Keywords

7.1 Research Approach and Conceptual Foundation

Refugees face challenges in resettlement countries, including language difficulties, acculturative stress, societal prejudice, and loneliness that jeopardize their integration (Beiser et al. 2011a, b; Ellis et al. 2010; McMichael and Manderson 2004; Karunakara et al. 2004; Stewart et al. 2010a, b). Refugees have been exposed to violent conflicts, and acute traumatic incidents, including forced separation from family members (Jaranson et al. 2004).

Social support has the potential to decrease refugees’ isolation and loneliness (Bhui et al. 2006; Jaranson et al. 2004); enhance their sense of belonging and life fulfillment; mediate the stress of discrimination (Brooker and Eakin 2001; Din-Dzietham et al. 2004); and, facilitate integration into a new society (Stewart et al. 2008a, b). Our previous Canadian research revealed refugees’ belief that social support can enhance health and reduce loneliness and isolation (Stewart et al. 2010a, b; Stewart et al. 2008a, b). However, several factors obstruct newcomers’ ability to mobilize social support in their countries of resettlement, including intergenerational conflicts, struggle for employment, inadequate knowledge of resources, language difficulties, and lack of transportation (Guerin et al. 2003). The loss of social support has detrimental impacts for refugees (Reynolds 2004; Simich et al. 2004). Loss of social support through migration and diminished social networks exert detrimental impacts on integration (Reynolds 2004; Merry et al. 2011; Simich et al. 2004). Lack of social support has a detrimental effect on mental health (Beiser et al. 2011a, b; Gottlieb and Bergen 2010). Separation from family exacerbates the severity of psychological problems. Newcomers with extensive social support are more likely to access professional services (Alegria et al. 2004). Social support can reduce refugees’ isolation and loneliness (Beiser et al. 2011a, b; Beiser et al. 2010; Bhui et al. 2006; Jaranson et al. 2004); enhance their sense of belonging and life satisfaction; mediate the stress of discrimination (Brooker and Eakin 2001; Din-Dzietham et al. 2004); and, facilitate integration into a new society (Stewart et al. 2008a, b).

Migration, with attendant lack of support from extended kin, may compromise the adaptation of refugee new parents and their children (Foss et al. 2004; Schweitzer et al. 2006; Warner 2007). Social isolation is amplified by restrictions on travel to home countries, and barriers to family reunification. Social relations that provide meaning in the country of origin are often disrupted in the new country (McMichael and Manderson 2004). Migration can alter the customary patterns of parenting and family care giving (Drummond et al. 2011; Merry et al. 2011). Recent migration can negatively affect children’s social development (Anne Casey Foundation 2006; Foss et al. 2004). Sole responsibility for family support, family composition, and length of time in the new country influence refugees’ experiences and perceptions of social support (Davies and Bath 2001; Simich et al. 2004). Newcomer mothers experience loss of supportive networks (Foss et al. 2004; Merry et al. 2011; Murray et al. 2010). Types of sources (Harrison et al. 1995; Morrison et al. 1997) and appraisal (Moon-Park and Dimigen 1994) of social support may differ cross-culturally and social support yields differing adaptive results for migrants from different source and host countries (Simich et al. 2010).

African refugees’ perceptions of their support needs and of interventions that could strengthen support have not been solicited. Despite the demonstrable importance of social support for refugees, research focused on culturally appropriate social-support interventions is rare (Barrio 2000) and the interaction between support and ethnicity has been neglected in social support intervention research (Gottlieb 2000). Although recent research suggests the potential beneficial effects of social support in ameliorating acculturative challenges, isolation, and resource deprivation (Beiser 1999; Davies and Bath 2001; Stewart et al. 2008a, b; Warner 2007), no support interventions for refugees have been designed and tested. Our review of research published from 1996 to 2011 revealed no social support intervention studies focused on African refugees. Differences among refugees reinforce the need to elucidate the role of ethnicity in the design of culturally-relevant social support interventions for refugees. Consequently, the studies described in this chapter explicate African refugees’ support needs, support resources and preferences for ethno-culturally based support interventions and the impacts of support interventions.

