 25 to 40 years old (93.7%) compared to those aged 15-24 years old (75.2%) (ꭓ² = 45.0, p < .001). Participants reporting greater racial discrimination had more psychosomatic symptoms (89.4%) compared to others (72.9%), ꭓ² = 39.2, p < .001). A moderated mediation model showed that everyday racial discrimination was positively associated with psychosomatic symptoms (B = 0.1, SE = 0.01, p < .001). The model showed that the association between racial discrimination and psychosomatic symptoms was partially mediated by resilience (B = -0.01, SE = 0.0, p < .01), and negatively moderated by gender (B = -0.04, SE = 0.01, p < .01). In other words, being a woman is associated with higher levels of psychosomatic symptoms among those who have experienced racial discrimination.

CONCLUSION

By highlighting the association between racial discrimination and psychosomatic symptoms and the role of resilience and gender in this relation, this article reveals important factors to integrate to improve healthcare services, prevention, and interventions among Black individuals with psychosomatic symptoms.

Association between time of residence and self-perception of distress, interpersonal relationships, and social role in Venezuelan immigrants in Lima, Peru 2018-19: mixed-methods study

BACKGROUND

Immigrants arriving in a new country face changes that affect their social, employment, and migratory status. We carried out a mixed-methods study in the rapidly growing Venezuelan immigrant population in Lima, Peru. The objective was to determine whether there was an association between time in Peru and self-perception of symptom distress (SD), interpersonal relationships (IR), and social role (SR).

METHODS

The quantitative central component consisted of a cross-sectional study, surveying 152 participants using the Outcome Questionnaire 45.2 (OQ-45.2). The qualitative component, based on phenomenology, explored experiences and challenges during the migration process. Semi-structured in-depth interviews were conducted in 16 informants.

RESULTS

An association that was observed was the increase in the risk of clinically significant SR score with additional years of age. All informants mentioned having witnessed or experienced xenophobia in Peru. Every informant stated that significant labor differences existed between the countries. The most reported somatic symptoms were symptoms of anxiety and alterations of sleep. Additionally, no informant expressed a desire to remain in Peru long term.

CONCLUSIONS

A minority of participants registered a clinically significant total score and in each of the three domains of SD, IR, and SR. No association between months in Lima and the self-perception of distress was found. However, this could be due to the short amount of time spent in Peru and any change in self-perception might only be perceived after years or decades spent in Peru. This study is one of the first to use mixed-methods to explore the mental health of the immigrant Venezuelan population.

Beliefs About Causes and Cures of Prolonged Grief Disorder Among Arab and Sub-Saharan African Refugees

Background

Many refugees have experienced the death of a loved one under traumatic circumstances. Accordingly, the prevalence of Prolonged Grief Disorder (PGD) among refugees is high. Culture-specific symptoms of PGD have been described previously, but beliefs about causes and cures of PGD among refugees remain unknown. We therefore aimed at identifying illness beliefs and treatment expectations regarding PGD among refugees.

Method

We focused on refugees from Arab countries (n = 14) and from Sub-Sahara Africa (n = 9) and applied qualitative and quantitative methods. In a semi-structured interview, participants first answered questions about assumed causes and potential cures for prototypical PGD symptoms according to ICD-11 that were presented in a vignette as representatives of their own culture. In the quantitative part, they completed the Cause Subscale of the Illness Perception Questionnaire (IPQ-R) that included additional culture-specific items. Interviews were analyzed with Qualitative Content Analysis.

Results

In both groups of refugees, PGD symptoms were predominantly attributed to a close relationship to the deceased, lack of social support, personal vulnerabilities, and circumstances of the death. Participants also named a number of flight-related causes (e.g., inability to perform or participate in rituals, feeling isolated in the host country). None of the participants attributed PGD symptoms to supernatural causes. Descriptive analyses of responses on the IPQ-R indicated that participants predominantly attributed PGD symptoms to psychological causes. Participants believed that PGD can be cured and predominantly mentioned social and religious support. Psychological help was only mentioned by a minority of participants. In both groups, participants emphasized that a therapist must be familiar with the patient's culture and rituals. Participants also mentioned stigma associated with seeking psychological help.

Conclusion

Results suggest specific beliefs of refugees regarding causes and cures of PGD as well as similarities with Western conceptualizations. A culture-sensitive approach to the treatment of PGD in refugees that can include knowledge of culture-specific rituals and incorporating religious beliefs as well as decreasing stigma and increasing mental health literacy seem important. The study is limited by its focus on only two groups of refugees and its small sample size.

Predisposing and Enabling Factors Associated with Venezuelan Migrant and Refugee Women's Access to Sexual and Reproductive Health Care Services and Contraceptive Usage in Peru

Objective

Over 6 million migrants and refugees from Venezuela have left their country in the past decade; 1 million of them reside in Peru. Venezuelan migrant and refugee women are known to have limited access to sexual and reproductive health care services (SRHS) and contraceptive usage. To date, research to understand factors influencing access to those services is limited. This study aims to determine which enabling and predisposing factors influence Venezuelan migrant and refugee women's access to SRHS and contraceptive usage.

Methods

This is a retrospective cross-sectional study of the first survey administered to the Venezuelan population residing in the Peru in 2018. The survey covered six cities in the country (Metropolitan Lima, Callao, Tumbes, Cusco, Trujillo, Arequipa). The sample for the study included Venezuelan migrant women of reproductive age (15–49 years old). Anderson's Behavior Model of Health Services is the conceptual framework of the investigation. Logistic regression models were fit to examine the relationship between different predisposing and enabling factors and women's access to SRHS and contraceptive usage.

Results

The sample size includes a total of 3378 Venezuelan women of reproductive age. 50.7% of the women were between the ages of 21–30 and over 90.6% of the sample were residing in Metropolitan Lima. Only 20.2% of the women reported they had access to modern contraceptives. Results from the study suggest having insurance, residing in Trujillo, and having a higher socio-economic status were associated with more access to certain sexual reproductive health care services and contraceptive usage.

Conclusion

This study identified different predisposing and enabling factors relevant to the access to SRHS and contraceptive usage. Difference in access and usage are particularly pronounced based on insurance status, geographical location, and socio-economic status. Displaced Venezuelans will remain abroad for an extended period of time, if not permanently. Focus should shift from providing humanitarian aid to integrating the migrants and refugees, particularly the most vulnerable groups, into the local economic and healthcare system.

