Today, we’re delighted to welcome guest contributor Sohail Jannesari – a PhD student at the Institute of Psychiatry, Psychology & Neuroscience, looking at the effects of the asylum process on mental health in Iranian and Afghan asylum seekers.
This blog post is about refugee mental health and what’s an appropriate comparison group to assess improvements (concluding that we should ask refugees to decide what an appropriate comparison is).
What group should we compare refugee health to? Refugees can provide the answer
Across the EU, countries have been starting up or increasing their refugee resettlement programmes. The UK, for instance, introduced the Syrian Resettlement Programme in 2015 in response to a public outcry around the death of the Syrian boy, Aylan Kurdi. The programme aims to resettle up to 20,000 Syrians in the UK by the end of 2020. With these programmes comes a desire to evaluate their effectiveness, particularly in regards to health. But what constitutes success, and what groups should be used as a benchmark for refugee health?
This problem is exemplified in academia with the ‘healthy migrant effect’. This theory states that healthy people are more likely to undertake the migration journey and the risks associated with resettlement. But refugees are variously compared to the host country population (e.g. Norredam et al. 2014), the population in the country of origin (e.g. Rubalcava et al. 2008) or economic migrants from similar parts of the world (e.g. Janevic et al. 2011).
It doesn’t seem sensible to compare refugees against migrants who come to the UK via other routes, though there are many similarities and overlaps in the experiences of refugees and migrants. Some struggles, including the circumstances which forced them to flee, the often perilous journey here and the bureaucratic contradictions of Home Office asylum process may have been very traumatic and are more likely to have been experienced by refugees.
Nor does the Government’s usual method of comparing refugee populations against each other seem entirely appropriate. For instance, in the evaluation of the UK Government’s long-standing Gateway resettlement programme, most of the comparisons are between different national groups who were in the same resettlement cohort. This method can identify if a group is falling behind in terms of the programme, but doesn’t tell us if the programme as a whole is working or if health indicators are progressing as they should be.
Government officials are always very wary of making potentially unfavourable comparisons with the host population and this route doesn’t quite work either. On arrival, refugee health is likely to be both more and less healthy than that of the host population in different areas. The differences might be particularly evident when thinking about mental health and the traumatic experiences people may have experienced (e.g. Silove et al. 1997), but they will also extend to physical illnesses (e.g. Norredam et al. 2014).
Complimenting one of these approaches with a user-led one could provide a solution. Academics, Government and even NGO research needs to spend more time asking refugees about their desired health outcomes. A recent report (Athman, 2017) on resettlement evaluation in the US state of Maryland acknowledges the lack of a refugee voice, suggesting that refugees could be involved in qualitative research design through advisory boards made up of other stakeholders. But researchers can go much further than this, helping refugees choose their own benchmarks of success in an informed and individualised manner.
The question we need to ask a refugee is “where do you want your health to be in 1 year, 5 years and 20 years?” And when we ask it, we need to provide insight and understanding on the indicators we might use to measure different aspects of health. Through a collaborative process, we can set a standard of success which, by definition, considers the peculiarities of refugee experience. This would produce a practically useful target for improvement in health which reflects people’s lives. Over time, we might see patterns in people from certain backgrounds and demographics and be able to develop more generalizable benchmarks which could be used in cross-sectional research. This approach would be paralleled by one where refugees inputted into the type of outcome measures and indictors used.
There are, of course, some drawbacks to this approach. Refugees might have unrealistic expectations of their health outcome, meaning that some are never achieved or achieved instantly. Researchers should, therefore, be clear with participants that they should provide an answer within the limits of what they think is possible and valuable if given the right support. Researchers should also control for confounding as expectations are likely to be differentially related to socioeconomic background and demographics. Another limitation is that it is very time intensive. Researchers need to explain in detail what measures mean, a task which doesn’t always have a clear answer even for academics. This method is probably most suitable for qualitative research and smaller scale quantitative work.
Overall, asking refugees to provide markers of progress in health can help solve a long-standing problem in migration and mental health research. Importantly, it does so in a way which empowers refugees and places their needs at the heart of any work.
Athman, A. (2017). Raising Refugee Voices: Promoting Participatory Refugee Resettlement Evaluation in Maryland [Report]. Roosevelt Institute.
Janavic, T. et al. (2011). Maternal education and adverse birth outcomes among immigrant women to the United States from Eastern Europe: A test of the healthy migrant hypothesis. Social Science & Medicine 73(3):429-435
Norredam, M. et al. (2014). Duration of residence and disease occurrence among refugees and family reunited immigrants: test of the ‘healthy migrant effect’ hypothesis. Tropical Medicine & International Health 19(8):958-67.
Rubalcava, L. et al. (2008). The Healthy Migrant Effect: New Findings from the Mexican Family Life Survey. American Journal of Public Health 98(1):78-84
Silove, D. et al. (1997). Anxiety, depression and PTSD in asylum-seekers: associations with pre-migration trauma and post-migration stressors. British Journal of Psychiatry 170(4):351-7.
Want to hear more from Sohail? Follow his blog about migrant and refugee rights at: http://adventurersandanarchists.com/
*Many individuals contribute to this blog, so all views and opinions presented are personal and are not necessarily representative of the views of King’s College London.