Refugee mental health: exploring the impact of community-based psychosocial interventions

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Author: Dr Ross White, University of Liverpool

The UNHCR (the United Nations Refugee Agency) indicated that, as of the end of 2017, 68.5 million people across the world had been forced to leave their homes [1]. Of all the continents, Africa hosts the largest number of refugees. Conflicts in countries such as South Sudan and Democratic Republic of Congo have led to substantial numbers of people seeking refuge in neighbouring countries. Uganda, for example, hosts over 1.4 million refugees [2]. Relative to other continents, Africa also has the highest proportion of ‘low-income’ countries [3] (as classified by the World Bank). So countries that receive the largest number of refugees are often those that have the least resources to support their needs.

Relative to indigenous populations, refugee populations experience elevated rates of mental health difficulties, including disorders such as depression and post-traumatic stress disorder [4,5,6,7]. Factors associated with these higher risks of mental health difficulties arise during three distinct periods: 1) before migration (e.g. from exposure to war, torture and persecution) 8]; 2) during migration (e.g. due to exploitation, lack of basic needs, violence and injury) [9], and 3) after migration (e.g. from discrimination, uncertainty about asylum status, and socioeconomic deprivation) [10,5]. An important point to emphasize here is that factors associated with day-to-day living, in addition to previous potentially traumatic events, can impact on the mental health of refugees [11]. Indeed, it has been shown that reductions in post-migration living difficulties are associated with lower levels of depression and anxiety experienced by refugees [12].

Psychosocial interventions are based on an appreciation that aspects of a person’s surrounding social environment can combine with psychological factors to impact on their physical and mental health. The Mental Health & Psychosocial Support Network webpage (https://mhpss.net) provides information about various forms of psychosocial support. Guidelines have also been proposed for delivering psychosocial support in emergency situation2 [13] and with refugees specifically [14,15]. However, in low- and middle-income countries, where the vast majority of refugees reside, there is a marked absence of highly skilled professionals available to deliver mental health support [16]. In such settings, group-based forms of psychosocial support that can be facilitated by community members who receive training offer great promise. These approaches are socially acceptable and effective in treating common mental disorders, whilst also decreasing pressure on primary health care [17,18].

Concerns have been raised about the comparatively low quality of research studies investigating the efficacy of interventions for refugees and asylum seekers [19] and a lack of sufficient research focus on what contributes to resilience in refugee populations [20]. The recently launched Community-based Sociotherapy Adapted for Refugees (COSTAR) project that I am involved in, aims to address these issues through interdisciplinary research activity. The project is a collaboration of academic partners (University of Liverpool, Makerere University, University of Rwanda), the UNHCR, local non-governmental organizations (Community-based Sociotherapy Rwanda, Humanitarian Initiative Just Relief), and representatives of the refugee community. It aims to adapt and evaluate a group-based psychosocial intervention called Community-based Sociotherapy (CBS), which has been extensively used in post-Genocide Rwanda, by assessing its impact on the mental health of Congolese refugees in Rwanda and Uganda.

Following the recent COSTAR Project launch event in Kigali, Rwanda, we visited Gihembe refugee camp, which will be one of the recruitment sites for the research. The camp manager (a representative of the Ministry in Charge of Emergency Management, Rwanda) informed us that 13,340 people are living in 44 villages densely packed into a hilltop location. What struck us most during the visit was the vast number of young children in the camp – children who were bearing the brunt of political upheaval and conflict occurring hundreds of miles away. An oft’ cited African proverb states ‘it takes a village to raise a child’. This emphasizes the important role that the community can play in helping people to develop throughout their lives. We hope that the six phases of community-based sociotherapy (i.e. Safety; Trust; Care; Respect; New life orientation, and Memories) that we are evaluating in the COSTAR project will help to build brighter futures for the people living in Gihembe.