7.1.1 Conceptual Foundation

Social support is a resource for coping with stressful situations (Gottlieb and Bergen 2010) (e.g., immigration, resettlement, stressful new parenthood). Social support is defined as interactions with family members, friends, peers, and professionals that communicate information, affirmation, practical aid, or understanding (Stewart 2000). Social networks provide varied types of support functions (Gottlieb and Bergen 2010; Stewart 2000), which should be specific to stressful situations (Cutrona 1990). As most social relationships have positive and negative elements (House et al. 1988; Thoits 1986), the supportive and non-supportive elements of interactions and relationships should be appraised (Gottlieb and Bergen 2010). Support can either endure or dissipate over time in stressful situations (Lawrence and Kearns 2005; Stewart et al. 2008a, b) (e.g., migration). Support-seeking as a coping strategy for managing stressful situations has been linked to greater provision of support, whereas people who use distancing and avoidance coping strategies tend to have fewer support resources (Thoits 1995). Social support and coping have bi-directional effects (House et al. 1988). For example, the ways refugees cope can provide clues to potential supporters about support needed. Conversely, the amount and type of support received can influence refugees’ choice of coping strategies. Variables that influence social support include community size, socioeconomic status, age, gender, marital status, and ethnicity (Maton et al. 1996; Gottlieb and Bergen 2010). Three social processes (social exchange, social comparison, social learning) can emerge within support groups and/or dyads in social support interventions. As close relationships develop between refugee parents and peers, reciprocity would be evident in dyadic and group interactions (social exchange theory) (House et al. 1988; Thoits 1995). According to social comparison theory, individuals compare themselves and affiliate with others (e.g. peers in dyads or groups who share language and culture) who have first-hand experiential knowledge of the stressful situation (House et al. 1988). Self-efficacy and communal efficacy, concepts integral to social learning theory (Thoits 1995), can be enhanced through support interventions. Peer support, based on personal ‘experiential knowledge’, is a critical source of social learning for vulnerable people and can supplement professional support derived from professional knowledge (Caputo et al. 1997; Health Canada 1996; Miller 1992).

7.1.2 Design/Methods

Consistent with principles of participatory research (Stewart et al. 2010a, b; Ahmed et al. 2004), participants specified their support needs and preferred type and substantive content of a support intervention in the studies described in this chapter. Support interventions have typically not been informed by participants’ assessment of their support resources, needs, and preferences (Gottlieb 2000; Gottlieb and Bergen 2010). Advisory committees composed of partners from public, practice, program, and policy domains were created in each city to provide advice and feedback on: the selection, screening and training of research staff; amendment of interview guides and measures; culturally appropriate recruitment strategies; design of the intervention; and, knowledge mobilization. Organizations serving African refugees participated in these community advisory committees. Moreover, use of experienced peers (former African refugees) to conduct interviews and provide support enhanced the credibility and acceptability of the studies.

The studies employed a multi-method research design (Ahmed et al. 2004; Stewart et al. 2008a, b) to address complex research problems (Tashkkori and Teddlie 2003). Qualitative and quantitative methods were used (Stewart et al. 2008a, b; Tashkkori and Teddlie 2003) to corroborate, elaborate, and illuminate understanding of the phenomena under study, thereby enhancing validity, transferability, and confidence (Beazley and Ennew 2006). Qualitative methods were employed to enhance understanding of sensitive issues and meanings, perceptions, beliefs, values, and behaviours of refugee new parents (Gottlieb and Bergen 2010; Tashakkori and Teddlie 2003). An interpretive critical perspective within ethnography (Carpecken 1996) emphasizes the cultural and structural context. Qualitative data on intervention processes helped to elucidate the “black box” (who, what, where, when, why, how) of this psycho-social intervention (Stewart et al. 2008a, b; Tashkkori and Teddlie 2003). Quantitative measurements were used to test psycho-social outcomes of the support intervention (Stewart et al. 2008a, b); elucidate distinctions among pertinent variables; extend, refine, and cross-check qualitative data; and, potentially enable generalization to other refugee populations (Beazley and Ennew 2006; Tashkkori and Teddlie 2003). Qualitative data are emphasized in this chapter.

Participants were given information and consent forms translated into their preferred language and were asked for permission to audiotape their confidential interview for later transcription and analysis. Peer interviewers were matched to participants by gender (wherever possible), language and ethnicity, and interviews were conducted in each participant’s preferred language, in sites accessible and acceptable to participants. Semi-structured interview guides for individual interviews and group interviews were translated into relevant languages including Shona, Ndebele and Arabic. Group interviews were conducted in the predominant language of group participants. All interviews were taped and transcribed for analysis. The demographic characteristics of participants and data collection strategies for the five studies are summarized in Table  7.1 .

