Immigrant and Refugees Health as a Community Mental Health Issue

Immigrant and Refugees Health as a Community Mental Health Issue

Immigrants and refugees experience stressors and irritants deriving from their experiences of migrating into host countries. These stressors initiate mental health challenges, which are further exacerbated by the low access to care that characterise this population group (Derr, 2016). Immigrant and refugee populations in Canada, for example, are at a high risk of untreated mental health conditions due to difficulties involved in accessing and using the available mental health services (Salami, Salma, & Hegadoren, 2019). The goal of this literature review is to analyse the available scholarship with the view to not only identifying the factors that make it difficult for immigrants and refugees to access and use mental health services but also exploring the solutions for addressing these dynamics.

Rationale

The issue of immigrant mental health is an important one, in large part due to the realisation that mental health is essential to the overall health and well-being of this population group. The second justification embeds in the fact that the vulnerability of immigrant and refugee populations to mental health challenges is high compared to the general population, hence the need to come up with interventions that ensure these individuals can access and use the available mental health services (George, Thomson, Chaze, & Guruge, 2015). Lastly, evidence shows that the world will continue to experience a high rate of international migration due to factors such as globalisation, improvements in transportation and communication technologies, and political unrest (Salami et al., 2019). This dynamic underscores the need for immigrant and refugee recipient countries and healthcare infrastructures to be equipped with skills and knowledge on how to increase accessibility to and use of mental health services for the identified population group.   

Analysis of the Research Literature

Sources of Mental Health Concerns

Several studies have focussed attention on identifying the risk factors that make most immigrants and refugees develop adverse mental health outcomes. Most of these studies have identified two variables as the likely culprit – environmentally-mediated stressors and lack of supportive resources. Specifically, the stressors identified in the literature include learning a new language, securing employment, experiencing war and persecution before migration, experiencing racism and discrimination in host countries, lacking vital social networks, navigating a foreign cultural and social system, and belonging to a minority group with low education level and low socioeconomic status (Buchmuller, Lembcke, Busch, Kumsta, & Leyendecker, 2018; Salami et al., 2019; Urindwanayo, 2018). On their part, George et al. (2015) note that the psychological and socio-cultural adaptations required by migrant and refugee populations to settle in host countries often lead to stressors.

In the lack of supportive resources, multiple research studies document how host countries fail to provide immigrant and refugee populations with adequate resources not only to improve their social networks but also to address their intersecting oppressions (Urindwanayo, 2018). Other risk factors associated with mental health conditions among immigrants and refugees include gender (being female), marital status, educational level, unemployment, job dissatisfaction, parenting stressors, poor living conditions, inadequate earnings, and economic challenges (Bas-Sarmiento, Saucedo-Moreno, Fernandez-Gutierrez, & Poza-Mendez, 2017).

Mental health Concerns affecting Immigrant and Refugee Populations

Several studies have identified the most common mental health concerns associated with immigrant and refugee populations. Bas-Sarmiento et al. (2017) document several studies associating immigrants and refugees “with a greater predisposition to depression (including major depression), depressive symptoms, anxiety disorders, and a greater tendency toward somatisation” (p. 114). These authors are clear that the identified mental health conditions often derive from the environmentally-mediated stressors associated with migration. The available scholarship shows that the incidence and prevalence of mental health concerns are higher in immigrant and refugee populations than in the general population.  Yet,  the immigrants’ use of mental health services is not at par with the general population due to several dynamics (Browne et al., 2017; Kallakorpi, Haatainen, & Kankkunen, 2019) These dynamics are assessed below.

Accessing and Using Mental Health Services

Several themes derive from the reviewed literature as having the most significant impact in hindering access to and use of mental health services in immigrant and refugee populations. The issue of informal mental health care providers ranks highly as one of the hindrances to accessing and using mental health services in the immigrant community. One of the main findings of the study by Derr (2016) shows that most immigrants and refugees prefer to turn to family members, religious leaders, and friends when faced with a mental health challenge, which in turn delays treatment with qualified mental health professionals. A study by George et al. (2015) found that most immigrants prefer informal help for their mental health and only seek assistance from qualified mental health practitioners as a last recourse. Likewise, the study by Kallakorpi et al. (2019) found that a good number of immigrants and refugees prefer to use alternatives such as acupuncture and traditional healers to address their mental health issues, rather than visiting qualified mental health practitioners.

