Health and Home Issues influencing refugee integration Policy Research Symposium

1. Health and Home Issues influencing refugee integration Policy Research Symposium SFU Harbour Centre, Vancouver November 7, 2008 Dr. Laura Simich University of Toronto

2. Theories of refugee mental health • Primary focus in refugee mental health research has been on the effects of trauma. • Growing recognition that post-migrationsocial conditions play a more important role than trauma or biological factors. • Refugees also show resiliency, which is important for mental health.

3. Research points to the role ofsocial determinants of refugee healthin Canada Poverty – From 1981 to 2001, the poverty rateof visible minority families in Toronto increased from just over 20% in 1981 to 30%. Social exclusion - Growing social exclusion in Canadian society, particularly for non-European immigrants and racialized communities. Unemployment- Racialized groups 3X more likely to be unemployed, despite the high credentials of many newcomers

4. e.g. Poverty and educational levelsof ethnoracial groups in Toronto—notably refugees Groups with 30% or more below LICO: • Somali (over 70%), Afghan, Ethiopian, Bangladeshi (50-60%), West Asian, Iraqi (over 40%) Groups with 25% or more non-high school graduates, ages 25-34 • Vietnamese (45%), Afghan, Tamil, SE Asian, Iraqi (35-40%)

5. Global refugee risk of mental illnessFazel et al in the Lancet (2005) 365: 1309–14 • 20 eligible surveys analyzed • 6743 adult refugees from seven countries • In larger studies, 9% were diagnosed with post-traumatic stress disorder (PTSD) • 5% (4–6%) had major depression, with evidence of much psychiatric co-morbidity • Five surveys of 260 refugee children from three countries yielded a prevalence of 11% for PTSD

6. Social factors associated with poor mental health among refugeesReview of refugee studies (1959-2002) by Porter and Haslam (2005) JAMA; 56 reports including 22,000 refugees Worse mental health outcomes experienced by: • refugees living in institutional accommodation, • experiencing restricted economic opportunity, • displaced internally within their own country, • repatriated to a country they had previously fled, • or whose initiating conflict was unresolved. • Refugees who were older, more educated, female, had higher pre-displacement socioeconomic status and prior rural residence also had worse outcomes.

7. The meaning of “home” • “Home” seems to be used rarely by refugees to describe life in Canada • Most often used in Canada in a comparative sense: contrasting positive aspects of “back home” with losses experienced in Canada

8. Home: Not just nostalgia Images of “back home” tend to be associated with • customary extended family support, • problem solving ability • fulfillment of social expectations • maintaining dignity • ability to support a household • a foundation for growth

9. Home in Canada In Canada, refugees talk about • the lack of extended family • increased family conflict • lack of means of resolving conflict • negative changes in gender roles • disabling underemployment • worries about children • lack of opportunity for growth

10. Safety in Canada is appreciated, and some have hopes for the future, but real needs “back home” are always psychologically present • There is a profound sense of being cut off from “home,” and being marginalized or even kept down in Canada • There is evidence of constant mental distress due to lack of reciprocity: lack of emotional support and the need to support family “back home”

11. Qualitative evidence • When I came (to Canada), people were not as open as back home. You sit down, where you always talk to each other, you visit each other. People (in Canada) don’t have time for one another. I found that very strange and I was very lonely. • There is a saying, “there is nowhere like home.” It’s so good you are here (in Canada) but the problem is… I’m not worried about getting shot by a bullet, but the problem is you miss your own people, relatives. • Most of us share the same issues because we have relocated from one country to the other and … that emotional support that we usually get from our mothers, aunts and uncles is not here anymore. One of the biggest challenges is baby sitting.

12. I went to school for one year and that is it. I can’t do it, because I need to work to support our families back home because they need help too. The government doesn’t give you enough money for food, rent, clothes other necessities and so there is need to work. • Back home where we come from, a man is the head of the family and he is the last decision maker and he is the person who is responsible for everything and everything else is on his neck back home. Now here in Canada is so different. That is the big challenge for both the man and the woman. • With no family here, sometimes you don’t want to share your problems with people you don’t know .. there are not a lot of people who can sit down to talk about the problem. And the problems are even bigger than the ones back home.

13. Back home (conflict resolution) is just by simple traditional laws that are our own laws and are a very peaceful traditional way … but here it is so problematic. Once the police get involved in family problems, the man will always feel like not going back to that wife for having put him to jail so …the man is not comfortable about being in the house. …They feel they are the head of the family … Some end up packing, going back home and leaving their families here. • If I call 911 and then I kick my husband out, when my parents hear that back home ….. (they say) Why you call 911? Why you call the police? if you want to separate or have a problem, call us back home and then we can talk on the phone. And we can solve everything and after that if you want to go, tell us but don’t call 911. It’s not good.

14. Quantitative evidence Linking mental health and “home” Sudanese for whom life in Canada was not what they expected and those who experienced economic hardship (as measured by worry over having enough money for food or medicine) experienced poorer overall health and reported a greater number of symptoms of psychological distress. Simich et al. 2006 Mental Distress, Economic Hardship and Expectations of Life in Canada Among Sudanese Newcomers, Transcultural Psychiatry

15. Individuals experiencing economic hardship were 2.6 to 3.9 times as likely to experience loss of sleep, constant strain, unhappiness and depression, and bad memories as individuals who did not experience hardship.. But WHY do post-migration social conditions such as poverty and unmet expectations affect refugee mental health? Sudanese survey findings

16. “Home” is where the heart (and mind) are… Life here is very difficult. … [Sudanese refugees] have more bills that they have had to pay for than any other time in their own life. The pressure to even make a living here is terrible and they have a lot of responsibilities.…If you think you’re not able to even help some of your people there [in Sudan], then it affects you, as if you have neglected your duty. You have failed. You are no longer thinking of bringing this person [to Canada]. You are not sending even a little money home.You’ve forgotten about them, so you really feel useless or cut off. You become very selfish, for yourself or your own family… this is stressful to think like that--that you’ve let people down, that you’re not caring about others.

17. Ways to fill the “home” gap and to promote refugee mental health • Faster family reunification • Better employment and educational opportunities to meet both men’s and women’s needs • Culturally-appropriate family counseling and conflict resolution • Community resources and social supports that are tailored to the culture of the refugee community • Restoration of damaged sense of dignity and respect