Table 7.1 Four Refugee Social Support Studies. (Source: Stewart et al. 2010a, b; Anderson et al. 2010; Stewart et al. 2008a, b; Makwarimba et al. 2013; Stewart et al. 2011, in press; Stewart et al. 2012; Stewart et al. 2011)
Full size table

7.2 Related Research Findings

7.2.1 Study 1 Assessment of Support Resources and Needs of Somali Refugees

We interviewed Somali refugees across three urban sites in three Canadian provinces—Ontario, British Columbia, and Alberta. Many Somali interviewees lived in poverty. They contrasted the notions of social support based on traditional norms of interdependence and reciprocity with norms and practices of a fragmented and impersonal service bureaucracy in Canada. Interviews with Somali refugees reveal a view of social support based primarily on historical cultural experiences of informal social networks. Influenced by norms of family connectedness and a deep sense of obligation to kin, Somali refugees continued to hold the same expectations for support that they did in their homeland, but circumstances forced them to rely on formal institutions. The Somali community in Canada is small and has limited social networks. These Somali refugees valued self-reliance, but coped independently primarily because of the relative lack of supports. Somali refugees revealed that culture influenced their support-seeking behaviors. They were guided by and found comfort in religious beliefs. This study revealed that social networks of newcomers and attendant supports dwindled upon immigration, particularly for Somali refugees. These findings complement McMichael and Manderson’s (2004) study of Somali women in Australia, which revealed that problematic social networks restricted the women’s capacity to use and create social capital in their new country. In our study, Somali refugees found it hard to support each other because of their poor financial standing, and the need to send money back to Somalia.

Our research revealed that Somali refugees experience unmet support needs, depleted social support networks, separation from families, difficulty establishing new ties in new communities, inadequate access to services, and lack of linguistically and culturally-appropriate support services. These newcomers described pathways through which social support influenced physical, mental, spiritual, and mental health. They emphasized the significant effects of social networks on health outcomes. In their view, social support facilitated their ability to meet basic needs; reduced stress; and, improved physical and mental health. Moreover, these newcomers believed that inadequate support exerted a negative influence on their health and use of health-related services, and conversely that poor health had a detrimental effect on their ability to seek or offer support. Our study demonstrated needs for support from ethnic peers and professionals. The major support needs and desires identified informed the design of a peer support intervention.

7.2.2 Study 2 Support Interventions for Somali and Sudanese Refugees- Assessment of Support Needs & Intervention Preferences

Somali and Sudanese refugees wanted assistance to enlarge and strengthen their existing networks and create new social networks. These newcomers faced difficulties establishing and maintaining social networks which impeded their integration in Canada. Participants reported experiencing many challenges including multiple low-paying jobs, lack of child care, family conflict, cramped living quarters in unsafe neighborhoods, financial worries, and language difficulties. These refugees wanted to explore ways to cope with their difficult circumstances and to access support. They desired culture-friendly programs encompassing other refugees from their cultural community. They recognized that there were many untapped resources in the community, and needed to know how to use these resources.

At arrival one is completely confused and does not know where to begin. The second stage is during the period of settling, this is the period when crises usually crop up and without adequate support a family can easily disintegrate.

Now the most needed support is at crisis time where frustrations have build up and expectations may not be up to one’s hopes. This is the tempting time where families break apart easily. This is when true love and genuine relationship is put to the test. Without adequate support or intervention it becomes very fluid.

Some challenges prolonged integration into the Canadian system and support was needed to overcome these challenges. Language difficulties encountered with service providers inhibited access to services. Many service providers did not speak these refugees’ languages.

Many participants lacked knowledge of the Canadian work culture and described discrimination manifested in job insecurity, poor treatment by employers, and inconsistent wages. Most participants perceived stigma about their religion and refugee status. Some reported humiliation when seeking services because they were treated as foreigners. Most participants faced difficulties navigating services such as education, health care, child care, legal aid, translation, community support, employment, recreation, and transportation. Lack of familiarity with these services, coupled with language barriers, made these refugees hesitant to approach service providers. These refugees reported loneliness and isolation which they attributed to discrimination and depleted social networks.

How do we integrate if we are isolated to our confines of either refugees or low income families?

Spousal conflicts also emerged as a significant challenge. Conflicts and tensions within participants’ families made it difficult for them to establish a new life in Canada. Conflicts arose when one spouse was dependent on the other for finances, language, and transportation. Moreover, changes in gender roles and responsibilities contradicted their culturally established husband-wife roles.

When I first arrived I was desperately in need of many of the supports but at the same time after staying for a little while challenges … arose in the house and this is the dangerous time where families can break apart. I think support is most needed on arrival but also at critical few months down the road when real issues begin to arise and the conflict in culture begins to take effect.

