Improving the mental wellbeing of Arabic speaking refugees: an evaluation of a mental health promotion program

The number of people being forcibly displaced from their homes is increasing, with the United Nations High Commission for Refugees (UNHCR) figures indicating 16.2 million newly displaced people in 2017 alone [1]. In the period of 2015–2016 a total of 17,555 refugees were resettled in Australia [2]. According to the Australian Bureau of Statistics (ABS) 2016 census, Iraq is the country of origin of the highest number of permanent humanitarian migrants, accounting for 17.6% of all such migrants in Australia [3].

High prevalences of Post-Traumatic Stress Disorder (PTSD) and depression in resettled refugee populations are well-established [4, 5]. A 2005 review of 20 studies of refugees resettled in Western countries showed a 10 fold increase in PTSD in these populations when compared with general population data [6]. A 2014 review of Iraqi refugees resettled in Western countries found rates of PTSD between 8 and 37.2% and rates of depression between 28.3 and 75% [5], levels of these conditions far exceeding those observed in general population samples in both the USA and Iraq [5].

Post-migration, refugees must deal with many issues, including cultural dislocation, racism, financial and housing insecurity, separation from family and limited social support [5, 7]. These challenges compound adverse effects of pre-migratory trauma on mental health, and evidence, including a recent study of Iraqi refugees resettled in Australia, suggests that a longer period since resettlement can lead to higher levels of psychological distress [7]. As such, pre-migratory traumatic events combined with post-migration and resettlement stressors put refugee populations at high risk for the development of trauma-related mental health problems [6].

Research has demonstrated that “mental health literacy” (MHL), including knowledge and beliefs about the nature and management of mental health problems, help-seeking and support services available [8‐12], may be particularly problematic in resettled refugee populations, and that this is a barrier to help being received when it is needed. In a study of Iraqi refugees resettled in Australia, employing a vignette methodology, only 14.2% of Iraqi participants correctly identified PTSD as the problem depicted in the vignette, compared to 34.3% in the 2011 National Survey of Mental Health Literacy and Stigma (NSMHLS) [8]. Further, only 19% of participants in this research reported seeking help for a mental health problem, despite high levels of PTSD symptoms and general psychological distress [10]. Similar findings have been reported in previous studies of refugees resettled in Australia where hospital admissions data in Victoria demonstrated that refugee populations were much less likely to have hospital admissions for mental/behavioural disorders than the Australian-born population sample [13].

In spite of these findings, few trials of programs designed to improve MHL in resettled refugee populations have been conducted. As we, and others, have noted [14], there are significant challenges involved in developing and implementing programs of this kind, for example, differing views of interpreting and expressing psychological distress which can influence help-seeking behaviours and sources of help sought. To the best of our knowledge, we were able to identify three programs that have direct relevance to this study, as they sought to either improve MHL or address aspects of help-seeking in refugee populations [15‐17]. Sanhori et al. [15] undertook a longitudinal study assessing 1529 internally displaced persons from two randomly selected areas in central Sudan. Participants were provided a short (four-hour) psychoeducational intervention, in which information about mental health, symptoms, treatment and mental-health-related stigma was presented [15]. Using a six item scale examining stigma and social distance levels, a follow up interview was completed 1 year after the baseline measure, with no significant reductions in stigma or social distance being noted [15]. A second recent study involved pre-post assessment of the effects of a six-day spirituality education program among diverse groups of refugees (n = 4504) in 38 camps within European nations [16]. The program focused on identifying mental health disturbance, addressing emotions, developing skills in centring, invoking a sense of calmness, and provision of instruction on mindfulness and wellbeing [16]. Pre and post intervention measures of trauma symptomology, levels of optimism and general psychological wellbeing were made. Authors noted an overall improvement across all three measures and pointed out that the most significant improvement was found in participants who self-reported willingness to practice the mindfulness and centring exercises [16]. Finally, Subedi et al. [17] reported on the impact of a 1 day mental health first aid (MHFA) training program delivered to Bhutanese refugee participants based in the United States. A total of 58 participants completed a pre and post- training survey which was a culturally adapted version of the MHL instrument developed for MHFA training in Australia [17]. Surveys were completed immediately prior to and after the MHFA intervention. The assessment included a vignette describing a person suffering depression followed by questions assessing knowledge and attitudes about mental health conditions and questions regarding post-resettlement stressors. Significant improvement was shown in correct identification of mental health conditions, knowledge of treatment options for the mental health problem in the vignette, and confidence relating to the provision of support for individuals suffering from mental health problems. However no change was observed for stigmatising attitudes [17].