The theme of cultural barriers to access and use of mental health services also reflects in the findings of several research studies. Derr (2016), for example, found that most immigrants and refugees are unable to access and use mental health services due to cultural issues “such as stigma and norms about mental health in immigrant communities” (p. 6). An analysis provided by this researcher reveals that most immigrants from these contexts stigmatise mental health services due to traditional beliefs that associate mental healthcare with madness, which in turn contributes substantially to lower use of mental health services in this population group. In their qualitative study, Salami et al. (2019) found that immigrant service providers in Canada identify mental health stigma, socio-cultural interpretations of mental disorders, and language barriers as the main cultural barriers that hinder immigrant access to and use of mental health services in the Canadian context. These cultural barriers reflect in other studies (for example, Morina, Akhtar, Barth, & Schnyder, 2018; Thomson, Chaze, George, & Guruge, 2017; Urindwanayo, 2018).

Other studies have identified the theme of structural barriers as a significant contributing factor toward low access to and use of mental health services by immigrant and refugee populations. The study by Derr (2019) found that environmental and systematic barriers play an important role in hindering immigrant and refugee populations from accessing and using the available mental health services. These barriers include high service costs, lack of insurance, language barriers, deportation fears, long wait times, lack of knowledge about mental health services, and lack of local service providers. Most immigrants and refugees, according to Derr’s review, lack to use mental health services since they are not aware that they have a diagnosable mental illness. In their study, Salami et al. (2019) note that most structural barriers to accessing and using mental health services are associated with the social determinants of health. In their review, Thomson et al. (2017) found that a substantial number of immigrants and refugees residing in Canada lack an awareness of the mental health services available in the healthcare context.

Moreover, the theme of lack of social support reflects in many research studies as a possible barrier to accessing and using mental health services. Here, several studies have underscored a positive relationship between the immigrant’s lack of social support and an inability to develop health-seeking behaviour to address mental health issues (Diaz et al., 2017; Kallakorpi et al., 2019). On his part, Derr (2019) found that “social systems influence how immigrants perceive their need for mental health services and can facilitate access to those services” (p. 10). Existing programs must have the capacity to nurture psychological coping strategies, social capital, and resilience to provide adequate social support services to immigrant populations (Agic, McKenzie, and Tuck, 2016).

The last theme relates to barriers associated with the settlement experience. Here, several studies have established that immigrants and refugees to Canada and other developed economies often face settlement-related challenges, which include low socioeconomic status and “povertisation” as a result of the immigrant status (Thomson et al., 2017), social exclusion and isolation from the dominant society (Browne et al., 2017), lack of social support systems (Diaz et al., 2017), and limited mobility (Kallakorpi et al., 2019). Other settlement-related barriers documented in the mainstream scholarly literature include experiences of discrimination at the individual and community level, administrative challenges in the delivery of mental health services targeting immigrant and refugee populations, and an incapacity by immigrants and refugees to negotiate the healthcare systems of host countries (Browne et al., 2017; Diaz et al., 2017; Thomson et al., 2017). Overall, the identified barriers not only increase health disparities but are a precursor to mental health challenges and low levels of trust in the available health services and social institutions.

Summary of the Literature Review

The reviewed literature demonstrates that the leading causes of poor mental health outcomes in immigrant and refugee populations include environmentally-mediated stressors, lack of supportive services, and inadequate psychological and socio-cultural adaptations. The risk factors associated with mental health conditions among immigrants and refugees include gender (being female), marital status, educational level, unemployment, job dissatisfaction, parenting stressors, poor living conditions, inadequate earnings, and economic challenges. Moreover, the review has found that the incidence and prevalence of mental health concerns such as depression, anxiety, and post-traumatic disorders are higher in immigrant and refugee populations than in the general population. Yet,  several dynamics restrict immigrants’ use of mental health services. The factors associated with low access to and use of mental health services among immigrant and refugee populations include an overdependence of informal mental health care providers, cultural barriers, structural barriers, lack of social support, and challenges associated with the settlement experience.