Refugees were often separated from their families for long periods of time. Participants were concerned about challenges facing family members left in their home country; their inability to communicate with their kin; and the prolonged process of family reunion. Some participants indicated that they had limited contact with their parents, children, or siblings who still lived in the home country or neighboring countries. They wanted to learn more about coping with the stresses of family separation and expediting the reunification process.

I would like to know why family reunion takes so long. There are many refugees who left their loved ones behind and feel incomplete without those loved ones. Does the Government care so much that this is part of the support that the refugee is desperate to have in a limited time frame?

Refugees who had personal problems preferred one-to-one support because their issues were sensitive and confidential. Participants believed they could share personal information related to their problems with individual support providers and work together to find the best remedy.

The one-on-one support is more important for me. It gives me the opportunity to express myself without fear. Sometimes we are scared of sharing our challenges with our own community members for fear of being talked about or laughed at.

Participants who preferred group support noted that some common problems are faced by refugees. Groups can save time and resources, provide opportunities for participants to share coping strategies, and promote networking. They thought that group support was appropriate for dealing with issues in general terms and for receiving information.

Face-to-face support was the preferred mode of support delivery as participants believed that there would be no barrier between them and the support provider. Moreover, face-to-face support offered an opportunity to explain their needs with the help of body language and other cues. They believed they would be more comfortable asking some questions in person rather than via the telephone or internet. Face-to-face meetings offered lonely and isolated newcomers opportunities to socialize and receive human contact.

In face-to-face type of service, I can try to explain what I need even if it is by gesture or by asking someone who knows my language to translate for me.

Participants preferred connecting with refugees who shared the same cultural background. For some participants, refugees shared similar experiences, while for others specific nationality was a distinguishing factor. Some, however, thought that culture-specific groups limited opportunities to learn from and integrate with people representing different backgrounds and cultures.

Many refugees from Sudan and Somalia were not proficient in English. In their view, common language should be the first consideration in creating support groups to enable newcomers to share experiences and learn from peers. Language was described as the key to effective support groups because refugees want to express themselves fully and seek answers without feeling self-conscious.

Group [members] … need to communicate or express their views to one another so they need to understand and speak [a] common language. Language is important in group support, for example I don’t understand French or English but if anyone in our group speaks such languages I cannot understand and at the same time there will be no communication.

Refugees in different age groups experience different challenges, aspirations and expectations. Although older newcomers may be more concerned about health, children, and retirement, younger refugees may be preoccupied by education, work, and entertainment. While older generation refugees based behaviors and roles on their past, younger refugees were more focused on the future and less ingrained in their country of origin’s traditions.

Peer and professional helpers who speak their language were considered particularly important to ensure that refugees’ concerns received serious consideration and their support needs were communicated. Peer and professional helpers could offer potential solutions to challenges and enable refugees to discuss settlement challenges.

As accessibility to support programs was very important to these refugees, they recommended community venues close to their place of residence, free transportation, or home visits. Provision of child care was needed to increase accessibility and acceptability of support programs.

7.2.3 Study 3 Support Interventions for Somali and Sudanese Refugees

The support intervention gave refugees opportunities to meet new people and socialize with peers. Participants reported that they shared their problems within their support group and received different perspectives on potential solutions. Support groups were a source of informational support. Peer facilitators noted that some challenges faced by newcomers could have been avoided if they had information on support resources and services. The intervention promoted information exchange among refugee group members.

In addition to facilitating mutual exchange of support among group members, peer and professional facilitators provided translation and interpretation. Peer helpers enabled participants to complete immigration documents and facilitate reunion with family members from their home country. They provided information on available services to expedite reunification. Practical support offered included resume writing, job interview skills, and cooking. Peer and professional facilitators explained workers’ rights and labor relations in Canada and provided information on conflict management, financial counseling, addressing spousal conflicts, supporting children with school work, dealing with discrimination, accessing services, and seeking optimum employment.

Participants shared stories of challenges at home and workplace, and suggested strategies to cope with these challenges. Participants had the opportunity to converse in their mother tongue with other refugees who shared the same cultural or ethnic background. Support sessions offered relief to participants who craved reconnection to their ethnic community. Prior to the intervention, they had no opportunity to meet with their peers. Refugees felt encouraged because they could bring their problems to the group and seek support. This social support intervention resulted in increased social integration, decreased loneliness, and expanded repertoire of coping strategies (Stewart et al. 2011).

Some participants indicated that support group sessions were not sufficiently long to discuss complex issues. Scheduling was challenging because most refugees worked multiple low-paying jobs, faced pressing issues, and had insufficient time. Although child care was provided in this support group intervention, it was not always convenient to travel with children to meeting venues, particularly for people who relied on public transit. For participants who did not prefer to bring their children to group meetings, finding trusted babysitters was sometimes challenging. A few participants mentioned that groups were intimidating for shy people, particularly when other participants had more education or better paying jobs.