The Traumatizing Impact of Racism in Canadians of Colour

Purpose of Review

While research has identified racial trauma in other contexts, it is often overlooked amongst Canadian society. Racial trauma occurs as a result of an event of racism or cumulative events over time whereby an individual experiences stress and consequent mental health sequelae. Given that the BIPOC (Black, Indigenous, and/or Person of Colour) population in Canada is increasing, it is imperative to identify racial discrimination and the subsequent stress and trauma associated with being racialized in Canada, which subjects BIPOC Canadians to various forms of racism, including microaggressions.

Recent Findings

This paper reviews the published literature on racism and racial discrimination that identifies or infers racial trauma as the source of the mental health implications for various groups (e.g., Indigenous people, Black Canadians, Asian Canadians, immigrants, and refugees). In addition, intersectionality of racialized persons is prominent to their psychological well-being as their psychosocial and socioeconomic position are complex. Therefore, this paper both provides insight into the Canadian experience as a person of colour and signifies the need for further research on racial trauma in a Canadian context.

Summary

Despite Canada’s emphasis on multiculturalism, racialized individuals are at risk for racial trauma due to prejudice and discrimination. The politicization of multiculturalism has permitted Canada to deny claims of racism, yet the historical basis of established institutions results in irrefutable systemic and systematic barriers for Canadian people of colour.

Perspectives of Black Immigrant Women on Mental Health: The Role of Stigma

Background:

Black immigrants are a major growing segment of the United States population. The intersection of race, gender, and migration places black immigrant women at the confluence of multiple social determinants of health, and thus, black immigrant women experience ongoing mental health disparities. Understanding their perspectives, mental health needs, and associated stigma is critical to promoting positive mental health outcomes.

Methods:

We conducted five focus groups (N = 22) among women from two black immigrant community organizations from February 2019 to June 2019. We used an inductive driven thematic analysis to identify codes and themes related to mental health and the role of stigma.

Results:

Overall five core themes associated with mental health and associated stigma concepts were found: The critical role of trusted sources and confidentiality, Conceptualization of mental illness and anticipated discrimination, Acculturative influence and migration as a source of emotional distress, Spirituality as a source of support and source of stigma, and Management of mental illness and addressing stigma.

Conclusion:

The conceptualization of mental illness and the associated stigma may be rooted in cultural and religious belief systems among black immigrants. Cultural beliefs and biopsychosocial models can coexist positively without interrupting the pathway toward optimized engagement in mental health care. Our mental health systems need to take these factors into consideration to implement programs that effectively serve black immigrant women's mental health needs.

New directions in the mental health care of migrants, including refugees-A randomized controlled trial investigating the efficacy of value-based counselling

OBJECTIVE

Specialized literature has identified a need for evidence-based, low-threshold, short-term, and intracultural psychological interventions that can be made available to migrants, including refugees, who suffer from psychological symptoms in host countries. The objective of the present study is to measure the efficacy of value-based counselling (VBC) as such an intervention.

METHOD

We conducted a pragmatic, rater-blinded randomized controlled trial employing a pre-post control group design to assess the efficacy of VBC based on a study sample of 103 migrants, including refugees, who resided in Germany at the time. A set of instruments was used to evaluate primary outcome measures of depression, posttraumatic stress disorder (PTSD) symptoms, perceived stress, generalized anxiety, and somatic complaints.

RESULTS

Per protocol analysis included 42 participants in the VBC group, and 43 in the waiting list. Compared with participants in the waiting-list group, the VBC group, following an average of four counselling sessions, experienced a clinically meaningful reduction of depression (adjusted difference 7.06, 95% CI [4.86, 9.26], effect size 0.68, p < .001), PTSD (adjusted difference 17.15, 95% CI [10.49, 23.81], effect size 0.76, p < .001), perceived stress (adjusted difference 9.25, 95% CI [6.23, 12.27], effect size 0.75, p < .001), anxiety (adjusted difference 5.34, 95% CI [3.47, 7.20], effect size 0.70, p < .001), and somatic complaints (adjusted difference 5.52, 95% CI [3.30, 7.74], effect size 0.72, p < .001). The positive outcomes were maintained at 3-month follow-up. Utilization of mental health services was significantly reduced at the 3-month follow-up conducted with participants of the VBC group.

CONCLUSIONS

VBC, a culturally sensitive and strength-based mental health service, is an effective short-term intervention which meets the specific mental health needs of migrants, including refugees.

A Mental Health Profile of 900 Newly Arrived Refugees in Denmark Using ICD-10 Diagnoses

(1) Background: Recognizing mental health problems in newly arrived refugees poses a challenge. Little is known of the mental health profile of refugees currently arriving in Northern Europe. (2) Method: In total, we included 900 adult (≥18 years old) refugees arriving in Aarhus, Denmark, between 1 January 2014 and 1 January 2020. All participants accepted an offer of a voluntary systematic health assessment from the municipality in Aarhus, including a mental health screening. (3) Results: Within this cohort, 26% (237/900) of the participants were referred to the Department of Psychiatry, Aarhus University Hospital, 24% (212/900) were in contact with the department and 21% (185/900) received ≥1 psychiatric diagnosis. Within the subpopulation referred (n = 237), 64% (152/237) were diagnosed with post-traumatic stress disorder (PTSD) (DF431), 14% (34/237) with neurotic, stress-related and somatoform disorders (F40–F48) and 13% (30/237) with major mood disorders (F30–F39). Among the participants referred to the Department of Psychiatry and participants receiving a diagnosis, we found an overrepresentation of participants originating from the Southern Asian region (Pakistan, Afghanistan and Iran) and with an age above 44 years. (4) Conclusion: We found a high prevalence of both referrals and psychiatric diagnoses in newly arrived refugees. Attention to psychiatric conditions in refugees and systematic health assessments during resettlement are needed.

Albanian Migrants in Cyclades: Contact with Mental Health Services and Implications for Practice

The purpose of this study was to examine the potential differences between Albanian migrants and Greeks in the islands of Paros and Antiparos with regard to seeking help from the local public mental health service, namely the Mobile Mental Health Unit of NE Cyclades Islands (EPAPSY-NGO). The study’s instruments include the Global Assessment of Functioning (GAF) and a questionnaire for recording psychosocial profile data and information concerning contact with the services. The results showed that significantly less Albanian migrants contacted the mental health services in the past in comparison to Greeks. When using the service, the Albanians were more likely to see a psychiatrist in the Unit, rather than a psychologist-psychotherapist, and they more often received prescriptions for medication. There was a significantly higher dropout rate among Albanian migrants. This study highlights the different aspects of access and use of mental health services among Albanian migrants compared with native residents. Further research should focus on the factors related to early dropouts and difficulties accessing mental health services in rural areas, in order to develop more focused and effective interventions and improve the quality of care provided.