Implications

Implications for Nursing Practice  

There are several implications for nursing practice that derive from the literature review and analysis. First, there is a need for mental health nurses to increase collaborations between families/communities and the formal service sector. These collaborations address the issue of immigrants and refugees failing to use formal mental health services due to an over-reliance on family members, friends, and other informal channels. Nurse professionals, for example, need to partner with the community and religious leaders with the view to raising awareness of the need for immigrants and refugees to seek professional help for their mental health challenges. The second implication encompasses the need to train mental health nurses on how to develop and implement viable community-based mental health programs and interventions targeting this group of the population. Here, nurses need to prepare on how to roll out plans with the capacity to nurture psychological coping strategies, social capital, and resilience in immigrant and refugee populations to reinforce their ability to deal with myriad stressors associated with migrant health (Agic et al., 2016). Nurse professionals also need to be trained on culturally-appropriate communication with migrant and refugee populations, developing trusting and confident relationships with this population group, and how to ensure continuity of care in providing mental health services to immigrants and refugees (Brandenberger, Tylleskar, Sontag, Peterhans, & Ritz, 2019).

The third implication embeds in the need for nurse professionals and immigrant mental health service providers to navigate the challenges by creating awareness around mental health within migrant and refugee communities. Indeed, service providers should use their positions within migrant communities to enhance psychological well-being and address existing cultural hindrances by “using culturally appropriate terminology to refer to mental health, honouring confidentiality, and building trust with clients” (p. 158). Other research studies have advocated for nurse practitioners to use community-based outreach programs not only to address the cultural barriers identified in this review but also to meet the unique needs of migrant and refugee populations (Brandenberger et al., 2019).  Finally, there is a need to educate nursing professionals on how to identify and address the risk factors that expose immigrant and refugee populations to poor mental health outcomes. Such education must also develop the competence of mental health nurses to address the needs of individuals and immigrant families and communities identified as high risk due to the stressors and situational variables identified in this review (Kallakorpi et al., 2019).

Implications for Policy and Programming

There exists a need for the existing mental health policy to improve the training of cultural brokers and community interpreters to reinforce their capacity to address the cultural barriers that hinder migrant populations from accessing and using mental health services. The training component should focus on assisting cultural brokers and community interpreters to not only identify the unique stressors experienced by immigrant and refugee populations but also to develop their capacity to refer the immigrants to relevant mental health services for assistance (Schink et al., 2018). There is also a need for governments to address the social determinants of health that continue to disadvantage immigrant and refugee populations in accessing and using mental health services. Developing policy frameworks to address the social determinants of health, according to Salami et al. (2019), will go a long way in reducing the structural barriers that limit access to and use of mental health services not only in Canada but also globally. Addressing the social determinants of health will, in turn, reduce the social inequities that make it hard for migrant and refugee populations to access and use mental health services (Buchmuller et al., 2018).

Moreover, mental health programs at the community level need to orient toward providing immigrants and refugees with adequate resources to enhance and broaden their social networks (George et al., 2015). These programs should also assist this population group in attaining a holistic health promotion intervention (Morina et al., 2018), and addressing the needs of individual immigrants (Agic et al., 2016). Finally, governments need to develop and implement more effective policy directions to facilitate and nurture immigrant settlement in host countries with the view to reducing the stressors associated with mental health challenges. The available scholarship is evident that “more government policies on prevention and health promotion are needed to find adequate resources for immigrants” to aid in preventing social exclusion and promoting their psychosocial well-being” (Bas-Sarmiento et al., 2017, p. 120). These policies should focus attention on addressing the barriers associated with the settlement experience.

Conclusion

The present literature review aimed to analyse the available scholarship with the view to identifying the factors that make it difficult for immigrants and refugees to access and use mental health services and the potential solutions to address these factors. The factors associated with low access to and use of mental health services among immigrant and refugee populations include an overdependence of informal mental health care providers, cultural barriers, structural barriers, lack of social support, and challenges associated with the settlement experience. The implications for nursing practice and policy/programming illuminate possible solutions for use in addressing low access to and use of mental health services in the identified population. These solutions include increasing collaborations between families/communities and the formal mental health service sector, training mental health nurses on how to develop and implement viable community-based mental health programs and interventions targeting this group of the population, and using community-based outreach programs. The solutions also include emphasising improved training of cultural brokers and community interpreters, addressing the social determinants of health, providing adequate resources to immigrant and refugee populations to enhance and broaden their social networks, and implementing more effective policy directions to facilitate and nurture immigrant settlement in host countries

References

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