Health and Home
Issues influencing
refugee integration
Policy Research Symposium
SFU Harbour Centre, Vancouver
November 7, 2008
Dr. Laura Simich
University of Toronto
Theories of refugee mental health
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Primary focus in refugee mental health
research has been on the effects of
trauma.
Growing recognition that post-migration
social conditions play a more important
role than trauma or biological factors.
Refugees also show resiliency, which is
important for mental health.
Research points to the role of
social determinants of refugee health
in Canada
Poverty – From 1981 to 2001, the poverty rate of
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
e.g. Poverty and educational levels
of 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%)
Global refugee risk of mental illness
Fazel et al in the Lancet (2005) 365: 1309–14
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20 eligible surveys analyzed
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6743 adult refugees from seven countries
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In larger studies, 9% were diagnosed with posttraumatic 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
Social factors associated with
poor mental health among refugees
Review of refugee studies (1959-2002) by Porter and Haslam (2005) JAMA;
56 reports including 22,000 refugees
Worse mental health outcomes experienced by:
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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.
The meaning of “home”
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“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
Home: Not just nostalgia
Images of “back home” tend to be
associated with
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customary extended family support,
problem solving ability
fulfillment of social expectations
maintaining dignity
ability to support a household
a foundation for growth
Home in Canada
In Canada, refugees talk about
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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
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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”
Qualitative evidence
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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.
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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.
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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.
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
Sudanese survey findings
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 postmigration social
conditions such as
poverty and unmet
expectations affect
refugee mental
health?
“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.
Ways to fill the “home” gap
and to promote refugee mental health
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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