Exploring migration experiences and mental health among refugees and asylum-seekers in Durban, South Africa: guidelines for mental health promotion interventions.

Abstract

Background: Refugees and asylum seekers flee war, state violence, persecution and economic hardships. They tend to be very poor, vulnerable and are often excluded from the health and socio-economic activities of the hosting communities. In these contexts, refugees and asylum-seekers are found to be among high-risk groups for mental health problems, especially those that resettle in Low-and-Middle Income Countries. Further, mental health issues of refugees are worsening in light of the sustained conflict and forced migration the world is witnessing. For a long time now, the need for mental health promotion among refugees has been a public health concern. However, it seems there has been limited research undertaken in Africa, particularly in South Africa regarding the migration experiences and mental health of refugees. This study therefore aimed to explore refugees’ and asylum-seekers’ migration experiences particularly the stressors, psychological problems and coping strategies at pre-, transit-, and post-migration stages. Understanding migration experiences provides an essential background for developing mental health intervention guidelines to promote psychological wellbeing among refugees. Methodology: The study utilised a sequential exploratory mixed-method strategy that allows first qualitative data collection and analysis followed by a second phase of quantitative data collection and analysis that builds on the results of the first qualitative phase. The main purpose of utilising this design was to initially explore the migration experiences of refugees and to understand their explanations and descriptions of migration and mental health experiences qualitatively. Then the quantitative phase aimed at expanding the initial qualitative results using a much larger sample. Based on a descriptive phenomenological method, qualitative data was collected from 14 purposefully selected participants using face-to-face interviews. The data was analysed using the five steps phenomenological descriptive analysis. A cross-sectional survey was utilised to collect data from 195 conveniently sampled respondents. A survey questionnaire was used to collect data and it included demographic questions and the following measures: Refugees Stress Scale (RSS), Post- Migration Living Difficulties Questionnaire (PMLD), Refugees’ Defenceless Scale (RDS), Connor-Davidson Resilience Scale (CD-RS), General Health Questionnaire (GHQ - 28) and Post-Traumatic Stress Disorder Checklist - civilian version (PCL -5). The data was analysed using the Statistical Package for the Social Science (SPSS version 25). Techniques of exploratory factor analysis, independent samples t-tests, ANOVA, Pearson- moment correlation coefficient and regression models were used to analyse the quantitative data. Results: The qualitative results revealed that throughout migration refugees have experienced life-threatening events and gross violation of human rights emanating from state-organized-violence, conflict and xenophobic violence or criminal attacks. Further, refugees also suffered from economic hardships mostly due to lack of employment opportunities, not knowing where they were going, travelling alone, lack of basic necessities, persecution and lack of security. As a result, their mental health experiences attest emotional and psychological distress resulting from the immediate stressors and lingering migration stressors. The participants described experiencing symptoms of PTSD, anxiety and depression throughout the migration process and beyond. The psychological distress of refugees who fled recently and experienced traumatic events have been further stressed by the lack of basic necessities in South Africa, is notably worrisome. Refugees were dealing with very negative experiences using different coping mechanisms, mainly, faith and religiosity, escaping danger, using hopeful thoughts and relying on some social support. The quantitative results revealed threats to life, forced separation from family, not having a clear vision about ones’ future, limited freedom and police or military follow-ups or beating as most common pre-migration stressors. The post-migration stressors are mainly insecurity and vulnerability that includes xenophobic threats, lack of job opportunity/ unemployment, worries about their children, discrimination, separation from family, unable to return to their original home in an emergency time and fear of repatriation. Regarding psychological distress, anxiety and insomnia are found as the most prevalent symptoms of distress, followed by social dysfunction, somatic complaints and depression. About one third of the participants are experiencing major symptoms of PTSD. Conclusion: The prevalence of psychological distress is relatively lower in this study when compared to other studies among African refugees, however, refugees who fled recently from traumatic experiences are found to be notably stressed with major PTSD symptoms. Further, lack of basic needs, minimal financial income and insecurity are found to be determinants of mental health of refugees. Mental health promotion interventions for refugees should consider their primary needs, health inclusive of mental health screening at entry and to follow-up by addressing their psychological problems through both individual and community-based psychosocial interventions to enable refugees to take better control of their health and wellbeing within an supportive and enabling environment.