Psychological distress among Ethiopian migrant returnees who were in quarantine in the context of COVID-19: institution-based cross-sectional study

BACKGROUND

In association with the novel coronavirus (SARS-CoV-2) disease 2019 (COVID-19) pandemic, many numbers of Ethiopian migrants are returning to their home country, and they are required to stay in mandatory quarantine centers. This results in severe disruptions of life routines, social isolation, and loss of freedom. Studies on psychological distress among Ethiopian migrant returnees in the context of COVID-19 are scarce. This study aimed to investigate the prevalence of psychological distress and associated factors among migrant returnees who were in quarantine during the time of COVID-19.

METHODS

A cross-sectional study was conducted with 405 migrant returnees recruited from quarantine centers in Addis Ababa. We developed a structured questionnaire to collect data on sociodemographic, migration related, quarantine related and COVID-19 related characteristics of participants. We used the 21 item Depression, Anxiety and Stress Scale to assess psychological distress. Univariate and multivariable negative binomial regression models were fitted to assess the association between exposure variables with depression, anxiety and stress separately.

RESULTS

A little more than half of the participants (55%) had depressive symptoms; around half had anxiety symptoms (48.9%) and more than a third (35.6%) experienced symptoms of stress. We found significantly higher prevalence of anxiety (ARR = 0.59; 95% CI = 0.39, 0.91) and depressive symptoms (ARR = 0.56; 95% CI = 0.39, 0.81) among women than men. Fear of discrimination after the quarantine was significantly associated with depressive (ARR = 0.76; 95% CI = 0.63, 0.92) and anxiety symptoms (ARR = 0.77; 95% CI = 0.62, 0.97). Experiencing COVID-19 like symptoms is associated with depressive (ARR = 0.40; 95% CI = 0.25, 0.65), anxiety (ARR = 0.35; 95% CI = 0.20, 0.62) and stress symptoms (ARR = 0.43; 95% CI = 0.28, 0.66). Have no a plan of what to do after the quarantine (ARR = 1.30; 95% CI = 1.09, 1.54) was significantly associated with increasing stress scores.

CONCLUSIONS

We found a very high prevalence of depressive, anxiety and stress symptoms among Ethiopian migrant returnees who were in quarantine due to the COVID-19 pandemic. Screening, integration of mental health services with other socioeconomic and psychosocial services, and effective and efficient referral may be useful to address the burden of psychological distress in this group.

Willingness to Use Mental Health Services for Depression Among African Immigrants and White Canadian-Born People in the Province of Quebec, Canada

Studies suggest that non-Caucasian immigrants to Canada are less likely than Canadian-born people to use mental health services. To meet the mental health needs of ethnocultural minorities, insights into their help-seeking attitudes are of great concern. This study examined the willingness of African immigrants and White Canadian-born to seek care for depression from conventional mental health services.  African immigrants (N = 262) and White Canadian-born people (N = 250) living in Montreal, Canada, indicated their willingness to use mental health services under different conditions varying as a function of four factors: the severity of symptoms, the waiting time for first consultation, the type of care offered in the mental health service, and whether informal sources of help were available.  Seven qualitatively different positions were identified: Never Consult (18% of the African immigrants and 1% of the White Canadian-born people); Hesitant (18% of the African immigrants and 7% of the White Canadian-born people); Depends on Waiting Time (16% of the African immigrants); Depends on Waiting Time and Symptoms (22% of the African immigrants); Depends on Symptoms (36% of the White Canadian-born people and 6% of the African immigrants); Willing to consult (33% of the White Canadian-born people and 2% of the African immigrants); Certain to Consult (9% of the White Canadian-born people and 4% of the African immigrants), while 14% of participants in each group did not express any position. African immigrants were more likely to underuse mental health services, compared with White Canadian-born people. The above diversity of positions strongly suggests that the design and implementation of interventions to reduce disparities in African immigrants' use of mental health care must not be "one size fits all" but must be tailored to address these immigrants' differing attitudes and needs.

Challenges and lessons learned in mental health research among refugees: a community-based study in Turkey

BACKGROUND

Turkey hosts nearly four million refugees and 99% live in urban areas. Research in urban settings pose different challenges and opportunities than research in refugee camps. In this article, we aimed to share the challenges and experiences we encountered in a mixed-methods study to assess mental health problems and barriers to accessing mental health care among refugees in urban areas of Turkey.

DISCUSSION

In our case, the main challenges in conducting research with refugees were collecting data from a highly traumatized population, difficulties with contacting undocumented asylum seekers including trust issues and the fear of deportation, the risk of secondary traumatization among data collectors, and the bureaucracy during study approval processes. Targeting a representative sample was not feasible, because of the lack of publicly available demographic data on a district level, presence of undocumented asylum seekers and high mobility among the refugees. Although respondents with significant psychological symptoms were routinely referred to available mental health services, we were able to do less for unregistered refugees with problems in accessing health care. Language/alphabet differences and differing dialects of Arabic posed another challenge in both translation and administration of the scales. Based on cultural characteristics, a gender-balanced team was used and the interviewers were gender-matched whenever needed. Also, the research team had to work after work hours and during weekends to be able to interview male refugees, since most refugee men were at work during working hours and most days of the week.

CONCLUSIONS

The research team's experience showed that refugee population characteristics including level of trauma, language, culture, gender, legal status, and urban setting characteristics including places of living, mobility, availability of publicly available demographic data, and outreach-related barriers lead to different challenges and ethical responsibilities of researchers and affect the research costs in terms of time, human resources and finance. Even in a host country with geographical, religious and cultural proximity to the refugees, profound challenges exist in conducting mental health research in urban settings. Learning from previous experience and collaborating with local researchers and institutions are vital for better public health research and practice outcomes.

Factors influencing utilization and perception of health care: a qualitative study among traumatized Yazidi refugees in Germany

BACKGROUND

Ensuring adequate utilization of healthcare services for displaced populations is critical, yet there are well-documented treatment gaps. Yazidi women captured by the Islamic State (IS) were subjected to extreme trauma and violence. This study aims to understand perceptions of healthcare providers and utilization of these services among women who experienced extreme trauma.

METHODS

This is a qualitative study with voluntary participation offered to approximately 400 women resettled through the Special Quota Program. An empirical approach was used to collect data and a grounded theory approach was used for content analysis. Participants ranked their interactions with providers on a Likert scale. Posttraumatic stress disorder (PTSD) symptoms were assessed using the impact of event scale-revised questionnaire.

RESULTS

A total of 116 Yazidi women participated in this study. The women experienced an average of 6.8 months of captivity by IS and 93% met criteria for probable PTSD. Eighty-three percent of the women interacted with a physician; 80% found this interaction helpful. Sixty-nine percent interacted with psychologists; 61% found this interaction helpful. Six themes emerged: "reminders of trauma" and "hopelessness" in relation to the traumatic experience; "immediate relief" and "healing through pharmaceutical treatment" in relation to provider interventions, and "support" and "cultural differences" in relation to interactions with providers.

