Community-Based Approaches to Understanding Refugee Resettlement and Mental Health:

1. Community-Based Approaches to Understanding Refugee Resettlement and Mental Health: Philadelphia Refugee Photovoice Project Ellen J Plumb*, Melissa Fogg**, Anna Escuder*, Christie Mulholland*, Michael Cafarchio*, James D Plumb*, Rickie Brawer* Thomas Jefferson University Hospital, Department of Family and Community Medicine, Center for Urban Health **Lutheran Children and Family Service INTRODUCTION RESULTS Opportunity Refugees are a population at high risk for mental health issues due to pre-migration, migration, and post-migration stressors. The Philadelphia Mental Health Collaborative is a citywide coalition aimed at identifying and developing refugee mental health services in Philadelphia. Through this innovative Collaborative, Philadelphia area refugee resettlement agencies, community-based arts organizations, and refugee clinical care providers have partnered to develop culturally and socially appropriate mental health programming for disparate refugee populations that address and reflect the complexity of the resettlement process. Panda Jar I thought when I came to the U.S. that I would have a better job and better salary. While it was not comfortable to live in the refugee camps in Malaysia, we did not have to pay bills there. In Philadelphia, there are so many bills to pay. I keep them in this jar. Jungle Fingers This represents my brother and I fleeing through the jungle from Malaysia. We followed an uncle from our village to the refugee camp. We were only 14 and 15 years old and we were very scared. Recruitment Camera Training Small Group Discussion Sharing Stories Welfare Building This is the welfare office, where many refugees go to receive support for healthcare and other services. It is very difficult to get our benefits, especially when we do not speak English well. Refugees who are fluent in English often accompany other refugees. It can take 2-3 hours per trip and many refugees are not aware of their benefits. ENVISIONING HOME: EXHIBIT CATEGORIES OBJECTIVES Mural of a Statue I like the woman in this mural. She describes life here. She has to carry heavy things. There are a lot of hard things in our life here but if we try hard we can make it. We must be insistent to carry our burdens, have patience, and think of our future. Honoring Our Roots-Culture:  The traditions that are distinctive of the individual's native country. These aspects include clothing, food, religion, art, and history. Where the Heart Is-Family:  The relationships, activities, and stresses of daily life. Between Earth and Sky-Environment:  How individuals perceive and engage with the world around them. Building Futures-Opportunity:  The opportunities and struggles experienced in the pursuit of growth and prosperity for individuals and families. The purpose of this study is to conduct a community-based assessment of mental health needs in Iraqi, Burmese, and Bhutanese refugee resettlement communities in Philadelphia using the Photovoice methodology in order to; • Identify migration and resettlement stresses that affect mental health and identify social, environmental, and cultural determinants of and concepts of mental health in Bhutanese, Burmese, and Iraqi refugee families • Gain a greater understanding of community development among refugee communities resettling in Philadelphia. • Develop socially and culturally appropriate mental health services for refugee populations in Philadelphia Culture DISCUSSION Although still in progress, this Photovoice project is providing important information about the resettlement experiences of Philadelphia-area refugees and guiding efforts to provide quality mental health care and services for disparate populations in transition in a clinical environment characterized by limited socio-cultural knowledge, communication challenges, insurance issues, and systems-level inefficiencies. The data collected is allowing us to address these quality of and access to care issues and answer important clinical questions, such as: When is the best time to screen for mental health in refugees? Who is the best provider for mental health in this population? Where is the best place to provide mental healthcare for these communities? What is a good model for mental healthcare for disparate refugee populations in Philadelphia. . This Photovoice project has also provided a foundation for innovative academic-community partnerships between Philadelphia area social service agencies, arts-based organizations, and clinical care providers. Through these partnerships, there has been a movement towards more culturally appropriate and community-focused mental health initiatives, including implementation of a refugee mural arts project by the City of Philadelphia Mural Arts Program and the development of a new community center with programming focused on community empowerment, preservation of cultural heritage, and economic development. Most importantly, the photographs and stories created by refugee participants as part of this Photovoice project will continue to be used to generate awareness of mental health and resettlement stress among refugees and advocate for policy-level changes aimed at improving access to mental health services for these populations. RESEARCH APPROACH Cemetery This is a cemetery. Cemeteries are very different here. They are like heaven, like a garden. Death is not a terrible thing here. In Iraq, everyone is scared of death. The cemeteries are very large and almost full. So many people have been killed. Face in Shadows This woman’s mother died. She is sitting alone in the darkness mourning her death. No-one is allowed to touch her during the 13 days of mourning. Ceremonial Feast When a new baby is born in our culture, we celebrate. After 11 days, we have a baby naming ceremony, Nuran. We invite friends and family for food. Here we are free to have these ceremonies. Community Based Participatory Research(CBPR)Approach is characterized by the equitable involvement of researchers and community members in the research process. The main goal of CBPR is to develop community health programs that address and recognize differences in culture, health beliefs, and disease presentations. Family Mother in Law This is my mother in law. For the first 10 days that she was here, she was feeling depressed. She feels like there is no life here, like no-one is related to each other and everyone is busy. She wasnts to go home. She feels strange here. Father at Home My father is new here. I came here two or three months before he came here. My father is old, so he doesn’t have a job. Being old, he cannot walk around the street so he is at home. He is isck, so he cannot do any work. RESEARCH METHODS Photovoice, a community based research methodology, is a process by which people can identify, represent, and enhance their community through a specific photographic technique, and it has three main goals: • enable people to record and reflect on their community’s strengths and concerns • promote critical dialogue about important issues through large and small group discussion of photographs • to reach policymakers. Multi-Step Process: training with camera, taking photographs, choosing photographs, large and small group discussions (focus groups), creating a narrative, telling a story Recruitment: through referrals from resettlement agencies and providers Environment Sneakers When I moved here, I noticed the shoes hanging on the telephone wires. I can’t believe how wasteful that is! Shoes are expensive. We did not understand that this was a symbol for a drug corner. This is outside of an elementary school. Trash There is a lot of garbage thrown on my block and in my neighborhood. We do not understand why people throw garbage on the ground-we thought America was a clean, beautiful place. Acknowledgments Lutheran Children and Family Services, Philadelphia Mental Health Collaborative, Jefferson Family Medicine Residency Program, Magic Gardens Philadelphia, City of Philadelphia Mural Arts Program, BuildaBridge, First Person Arts