Findings from the abovementioned studies suggest that positive results from mental health promotion programs designed to improve MHL in resettled refugee populations are possible, and with improved MHL, greater help-seeking intentions and behaviours may enable mental health needs to be addressed at an early and appropriate level. However, there is a need for further research in this field. In particular, efforts to develop an intervention program tailored to address the influence of unique cultural, religious and social values on the mental health literacy and help-seeking of specific groups of refugees remains lacking, and was a motivating factor for this study. Thus, the goal of the current study was to expand the current evidence base by conducting a preliminary trial of a culturally tailored mental health promotion program designed to improve MHL among two Arabic-speaking refugee populations in South Western Sydney, Australia.

We conducted a preliminary trial of a mental health promotion program designed to improve aspects of MHL and related variables among Arabic-speaking refugees resettled in an urban area of Sydney, Australia. An uncontrolled, pre-post design was employed in which assessments were conducted immediately prior, immediately following, and 3 months following program implementation. Immediately following the intervention, there were non-significant improvements in most aspects of MHL assessed, including problem recognition, positive beliefs about the use of interventions most likely to be helpful, stigmatising attitudes and beliefs, and help-seeking intentions. In most cases these improvements were sustained at follow-up. However, only changes relating to stigmatising attitudes, and a reduction in perceived need for social distance in particular, reached statistical significance. There was also a statistically significant decrease in participants’ levels of general psychological distress following the intervention, and this change was sustained at follow-up.

The study findings need to be interpreted with caution, given that this was a preliminary trial with a relatively small sample size and with no control group. Nevertheless, it is encouraging that positive changes in most aspects of MHL assessed were observed, that these changes tended to be sustained at follow-up and that effect sizes for at least some of the changes were large enough for statistical significance to be reached despite sample size. When comparing these findings to similar previous interventions in resettled refugee populations, the observed reductions in stigmatising attitudes in particular are encouraging, given that both Sanhori et al. [15] and Subedi et al. [17] were unable to demonstrate reductions in these attitudes, despite having larger sample sizes. Indeed, reductions in stigma have proven challenging even in the general population [32]. The relatively intensive nature of the intervention employed in the current study, the use of bilingual project staff, delivery of the intervention face-to-face rather than via telephone or online [33], and the fact that most participants in the current study (68.8%) had high baseline levels of general psychological distress, may all have contributed to the relatively positive results in this regard [14, 32, 33]. It is possible that even stronger results would have been observed had it been possible to build consumer involvement and contact (that is, someone with a diagnosed mental illness such as PTSD) into the intervention. To our knowledge, the potential benefits of consumer contact in improving the MHL of refugee populations has not yet been examined, despite evidence from general population studies suggesting that contact of this kind is beneficial in reducing stigmatising attitudes towards individuals suffering from at least certain mental health problems [34]. Hence, this would be of interest in future research.

While increased awareness of the potential benefits of medication in the treatment of PTSD following the intervention was among the changes that did not reach statistical significance in the study, a statistically significant positive association was observed between the perceived helpfulness of antidepressant medication in the treatment of PTSD and time spent living in Australia. This finding is notable given that poor awareness and understanding of the use of psychotropic medication in the treatment of PTSD and comorbid mental health problems is a known barrier to compliance among resettled refugees taking this medication [35]. Greater exposure to and education about the Australian health system with time may be a factor in this association. Participants in the current study had lived in Australia for 5 years on average. Hence, relatively greater familiarity with the Australian health system among participants in the study, including the role played by general practitioners in the treatment of mental health problems, may also account for the relatively high proportion of participants at baseline who endorsed the use of interventions for PTSD consistent with current guidelines [24].