CONCLUSIONS

There exist major barriers to care for Yazidi women who experienced extreme trauma, particularly in regards to psychiatric care. Perceptions of healthcare providers and perceived effectiveness of therapy are critical factors that must be taken into consideration to improve healthcare utilization and outcomes.

Inspiring Muslim Minds: Evaluating a Spiritually Adapted Psycho-educational Program on Addiction to Overcome Stigma in Canadian Muslim Communities

The stigma of addiction in Muslim communities is a significant barrier to accessing mental health services. The objective of this study was to evaluate the impact of a newly developed spiritually-adapted addictions psychoeducational program with adult Muslims in the mosque setting. Ninety-three individuals were recruited from nine different mosques within Toronto, Canada. Ninety-minute seminars were presented. This study used a convergent mixed method design. There was a significant increase in the participants' self-reported knowledge (t = 3.6; p < 0.001), a more positive attitude on two scales (t = 3.7; p < 0.001 and t = 2.9; p = 0.005) and an increase in willingness to seek help from a medical doctor and mental health professional (t = 4.4; p < 0.001 and t = 2.2; p = 0.03, respectively) post-seminar as compared to baseline. Qualitative data confirmed these changes. Evidence-informed spiritually-adapted outreach program in the mosque setting can help reduce addiction related stigma in Muslim communities.

Understanding the health and housing experiences of refugees and other migrant populations experiencing homelessness or vulnerable housing: a systematic review using GRADE-CERQual

BACKGROUND

A growing number of migrants experience precarious housing situations worldwide, but little is known about their health and housing experiences. The objective of this study was to understand the enablers and barriers of accessing fundamental health and social services for migrants in precarious housing situations.

METHODS

We conducted a systematic review of qualitative studies. We searched the databases of MEDLINE, PsycINFO, CINAHL, Scopus, Web of Science, Social Sciences, Canadian Business & Current Affairs and Sociological Abstracts for articles published between Jan. 1, 2007, and Feb. 9, 2020. We selected studies and extracted data in duplicate, and used a framework synthesis approach, the Bierman model for migration, to guide our analysis of the experiences of migrant populations experiencing homelessness or vulnerable housing in high-income countries. We critically appraised the quality of included studies using the Critical Appraisal Skills Programme checklist and assessed confidence in key findings using the Grading of Recommendations Assessment, Development and Evaluation Confidence in the Evidence from Reviews of Qualitative Research (GRADE-CERQual) approach.

RESULTS

We identified 1039 articles, and 18 met our inclusion criteria. The studies focused on migrants from Asia and Africa who resettled in Canada, Australia, the United States, the United Kingdom and other European countries. Poor access to housing services was related to unsafe housing, facing a family separation, insufficient income assistance, immigration status, limited employment opportunities and lack of language skills. Enablers to accessing appropriate housing services included finding an advocate and adopting survival and coping strategies.

INTERPRETATION

Migrants experiencing homelessness and vulnerable housing often struggle to access health and social services; migrants may have limited proficiency with the local language, limited access to safe housing and income support, and ongoing family insecurities. Public health leaders could develop outreach programs that address access and discrimination barriers.

PROSPERO REGISTRATION

CRD42018071568.

The impact of parental trauma, parenting difficulty, and planned family separation on the behavioral health of West African immigrant children in New York City

OBJECTIVE

The association between parental mental health difficulties and poor child outcomes is well documented. Few studies have investigated the intergenerational effects of trauma in immigrant populations. This study examined the relationships among parental trauma, parenting difficulty, duration of planned family separation, and child externalizing behavior in an archival dataset of West African voluntary and forced immigrants in New York City. We hypothesized that parenting difficulty would mediate the association between parental posttraumatic stress and child externalizing behavior and that this association would be stronger for parent-child dyads that had undergone lengthier separations during migration.

METHOD

Ninety-one parents reported on their posttraumatic stress symptoms using the Harvard Trauma Questionnaire (HTQ) and on the behavioral health of one child between the ages of 5 and 12 years using the externalizing items of the Child Behavior Checklist (CBCL Externalizing). A 4-item self-report scale assessed difficulty parenting in the last month.

RESULTS

Linear regression analyses showed that parenting difficulty partially mediated the relationship between HTQ and CBCL scores. The relationship between HTQ and CBCL scores was not significant for parents separated from their children for one year or less but was significant for those never separated or separated for longer than 1 year. Higher HTQ scores were most strongly associated with higher CBCL Externalizing scores for those separated longer than one year.

CONCLUSIONS

Findings suggest that children of immigrants recovering from trauma are at risk of exhibiting behavioral symptoms and highlight a potential intervention target for improving child outcomes in immigrant families. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Mental Health Stigma Among Black Immigrant Women in An Urban Setting

BACKGROUND

Mental health stigma results in unmet mental health needs. Research describing predictors of stigma remains limited among Black immigrants. We aim to examine stigma associated with mental illness among a group of Black immigrant women.

METHODS

We examined data from 22 women from two Black immigrant community centers. We collected surveys on demographics, cultural beliefs, migration status, religiosity and mental health stigma. Simple linear regression was used to model the unadjusted association between each component variable and overall stigma scores. All analyses were conducted using R and assumed a two-sided, 5% level of significance.

RESULTS

A linear relationship was found between author-generated scale, the Stigma and Culture Survey (SCS) and the Depression Self Stigma Scale (DSSS). Among respondents, use of religious resources was associated with less stigma (p-value: 0.04). Whereas spirituality and morality was associated with greater stigma (p-value: 0.003). United States citizenship was associated with less stigma (p-value: 0.0001).

DISCUSSION/CONCLUSION

Religion and spirituality are critical to understanding mental health stigma among Black immigrants. Studies aimed at assessing and reducing stigma need to critically engage with cultural and religious factors.

Global Mental Health and Services for Migrants in Primary Care Settings in High-Income Countries: A Scoping Review

Migrants are at a higher risk for common mental health problems than the general population but are less likely to seek care. To improve access, the World Health Organization (WHO) recommends the integration of mental health services into primary care. This scoping review aims to provide an overview of the types and characteristics of mental health services provided to migrants in primary care following resettlement in high-income countries. We systematically searched MEDLINE, EMBASE, PsycInfo, Global Health, and other databases from 1 January 2000 to 15 April 2020. The inclusion criteria consisted of all studies published in English, reporting mental health services and practices for refugee, asylum seeker, or undocumented migrant populations, and were conducted in primary care following resettlement in high-income countries. The search identified 1627 citations and we included 19 studies. The majority of the included studies were conducted in North America. Two randomized controlled trials (RCTs) assessed technology-assisted mental health screening, and one assessed integrating intensive psychotherapy and case management in primary care. There was a paucity of studies considering gender, children, seniors, and in European settings. More equity-focused research is required to improve primary mental health care in the context of global mental health.