References:

  1.  http://www.unhcr.org/globaltrends2017/
  2.  http://www.unhcr.org/uk/news/latest/2018/3/5a9959444/uganda-launches-major-refugee-verification-operation.html
  3. http://www.spiegel.de/international/tomorrow/poverty-and-themiddle-income-country-designation-a-1100176.html
  4. Charlson, F. J. et al. (2016). Post-traumatic stress disorder and major depression in conflict affected populations: an epidemiological model and predictor analysis. Global Mental Health, 3(e4),1e-e4.
  5. Priebe, S. et al. (2016). Public health aspects of mental health among migrants and refugees: a review of the evidence on mental health care for refugees, asylum seekers and irregular migrants in the WHO European region. WHO, Geneva.
  6. Vossoughi, N. et al. (2016). Mental health outcomes for youth living in refugee camps: a review. Trauma, Violence, & Abuse, 19(5),528-42.
  7. Steel, Z., et al. (2009). Association of torture and other potentially traumatic events with mental health outcomes among populations exposed to mass conflict and displacement: a systematic review and meta-analysisJAMA302(5),537-49.
  8. Hollifield, M. et al. (2002). Measuring trauma and health status in refugees: a critical reviewJAMA288(5),611-21.
  9. International Organization for Migration (2015). World Migration Report – Migrants and Cities:New Partnerships to Manage Mobility. Geneva: International Organization for Migration.
  10. Laban, C. J. et al. (2008). The impact of a long asylum procedure on quality of life, disability and physical health in Iraqi asylum seekers in the NetherlandsSocial Psychiatry and Psychiatric Epidemiology43(7),507.
  11. Miller, K.E. & Rasmussen, A. (2014). War experiences, daily stressors and mental health five years on: elaborations and future directionsIntervention12,33-42.
  12. Schick, M. et al. (2018). Changes in Post-migration Living Difficulties Predict Treatment Outcome in Traumatized RefugeesFrontiers in Psychiatry9, 476.
  13. Inter-Agency Standing Committee. (2007). IASC guidelines on mental health and psychosocial support in emergency settings. Inter-Agency Standing Committee. Geneva: IASC
  14. UNHCR (2017) Community-based Protection & Mental Health & Psychosocial support. Geneva: UNHCR.
  15. UNHCR (2013) Operational Guidance Mental Health & Psychosocial Support Programming for Refugee Operations. Geneva: UNHCR.
  16. Mendenhall, E. et al. (2014). Acceptability and feasibility of using non-specialist health workers to deliver mental health care: stakeholder perceptions from the PRIME district sites in Ethiopia, India, Nepal, South Africa, and UgandaSocial Science & Medicine118,33-42.
  17. Tol, W.A. et al. (2011). Mental health and psychosocial support in humanitarian settings: linking practice and research. The Lancet, 378(9802),1581-91.
  18. Ventevogel, P. (2014). Integration of mental health into primary healthcare in low-income countries: Avoiding medicalization. International Review of Psychiatry, 26(6),669-79.
  19. Turrini, G. et al. (2017). Common mental disorders in asylum seekers and refugees: umbrella review of prevalence and intervention studiesInternational Journal of Mental Health Systems11(1),51.
  20. Siriwardhana, C. et al. (2014). A systematic review of resilience and mental health outcomes of conflict-driven adult forced migrantsConflict and Health8(1),13.

About the author:

Dr Ross White is an Associate Professor of Clinical Psychology at the University of Liverpool in the UK. His research focuses on adapting and evaluating interventions for refugees and asylum seekers. He is Principal Investigator on the ESRC GCRF funded COSTAR Project being conducted in Uganda and Rwanda to investigate a community-based intervention for promoting emotional wellbeing of Congolese refugees. Dr White is a co-investigator on the EU Horizon2020 funded RE-DEFINE Project testing a guided self-help intervention for preventing mental disorders in five EU countries and Turkey, and on the PROSPER project. He received the AHRC/Wellcome/UKRI ‘Health Humanities Best International Research’ Award in 2018.

 

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