7.2.4 Study 4—Support Needs and Support Intervention Preferences of Zimbabwean and Sudanese Refugee New Parents

Seventy-two new mothers and fathers from Sudan and Zimbabwe who came to Canada in the past five years and who had a first baby born in Canada under 12 months old, were interviewed individually. Support needs identified in interviews included isolation, loneliness, lack of culturally sensitive support, and information gaps regarding parenting skills, marital challenges, family disintegration, cultural conflict, employment, gender roles, and upgrading education. Following individual interviews, four group interviews were conducted with Sudanese (n = 18) and Zimbabwean (n = 15) new parents to seek information on support intervention preferences.

These new refugee parents were isolated and lonely. They lacked traditional family support during pregnancy, birth, and early postpartum and many had little contact with people from similar cultural backgrounds. Developing supportive networks is difficult because Sudanese and Zimbabwean family members were geographically dispersed. These interviews revealed significant needs for information about culturally appropriate services, more supportive service providers, and peer support to supplement professional support.

Some participants reported unprofessional attitudes from nurses and physicians. Many Sudanese female participants believed that their rights were violated when they had to sign hospital papers, without proper explanation in their own language. Refugee participants believed that their signatures were just a routine to protect hospital staff without considering their own preferences.

I felt ignored at the hospital because I could not express myself in English. I was speaking [to] my husband. I told him—I feel pain and please tell the nurses. I didn’t even have painkillers because the baby already came, because they hadn’t really believed me because I wasn’t crying or speaking for myself (Sudanese woman).

Men from both cultural communities expressed concerns regarding cultural family dynamics that threatened or disrupted newcomer homes. Access to supportive counseling and cultural sensitiveness by service providers was seen as essential. They reported that there is need for support programs that help families stay together. Some men believed that many programs were geared to support women at the expense of men and children. They noted that agencies should include settlement workers who are informed about the background and cultural context of family challenges.

These elders could counsel families or couples and tell them, “my children what you are doing in your marriage is not part of our culture, this foreign behavior is ruining you, this is how you should treat your wife and this is how a man is treated.” (Zimbabwean man)

Zimbabwean male participants discussed division of work at home. Some men felt that the circumstances in Canada warranted that spouses assume equal roles in the home. Others, however, believed men should take a helping role when they see the need but housework should remain the domain of the wife.

Refugee communities need outside support to address challenges such as marital conflicts and reconcile cultural differences. Suggested solutions include the use of peers in initiating dialogue around sensitive topics such as sharing household chores and family budgets.

7.3 Implications for Refugee Mental Health Practice and Policy

7.3.1 Study 5 Insights of Service Providers and Policy Influencers Regarding Refugee Support Needs

Group interviews with service providers and with policy makers revealed that services are disjointed and refugees do not have the knowledge or skills to find culturally appropriate supports. Both service providers and policy makers agreed that informal cultural networks were most effective in helping newcomers to navigate the systems and reduce isolation. Developing peer support and mentoring skills within refugee communities has the potential to build sustainable capacity. Services providers noted that research and evaluation focused on support programs is critical. Some service providers reported that loneliness was a major issue for refugee new parents. Service providers highlighted the need for family support at the time of giving birth. One way of dealing with loneliness for refugees was to create little villages in apartments. Although this approach has been criticized for creating ghettos, some participants thought that it was an effective strategy to deal with loneliness. In their view, hospitals could improve support for patients with language barriers by hiring more qualified interpreters. Inability to speak English was considered a major problem for many refugees. Participants noted that language barriers prevail in hospitals, physician offices, and clinics. Language was also cited as a barrier to giving consent.

Some participants reported that the system was too complex for most refugees to understand. Information and education on how the system operated is needed, starting from arrival in Canada, to “settling in” and then accessing other services once settled. Participants reported that some available services were not well coordinated. Information was scattered and difficult to access and intra-agency communication was rare.

7.3.2 Implications for Practice and Programs

  • The experiential knowledge and credibility of ethnic peers can supplement and interpret the professional knowledge of service providers in health and social sectors.

  • Peer support interventions can diminish African refugees’ loneliness and enhance their social integration, factors influencing health.

  • Peer support interventions can improve African refugees’ support seeking skills for coping with social and health- related challenges.

  • Culturally and linguistically appropriate and gender-sensitive support programs could be adapted and tested in community-based intervention trials prior to integration in social and health services for vulnerable refugees.