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.

Undiagnosed depression, persistent depressive symptoms and seeking mental health care: analysis of immigrant and non-immigrant participants of the Canadian Longitudinal Study of Aging

AIMS

Early diagnosis and treatment of depression are associated with better prognosis. We used baseline data of the Canadian Longitudinal Study on Aging (2012-2015; ages 45-85 years) to examine differences in prevalence and predictors of undiagnosed depression (UD) between immigrants and non-immigrants at baseline and persistent and/or emerging depressive symptoms (DS) 18 months later. At this second time point, we also examined if a mental health care professional (MHCP) had been consulted.

METHODS

We excluded individuals with any prior mood disorder and/or current anti-depressive medication use at baseline. UD was defined as the Center for Epidemiological Studies Depression 10 score ⩾10. DS at 18 months were defined as Kessler 10 score ⩾19. The associations of interest were examined in multivariate logistic regression models.

RESULTS

Our study included 4382 immigrants and 18 620 non-immigrants. The mean age (standard deviation) in immigrants was 63 (10.3) years v. 65 (10.7) years in non-immigrants and 52.1% v. 57.1% were male. Among immigrants, 12.2% had UD at baseline of whom 34.2% had persistent DS 18 months later v. 10.6% and 31.4%, respectively, among non-immigrants. Female immigrants were more likely to have UD than female non-immigrants (odds ratio 1.50, 95% confidence interval 1.25-1.80) but no difference observed for men. The risk of persistent DS and consulting an MHCP at 18 months did not differ between immigrants and non-immigrants.

CONCLUSIONS

Female immigrants may particularly benefit from depression screening. Seeking mental health care in the context of DS should be encouraged.

Syrian refugees' experiences with mental health services in Turkey: "I felt lonely because I wasn't able to speak to anyone"

PURPOSE

This study examined Syrian refugee adults' experiences with mental health services due to a mental complaint.

DESIGN AND METHODS

This qualitative study used a phenomenological design. The data were collected in semi-structured focus group interviews between June and August 2018. A total of 24 individuals participated in the study. The data were analyzed using Colaizzi's method of phenomenological interpretation.

FINDINGS

Seven themes were identified by thematic analysis of the interviews: (a) difficulties making appointments, (b) difficulties obtaining medicine, (c) personal rights, (d) lack of information, (e) language barrier, (f) discrimination, and (g) confidence versus anxiety.

PRACTICE IMPLICATIONS

Nurses should be aware of the barriers experienced by refugees that affect the quality and accessibility of psychiatric services.

Depression in migrant workers and nationals of Qatar: An exploratory cross-cultural study

BACKGROUND

The aim of this study was to compare the prevalence of depressive symptoms among migrants and non-migrants living in Qatar and identify variables associated with depressive symptomology in these groups, including culture of origin, time living in country and perceived quality of life. In addition, we tested if the latter two variables moderated the effect of culture of origin on depressive symptomology in the migrant groups.

SUBJECT AND METHODS

A telephone survey of a probability-based sample of 2,520 participants was conducted in February 2016. The sample was divided into three groups based on nationality and income: labour migrants (LMs), white-collar migrants (WCMs) and non-migrants or Qatari nationals (QNs). Participants completed the Whooley two-question test for depression.

RESULTS

The odds of depression were significantly increased in LMs (OR = 3.31, 95% CI = 2.36-4.65) and WCMs (OR = 1.40, 95% CI = 1.04-1.90) compared with non-migrants. Among LMs, having a problem with current employer in the last 3 months was also associated with depressive symptoms (OR = 2.10, 95% CI = 1.14-3.84). Culture of origin was significantly associated with depressive symptoms including South Asians (OR = 3.12, p < .001), East Asians (OR = 0.52, p = .013) and Westerners (OR = 0.45, p = .044) relative to Arabs. LM status remained strongly associated with depressive symptoms independent of culture of origin (OR = 2.02, p < .001).

CONCLUSION

Perceived quality of life, but not length of stay, appears to be an important variable in explaining differences in symptoms between some cultural groups. Findings from this study highlight the importance of the context of migration and culture of origin as potential determinants of depressive symptomology in the host country.

Gender-Based Expectations and their Effect on Mental Health Amongst Black African Immigrant Young Men Living in Canada

Black African immigrant men’s mental health is relatively understudied. This article is part of a larger study that explored the perceptions of mental health amongst African immigrant youth living in Canada. Using an interpretive description methodology, underpinned by an intersectional and critical lens, this article addresses racial, societal, and cultural expectations that could have an effect on Black African immigrant men’s mental health. Eight men and women who self-identified as Black African immigrants between the ages of 18 and 25 participated in the overall study, while five participants contributed the data for this article. Masculinity as a determinant of health, the resilience of African men, and the intersections of identity and vulnerability are discussed. It is concluded that the stigma surrounding Black African men speaking out about their mental health warrants a deeper examination in relation to their mental health outcomes. Areas of further inquiry include exploring mental health service utilization amongst Black African immigrant men.

Psychiatric nursing care experiences of immigrant patients: A Focused ethnographic study

This study aimed to describe the psychiatric nursing care experiences of immigrant patients. The incidence of mental health problems is higher and the use of mental health services is lower among immigrants, especially refugees, compared with the majority of the population. The study uses a qualitative research approach, with an emphasis on focused ethnography research methods. The participants were immigrant patients (N = 14) residing in adult psychiatric wards of certain hospitals (N = 3) selected for the study. A majority of the participants were refugees or asylum seekers. A total of 21 in-depth interviews were conducted. The experiences of these immigrant patients, both in their home countries and in their country of residence, had had an adverse effect on their mental health, with past traumatic experiences being the most central factor. Their symptoms included depression, anxiety, somatization, and psychosis. The findings show that the categories of factors that helped promote recovery among immigrant patients were nursing, medical treatment, care environment, and the patients' own methods. Based on the findings, a systematic evaluation of traumatic experiences is recommended for immigrants from countries with a history of war and/or political violence. Healthcare providers should also consider the importance of cultural desire in psychiatric nursing for the recovery of patients.