Arguably the most notable finding of this study is that the intervention was associated with marked improvement in participants’ actual mental health, as measured by the Kessler Psychological Distress scale, from baseline to follow-up. Previous research has demonstrated that higher distress levels were associated with longer resettlement periods amongst Iraqi refugees in Australia [7] and this was also noted in this study. Some postulated contributors to such elevated distress levels have been noted to include racism, perceived discrimination and cultural bereavement [36] and are beyond the scope of the current intervention. However, the ability to provide participants with skills in reducing levels of arousal and reactivity to negative emotions through the mindfulness practices is important and should not be discounted. Nonetheless, given participants’ high levels of distress at baseline, the potential for regression to the mean and the lack of a control group, attribution of this change to the intervention is problematic. It is also possible that the improvements in psychological distress may have been attributable to the act of coming together on a regular basis; however given that most participants had been attending the English college for some time prior to the intervention, this seems less likely. Finally, it is also not possible to know which changes in MHL, if any, were more or less conducive to the observed reductions in levels of distress. It is worth noting, however, that the self-help strategies delivered in the final session of our program were derived from a recently evaluated mindfulness intervention, also delivered entirely in Arabic over a 5-week period, and which also found marked improvements in general psychological distress among Arabic-speaking refugees both immediately following and 12 weeks following the intervention [37]. Participants in that study, like those in the current study, agreed that mindfulness was congruent with their religion, culture and way of life and this was likely a factor in the positive feedback participants provided about the program [16, 37]. Our findings are also consistent with findings noted by Pandya [17] where the mental wellbeing of those participants who self-practiced mindfulness exercises demonstrated most improvement. A pre-post comparison of the reported use of these strategies and their perceived helpfulness over time would be a useful addition in future research of this kind. The finding that levels of distress were positively correlated with time spent in Australia among participants in the current study, which is consistent with previous research in Iraqi refugees [7], may reflect an increasingly adverse impact of post-migration stressors on mental health over time [38]. It highlights the importance of mental health programs for refugees being implemented as soon after resettlement as possible. As we have argued elsewhere [12], mental health promotion programs, which target the refugee community as a whole, would ideally be integrated with early intervention programs that target individuals with symptoms of PTSD and related conditions.

As this was a pilot study, sample size was small, thereby limiting statistical power to detect pre-post change, and a quasi-experimental (uncontrolled, pre-post) study design was employed. Funding limitations precluded the ability to recruit a control group. Clearly a larger, controlled trial, in which the effect of modifiers and mediators can also be considered, will be an important next step. While attrition was low in the current study, missing data were problematic in some sections of the survey. In future, online or interviewer-administered surveys could reduce missing data. Recruitment of participants via the Adult Migrant English Program (AMEP) may have detracted from sample representativeness, however it should be noted that the AMEP is a core component of the resettlement program for humanitarian migrants to Australia. Finally, the possibility of selection bias with those committed to improving their mental wellbeing agreeing to participate in the study cannot be discounted and in future, investigations employing a randomised approach should be undertaken. Strengths of the current research include the availability of all program and study materials in Arabic and the use of bilingual staff to facilitate program presentation and data collection [14]. No doubt attention to these details was a factor in the program being well-received and in attrition being lower than in other studies [16]. Longer term, the program could be expanded to other refugee populations and more broadly disseminated, for example via other AMEP centres.

While further research, employing a more rigorous study design and larger sample size, will be needed, results of this initial trial suggest that a culturally tailored mental health promotion program targeting key aspects of mental health literacy can improve the mental health of Arabic-speaking refugees resettled in a Western nation.