Theses Doctoral

Mental health of refugees and asylum-seekers in low- and middle-income countries

Brooks, Mohamad Adam

There is a growing acknowledgement of the importance of mental health and well-being among refugees and asylum-seekers as a result of high rates of mental distress. Most research, however, has focused on refugees and asylum-seekers who live in high-income countries, even though the vast majority (approximately 80 percent) reside in lower- and middle-income countries (LMICs). This three-paper dissertation brings attention to this research gap and examines issues surrounding the mental health of refugees and asylum-seekers living LMICs. Three different cross-sectional data sources were included in this dissertation from study participants recruited from Malaysia, Jordan, and Turkey in 2018. Additionally, three separate analyses were conducted, which include descriptive analyses and multivariable regressions.

The first dissertation paper examines the scope and prevalence of mental health counseling utilization in Malaysia. Using Andersen’s Health Service Utilization as a conceptual framework, I examine how certain predisposing factors (socio-demographic characteristics), enabling factors (availability of resources), and need factors (mental health symptom severity) are associated with counseling utilization. The second dissertation paper examines suicidal behaviors among Syrian refugee women living in Jordan. Incorporating the Three-Step Theory (3ST) of suicidal behaviors, I examine how psychological pain, connectedness, and postmigration stressors are associated with suicidal behaviors. Lastly, my third dissertation paper examines the scope and prevalence of vicarious posttraumatic growth (VPTG) among service providers working with Syrian refugees in Istanbul, Turkey. Using a constructivist self- development theory, I examine how greater exposure to traumatic material, in addition to having a greater support system, and having greater years of professional experience is associated with higher levels of VPTG.

Study results from Malaysia emphasize the need to understand individual and contextual determinants of mental health service use. I hypothesize that refugees and asylum seekers with certain predisposing factors (female, older age, married, higher education, lived longer in Malaysia, registered refugee), have greater enabling factors (easy access to healthcare, larger household income, do not need interpreter services, greater health literacy, and live with greater number of people in household), and have greater need factors (higher PTSD symptoms) will be more likely to attend counseling services. Almost three-quarters (71.89%) of participants surveyed had never attended mental health counseling services. The majority (71.89%) had never attended mental health counseling services, and among those who screened positive for PTSD, only a minority (16.49%) attended counseling services. My hypothesis was partially supported. Participants from Afghanistan and Myanmar were less likely to attend mental health counseling compared to Somalia and other countries (p<0.001). Not having easy access to health facility (OR:0.10, 95% CI:[0.03, 0.32]), needing interpreter services (OR:0.23, 95% CI:[0.07, 0.75]), and higher PC-PTSD scores (OR:0.69, 95% CI:[0.52, 0.91]) was associated with lower odds of counseling attendance. Other determinants of health service use such as gender, marital status, education level, years in Malaysia, registration status, household income, health literacy, and number of people in household did not show significant associations.

Study results from Jordan highlight that greater research and public awareness regarding suicidal behaviors is needed among Syrian refugee women. I hypothesize that screening positive for PTSD, social isolation (have no friends or family members available to help), and greater number of postmigration stressors is associated with suicidal behaviors. Approximately one-tenth (9.86%) of participants reported suicidal behaviors (suicidal ideation and/or attempt) in the past 6-months. My hypothesis was partially supported. Screening positive for PTSD (aOR:4.02, 95% CI:[1.33, 12.15]) was associated with increased odds of suicidal behaviors, while having 1 friend or family member available to help when in need (OR:0.31, 95% CI:[0.13, 0.78]) decreased odds of suicidal behaviors. No associations between the number of postmigration stressors and suicidal behaviors were found.

Lastly, results from Turkey emphasizes the importance of focusing on service providers wellbeing. I hypothesize that greater exposure to traumatic material, in addition to having a greater support system, and having greater years of professional experience is associated with higher levels of VPTG. Among service providers recruited 44.66% reported moderate-to-high levels of VPTG. My initial hypothesis was partially supported. Moderate/high/severe secondary traumatic stress (aOR:3.98, 95% CI:[1.26, 12.59]), greater social support (aOR:1.05, 95% CI:[1.00, 1.10]), and greater organizational support (OR:1.11, 95% CI:[1.02, 1.20]) was associated with moderate-to-high VPTG. Proportion of clients who disclose trauma, and years in profession did not show significant associations.

Mental health utilization, suicidal behaviors, and the well-being of service providers are issues that have all been linked to the mental health and well-being of refugees and asylum-seekers. These topics have been minimally examined among forcibly displaced people living in LMICs. Clinicians and organizations must promote greater awareness of and screening for mental health conditions. Additionally, mental health and suicidal behaviors is often associated with stigma and discrimination, which means that providing basic psychoeducation surrounding mental health, its impact, as well as awareness of services available, and normalizing treatment at the individual and clinic level is essential for increasing engagement of mental health services.

To further reduce global mental health disparities and provide equity in mental health care and treatment, future research and psychosocial interventions must prioritize and focus on the well-being of refugees and asylum-seekers living in LMICs.


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More About This Work

Academic Units
Social Work
Thesis Advisors
El-Bassel, Nabila
Ph.D., Columbia University
Published Here
July 26, 2023