A Clinical-Psychological Perspective on Somatization Among Immigrants: A Systematic Review

Background: Somatic and psychopathological conditions (e.g., anxiety, depression, post-traumatic stress disorder, and somatization) are frequent among immigrants belonging to various ethnic groups. Worldwide findings on the epidemiology regarding specific mental conditions still vary with respect to different migration samples and migration contexts. This inconsistency also holds true in the incidence of somatization among migrants. We carried out a systematic review analyzing the relationship between migration and somatization by providing a qualitative data synthesis of original research articles on the topic.

Methods: According to PRISMA guidelines, we conducted a systematic search of the literature on PubMed, Scopus, ISI Web of Science, PsycINFO, Google Scholar, and ScienceDirect. The articles were selected using multiple combinations of relevant search terms (e.g., defined somatization and related disorders, and migration status). Each database was searched systematically from January 2000 to December 2017.

Results: The initial search identified 338 records, of which 42 research reports met the predefined inclusion criteria and were analyzed. Most studies (n = 38; 90%) were cross-sectional. The main findings of this study are that migrants with somatization exhibited more psychological distress, had an increased perceived need for healthcare service utilization, and reported more post-migration living difficulties and/or post-traumatic stress disorder than those without somatization. It was also found that specific individual features mediate the association between somatization and migration. The prevalence and correlates of somatization were found to vary across the immigrant groups, depending on cultural variation in reasons for migration, stress exposure, explanatory models of illness, coping, and other individual variables.

Conclusion: Somatization is a challenge for health professionals due to its vague nature. In this regard, clinical management of immigrant patients should include further efforts to address emotional distress, with special attention to social, cultural, and linguistic differences.

'Only God can promise healing.': help-seeking intentions and lay beliefs about cures for post-traumatic stress disorder among Sub-Saharan African asylum seekers in Germany

Background: Epidemiological studies have reported high rates of post-traumatic stress disorder (PTSD) among asylum seekers from Sub-Saharan Africa. In order to provide appropriate and culturally sensitive mental health care for this group, further knowledge about treatment preferences might be necessary. Objective: We aimed to provide insights into help-seeking intentions and lay beliefs about cures for PTSD held by asylum seekers from Sub-Saharan Africa living in Germany. Methods: To address this objective, we used a quantitative and qualitative methodological triangulation strategy based on a vignette describing symptoms of PTSD. In the quantitative part of the study, asylum seekers (n = 119), predominantly from Eritrea (n = 41), Somalia (n = 36), and Cameroon (n = 25), and a German comparison sample without a migration background (n = 120) completed the General Help-Seeking Questionnaire (GHSQ). In the qualitative part, asylum seekers (n = 26) reviewed the results of the questionnaire survey within eight focus group discussions sampled from groups of the three main countries of origin. Results: Asylum seekers showed a high intention to seek religious, medical, and psychological treatment for symptoms of PTSD. However, asylum seekers indicated a higher preference to seek help from religious authorities and general practitioners, as well as a lower preference to enlist psychological and traditional help sources than Germans without a migration background. Furthermore, asylum seekers addressed structural and cultural barriers to seeking medical and psychological treatment. Conclusion: To facilitate access to local health care systems for asylum seekers and refugees, it might be crucial to develop public health campaigns in collaboration with religious communities. When treating asylum seekers and refugees from Sub-Saharan Africa, practitioners should explore different religious and cultural frameworks for healing and recovery in order to signal understanding and acceptance of varying cultural contexts.

A Review of Health Survey Research for People with Refugee Background Resettled from Africa: Research Gaps and Methodological Issues

We reviewed 27 studies on adults with a refugee background resettled from Africa published between 1999 and 2017 to appraise their methodological issues for survey research. Out of 27 studies, eleven used a single sampling method (referral = 1, convenience = 10), and 16 relied on multiple sampling methods, many of which were combinations of referral and convenience. The two most salient recruitment strategies found were building trusted relationships with the community (n = 15), and using recruiters who were culturally and linguistically matched to the refugee communities of interest (n = 14). Fifteen studies used existing data collection instruments, while in 13 studies, researchers developed their own data collection instruments. In-person or phone interviews using bilingual interviewers (n = 21) were the most frequently used mode of data collection, followed by a self-administered survey (n = 7). Our review presents methodological gaps in current refugee health studies, such as limited use of probability sampling approach due to system barriers, lack of information in community engagement and recruitment processes, and insufficient considerations of unique culture and experiences of refugee communities when developing or adapting the instruments. Efforts can be made to guide and facilitate appropriate reporting and development of more scientifically robust survey methodologies for refugee health studies, as well as to improve registration system infrastructure that may help identify these hidden populations more effectively.

Ethnic Differences in Mental Health Status and Service Utilization: A Population-Based Study in Ontario, Canada

BACKGROUND

The purpose of this study was to compare the prevalence of self-reported mental health factors, mental health service use, and unmet needs across the 4 largest ethnic groups in Ontario, Canada: white, South Asian, Chinese, and black groups.

METHODS

The study population was derived from the Canadian Community Health Survey, using a cross-sectional sample of 254,951 white, South Asian, Chinese, and black residents living in Ontario, Canada, between 2001 and 2014. Age- and sex-standardized prevalence estimates for mental health factors, mental health service use, and unmet needs were calculated for each of the 4 ethnic groups overall and by sociodemographic characteristics.

RESULTS

We found that self-reported physician-diagnosed mood and anxiety disorders and mental health service use were generally lower among South Asian, Chinese, and black respondents compared to white respondents. Chinese individuals reported the weakest sense of belonging to their local community and the poorest self-rated mental health and were nearly as likely to report suicidal thoughts in the past year as white respondents. Among those self-reporting fair or poor mental health, less than half sought help from a mental health professional, ranging from only 19.8% in the Chinese group to 50.8% in the white group.

CONCLUSIONS

The prevalence of mental health factors and mental health service use varied widely across ethnic groups. Efforts are needed to better understand and address cultural and system-level barriers surrounding high unmet needs and to identify ethnically tailored and culturally appropriate clinical supports and practices to ensure equitable and timely mental health care.

