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Exploring Resettlement Stressors and Help-Seeking for Mental Health

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Exploring Resettlement Stressors and Help-Seeking for Mental Health Exploring resettlement stressors and help-seeking for mental health support with women from refugee backgrounds Rose Burford-Rice School of Psychology The University of Adelaide This thesis is submitted in fulfilment of the requirements for the degree of Doctor of Philosophy in the Faculty of Health and Medical Sciences, School of Psychology, at the University of Adelaide January 2020 1 Table of Contents Thesis abstract ............................................................................................................ 4 Declaration ................................................................................................................. 7 Acknowledgements .................................................................................................. 10 Thesis overview ....................................................................................................... 12 Chapter 1. Background, aims and overview ........................................................... 15 1.1 Preface ................................................................................................................ 15 1.2 Note on terminology .......................................................................................... 16 1.3 Global and historical context ............................................................................. 22 1.4 Migration stressors ............................................................................................. 30 1.5 Mental health and service access ....................................................................... 38 1.6 Social determinants of health and access to mental health care ........................ 50 1.7 The current project ............................................................................................. 63 1.8 Aims and objectives of the present thesis .......................................................... 73 Chapter 2: Theoretical underpinnings..................................................................... 75 2.1 Help-seeking ...................................................................................................... 76 2.2. Kleinman’s explanatory model ......................................................................... 81 2.3 Andersen’s health model .................................................................................... 88 Chapter 3. Epistemological assumptions and reflexive practice ........................... 91 3.1 Critical inquiry ................................................................................................... 91 3.2 Critical realism ................................................................................................... 93 3.3 Postcolonial feminism ........................................................................................ 96 3.4 Role of the researcher ...................................................................................... 100 Chapter 4: Community-based participatory research and methodology ........... 108 4.1 Community-based participatory research (CBPR) .......................................... 108 4.2 Participants ....................................................................................................... 111 4.3 Recruitment and access .................................................................................... 112 2 4.4 Interviews ......................................................................................................... 114 4.5 Method of data collection ................................................................................ 116 4.6 Data coding, analysis and interpretation .......................................................... 118 4.7 Ethical considerations ...................................................................................... 120 Chapter 5. Study 1 ................................................................................................... 125 5.1 Help-seeking for mental health services among Afghan women from refugee backgrounds in South Australia ............................................................................. 125 Chapter 6. Study 2 ................................................................................................... 157 6.1 Resettlement stressors and challenges for South Sudanese women with refugee backgrounds: a South Australian study ................................................... 157 Chapter 7. Study 3 ................................................................................................... 185 7.1 “That’s what they say in our language: one onion, all smell”: The impact of racism on the resettlement experiences of South Sudanese women in Australia .................................................................................................................................... 185 Chapter 8. Study 4 ................................................................................................... 219 8.1 Social determinants of women’s mental health and barriers to help-seeking: perspectives of service providers working with women from refugee backgrounds ............................................................................................................. 219 Chapter 9. Discussion .............................................................................................. 260 9.1 Key findings ..................................................................................................... 260 9.2 Limitations of the current research .................................................................. 277 9.3 Limitations to using a CBPR approach ............................................................ 283 9.4 Recommendations ............................................................................................ 285 9.5 Conclusion ....................................................................................................... 288 Appendices ................................................................................................................ 290 References ................................................................................................................. 312 3 Thesis abstract Despite the well-documented mental health risk factors for people with refugee backgrounds, there remain gaps in understanding resettlement stressors and barriers to help-seeking, and access to and use of mental health services for specific refugee communities in Australia. The overarching aim of this thesis was to explore resettlement stressors and barriers to help-seeking with women from two different refugee communities and to provide clinical implications for services working with these populations. This project was guided by postcolonial feminist theory, used a Community- Based Participatory Research (CBPR) approach, and was informed by Kleinman’s Explanatory Model (1978, 1980) and Andersen’s Model of Health Utilisation (Andersen & Newman, 1973). In exploring resettlement factors, the thesis also takes a Social Determinants of Health approach to understanding effects on health and wellbeing. Semi-structured interviews were conducted with three groups of people, including women from the Afghan (Hazara) community with refugee backgrounds (study 1), women and men from the South Sudanese community with refugee backgrounds (study 2 & 3), and service providers working with women from refugee backgrounds in mental health services (study 4). Interview data was transcribed verbatim and thematically analysed. In study 1, findings suggested that older women from the Afghan community may face multiple social and cultural barriers to help-seeking, including stigma regarding mental health, differences in cultural conceptualisations of mental health, racism, domestic violence, husbands acting as gatekeepers to help-seeking, language and communication difficulties, and informal help-seeking preferences. 4 Initially, study 2 also had a focus on barriers to help-seeking, but participants instead prioritised speaking about resettlement stressors and challenges during interviews. As such, drawing on a CBPR framework, the second study explored these issues, with results indicating that dealing with practical concerns and resettlement stressors took precedence over accessing mental health services. In particular, results identified that concerns about the younger generation, racism and discrimination, social isolation, changing gender roles, and domestic violence were key factors in womens’ experiences in Australia and had ongoing effects on mental health. Stemming from the analysis of the same data, study 3 specifically discussed the impact of negative media and political depictions of the South Sudanese community on their psychological health and well-being. Participants discussed enduring experiences of racism and discrimination that had damaging effects on their sense of identity, mental health, and hope for the future in their resettlement country. Moreover, given the specific focus of media attention on South Sudanese youth, participants expressed considerable concern about the mental health and wellbeing of their children and future generations. Finally, study 4 focused on service providers’ perceptions of the social determinants of women with refugee background’s mental health and barriers to help- seeking. Barriers were identified as existing at the individual (language, gender), interpersonal (stigma, conceptualisation of mental health, isolation, racism), organisational (child protection, missed opportunity
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