Mental Health Consultation Among Ontario's Immigrant Populations

To determine the prevalence rates and characteristics of past-year mental health consultation for Ontario's adult (18 + years old) immigrant populations. The Canadian Community Health Survey (CCHS) 2012 was used to calculate the prevalence rates of past-year mental health consultation by service provider type. Characteristics associated with mental health consultation were determined by carrying out multivariable logistic regression analysis on merged CCHS 2008-2012 data. Adult immigrant populations in Ontario (n = 3995) had lower estimated prevalence rates of past-year mental health consultation across all service provider types compared to Canadian-born populations (n = 14,644). Amongst those who reported past-year mental health consultation, 57.89% of Ontario immigrants contacted their primary care physician, which was significantly higher than the proportion who consulted their family doctor from Canadian-born populations (45.31%). The factors of gender, age, racial/ethnic background, education level, working status, food insecurity status, self-perceived health status, smoking status, alcohol drinking status, years since immigration, and age at time of immigration were significantly associated with past-year mental health consultation for immigrant populations. Ontario's adult immigrant populations most commonly consult their family doctor for mental health care. Potential exists for expanding the mental health care role of primary care physicians as well as efforts to increase accessibility of specialized mental health services. Integrated, coordinated care where primary care physicians, specialized mental health professionals, social workers, and community educators, etc. working together in a sort of "one-stop-shop" may be the most effective way to mitigate gaps in the mental health care system. In order to effectively tailor mental health policy, programming, and promotion to suit the needs of immigrant populations initiatives that focus on the connection between physical and mental health and migration variables such as length of stay in Canada, years since immigration, and other important migration variables (beyond the scope of the CCHS which require further study) need to be developed. Examination of the social determinants of mental health is critical to understand how we can best serve the mental health needs of Ontario's immigrant populations.

Mental Health of Refugees and Non-refugees from War-Conflict Countries: Data from Primary Healthcare Services and the Norwegian Prescription Database

High rates of mental health problems are consistently found among immigrants from refugee generating countries. While refugees and their family members may have experienced similar traumas, refugees are more likely to have undergone a stressful asylum period. This study aims to determine whether their mental health differs. Using national registry data, refugees and non-refugees from the same countries were compared on primary healthcare service use for mental health problems and purchase of psychotropic medicine. Refugees had higher odds of using primary health care services than non-refugees. Refugee women were more likely to purchase psychotropic medicine than non-refugee women. Refugee men were more likely to purchase anti-depressants. The findings suggest that refugees have poorer mental health than non-refugees. This may be due to a combination of greater pre-migration trauma and post-migration stressors such as enduring a difficult asylum period.

"It's That Route That Makes Us Sick": Exploring Lay Beliefs About Causes of Post-traumatic Stress Disorder Among Sub-saharan African Asylum Seekers in Germany

Many asylum seekers have been confronted with traumatizing events, leading to high prevalence rates of post-traumatic stress disorder (PTSD). Within the diagnostic context, clinicians should take into account patients' culturally shaped presentation of symptoms. Therefore, we sought to provide insights into beliefs about causes of PTSD held by Sub-Saharan African asylum seekers living in Germany. To this aim, we used a quantitative and qualitative methodological triangulation strategy based on a vignette describing symptoms of PTSD. In the first part of the study, asylum seekers (n = 119), predominantly from Eritrea (n = 41), Somalia (n = 36), and Cameroon (n = 25), and a German comparison sample without a migration background (n = 120) completed the Revised Illness Perception Questionnaire (IPQ-R). In the second part, asylum seekers reviewed the results within eight focus group discussions (n = 26), sampled from groups of the three main countries of origin. Descriptive analyses of the first part demonstrated that asylum seekers predominantly attributed PTSD symptoms to psychological and religious causes, and rather disagreed with supernatural causes. In comparison to the German sample without a migration background, asylum seekers attributed symptoms less strongly to terrible experiences, but more strongly to religious and supernatural causes. Within the focus group discussions, six attribution categories of participants' causal beliefs were identified: (a) traumatic life experiences, (b) psychological causes, (c) social causes, (d) post-migration stressors, (e) religious causes, and (f) supernatural causes. Our findings suggest that the current Western understanding of PTSD is as relevant to migrants as to non-migrants in terms of psychological causation, but might differ regarding the religious and supernatural realm. While awareness of culture-specific belief systems of asylum seekers from Sub-Saharan Africa regarding PTSD is important, our findings do underline, at the same time, that cultural differences should not be overstated.

The emotional distress of asylum seekers in Israel and the characteristics of those seeking psychiatric versus medical help

Israel has become a destination for asylum seekers. Asylum seekers often experience emotional distress, but have limited access to health services and rarely use psychiatric services. This study sought to understand and characterize the use of psychiatric versus medical services by asylum seekers in Israel. We compared the emotional distress, stressful life events and previous treatment consultations of 21 psychiatric service users (PSU) and 55 medical service users (MSU) at the Open Clinic of Physicians for Human Rights in Tel-Aviv. Participants completed a socio-demographic questionnaire, the General Health Questionnaire (GHQ-12), the Stressful Life Events Scale and the Health Care Utilization Questionnaire. PSU and MSU did not have significantly different levels of emotional distress. PSU reported significantly more stressful life events during the past year than MSU ( M = 5.81, SD 3.47 vs. M = 3.8, SD 2.35, p < 0.01). In comparison to MSU, PSU utilized more medical ( M = 4.33, SD 2.28) and non-medical ( M = 2.38, SD 1.92) services ( p < 0.001) than MSU. Asylum seekers who consulted multiple treatment agencies in the last year were 1.55 times more likely to seek psychiatric treatment than those who had consulted only a few treatment agencies. Emotional distress in asylum seekers appears to be under-diagnosed in the Open Clinic and under-treated by mental health professionals. To better detect this distress, a thorough screening is recommended at assessment. Collaboration with mental health professionals and community and religious leaders consulted in the past is important and can contribute to good health care outcomes in this population.

Patients' Mental Health Journeys: A Qualitative Case Study with Interactive Computer-Assisted Client Assessment Survey (iCASS)

Despite growing concerns about common mental disorders (CMDs), challenges persist in accessing timely and appropriate care, especially for immigrant, refugee, racialized and low-income groups. Partnering with a community health centre serving these populations in Toronto, we examined the Interactive Computer-assisted Client Assessment Survey (iCCAS) that screens for CMDs (depression, generalized anxiety, post-traumatic stress, and alcohol overuse) and related social factors. In this case study design with embedded units, we explored the mental health care journeys of patients who screened positive for a CMD. The analysis identified three major pathways of care: (1) early detection of previously unidentified CMDs; (2) detection of comorbid mental health conditions; and (3) prevention of possible relapse and/or management of existing previously recognized mental health condition. These cases indicate iCCAS holds potential to facilitate more open, tailored, and informed collaborations between patients and clinicians regarding mental health care plans.

Prevalence and associated factors of common mental disorders among Ethiopian migrant returnees from the Middle East and South Africa

BACKGROUND

Ethiopian migrants to the Middle East and South Africa experience a range of problems at various stages of their migration including overwork, sleep deprivation, denial of food, emotional abuse, difficulty adapting to the host culture, salary denial, sexual abuse, labor exploitation, confiscation of their travel documents, confinement, denial of medication, lack of access to legal service and degrading attitude by employers, traffickers and smugglers. These experiences can be associated with different types of mental disorders. This study sought to determine the prevalence of common mental disorders (CMD) and socio-demographic and other migration related associated factors among Ethiopian migrant returnees from the Middle East and South Africa.

METHOD

A cross-sectional study was conducted using non-probability (i.e. purposive, availability and snowball) sampling techniques. Migrant returnees (n = 1036) were contacted individually at their homes in eight high prevalent immigrant returnee locations in Ethiopia. Common mental disorders were assessed using the self-reporting questionnaire (SRQ-20) and a structured questionnaire was employed to collect data on socio-demographic and migration related characteristics. Data were analyzed using descriptive statistics, univariate logistic regression, and multivariable logistic regression.

RESULTS

The prevalence of CMD among migrant returnees was found to be 27.6%. Highly prevalent specific CMD symptoms included headaches, poor appetite, being tired, sleeping problems, and feeling unhappy or nervous. Being originally from Amhara and Oromia regions, being Christian, being divorced, not receiving salary on time, not being able to contact family, unable to prepare for domestic labor abroad, lack of cross- cultural awareness, and lack of knowledge and skills for work were all important risk factors for CMD. Migrants experienced adversities at different stages of their migration which are associated with psychological distress and even to long term mental illnesses.

CONCLUSIONS

CMD symptoms were found to be prevalent among Ethiopian migrant returnees. As pre-migration factors are associated with CMD symptoms, pre-departure training could be useful to mitigate the risk factors. Creating and routinely arranging mental health interventions and rehabilitation services are advisable for returnees who are screened for, or diagnosed with, mental health problems.

A systematic review of studies with a representative sample of refugees and asylum seekers living in the community for participation in mental health research

BACKGROUND

The aim was to review the literature to identify the most effective methods for creating a representative sample of refugee and asylum seeker groups living in the community to participate in health and mental health survey research.

METHODS

A systematic search of academic and grey literature was conducted for relevant literature with 'hidden' groups published between January 1995 and January 2016. The main search used Medline, PsycINFO, EMBASE, CINAHL and SCOPUS electronic databases. Hidden groups were defined as refugees, asylum seekers, stateless persons or hard/difficult to reach populations. A supplementary grey literature search was conducted. Identified articles were rated according to a created graded system of 'level of evidence for a community representative sample' based on key study factors that indicated possible sources of selection bias. Articles were included if they were assessed as having medium or higher evidence for a representative sample. All full-text papers that met the eligibility criteria were examined in detail and relevant data extracted.

RESULTS

The searches identified a total of 20 publications for inclusion: 16 peer-reviewed publications and four highly relevant reports. Seventeen studies had sampled refugee and asylum seekers and three other hidden groups. The main search identified 12 (60.0%) and the grey search identified another eight (40.0%) articles. All 20 described sampling techniques for accessing hidden groups for participation in health-related research. Key design considerations were: an a priori aim to recruit a representative sample; a reliable sampling frame; recording of response rates; implementation of long recruitment periods; using multiple non-probability sampling methods; and, if possible, including a probability sampling component. Online social networking sites were used by one study. Engagement with the refugee and asylum seeker group was universally endorsed in the literature as necessary and a variety of additional efforts to do this were reported.

CONCLUSIONS

The strategies for increasing the likelihood of a representative sample of this hidden group were identified and will assist researchers when doing future research with refugee groups. These findings encourage more rigorous reporting of future studies so that the representativeness of samples of these groups in research can be more readily assessed.

What are the barriers to access to mental healthcare and the primary needs of asylum seekers? A survey of mental health caregivers and primary care workers

BACKGROUND

We aimed to assess the opinion of primary care workers, social workers, translators and mental health caregivers who work with asylum seekers about the latter's unmet needs and barriers to access to mental healthcare.

METHODS

We used a Likert scale to assess the opinion of 135 primary care workers (general practitioners, nurses, social workers and translators) and mental health caregivers about the proportion of asylum seekers with psychiatric disorders, their priority needs and their main barriers to mental health services.

RESULTS

Insufficient access to adequate financial resources, poor housing and security conditions, access to employment, professional training and legal aid were considered as priority needs, as were access to dental and mental healthcare. The main barriers to access to mental healthcare for asylum seekers included a negative representation of psychiatry, fear of being stigmatized by their own community and poor information about existing psychiatric services.

CONCLUSIONS

We found a good correlation between the needs reported by healthcare providers and those expressed by the asylum-seeking population in different studies. We discuss the need for greater mobility and accessibility to psychiatric services among this population.

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

BACKGROUND

Refugees are one of the most vulnerable groups in Australian society, presenting high levels of exposure to traumatic events and consequently high levels of severe psychological distress. While there is a need for professional help, only a small percentage will receive appropriate care for their mental health concerns. This study aimed to determine cultural considerations required when providing mental health first aid to Iraqi refugees experiencing mental health problems or crises.

METHOD

Using a Delphi method, 16 experts were presented with statements about possible culturally-appropriate first aid actions via questionnaires and were encouraged to suggest additional actions not covered by the questionnaire content. Statements were accepted for inclusion in a guideline if they were endorsed by ≥90 % of panellists as 'Essential' or 'Important'.

RESULTS

From a total of 65 statements, 38 were endorsed (17 for cultural awareness, 12 for cross-cultural communication, 7 for stigma associated with mental health problems, and 2 for barriers to seeking professional help).

CONCLUSION

Experts were able to reach consensus about how to provide culturally-appropriate first aid for mental health problems to Iraqi refugees, demonstrating the suitability of this methodology in developing cultural considerations guidelines. This specific refugee study provided potentially valuable cultural knowledge required to better equip members of the Australian public on how to respond to and assist Iraqi refugees experiencing mental health problems or crises.

Immigrant Mental Health, A Public Health Issue: Looking Back and Moving Forward

The Mental Health Commission of Canada's (MHCC) strategy calls for promoting the health and wellbeing of all Canadians and to improve mental health outcomes. Each year, one in every five Canadians experiences one or more mental health problems, creating a significant cost to the health system. Mental health is pivotal to holistic health and wellbeing. This paper presents the key findings of a comprehensive literature review of Canadian research on the relationship between settlement experiences and the mental health and well-being of immigrants and refugees. A scoping review was conducted following a framework provided by Arskey and O'Malley (Int J Soc Res Methodol 8:19-32, 2005). Over two decades of relevant literature on immigrants' health in Canada was searched. These included English language peer-reviewed publications from relevant online databases Medline, Embase, PsycInfo, Healthstar, ERIC and CINAHL between 1990 and 2015. The findings revealed three important ways in which settlement affects the mental health of immigrants and refugees: through acculturation related stressors, economic uncertainty and ethnic discrimination. The recommendations for public health practice and policy are discussed.