Improving mental health and wellbeing in recently-arrived refugee families and children

355 Pages·2011·3.79 MB·English

by  Jenny Tsoupas

i

Improving mental health and wellbeing
in recently-arrived refugee families and
children

J. Tsoupas

Doctor of Psychology

2011

RMIT
ii

Improving mental health and wellbeing
in recently-arrived refugee families and
children

A thesis submitted in partial fulfilment of the requirements for
the degree of Doctor of Psychology

Jenny Tsoupas
B.App.Sci. (Psychology)(Hons)

School of Health Sciences
College of Science, Engineering and Health
RMIT University
June 2011
ii

Declaration of Authorship
I certify that except where due acknowledgement has been made, the work is that of
the author alone; the work has not been submitted previously, in whole or in part, to
qualify for any other academic award; the content of the thesis is the result of work
which has been carried out since the official commencement date of the approved
research program; any editorial work, paid or unpaid, carried out by a third party is
acknowledged; and, ethics procedures and guidelines have been followed.

Signed:

______________________
Jenny Tsoupas

10 June, 2011
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Acknowledgements
I wish to thank the following people in the production of this thesis.
First and foremost, I would like to extend a special thanks to all the children and
parents who agreed to participate in this research. I am grateful for their time, honesty,
and willingness to share their experiences with me. Without their support and
involvement, this research would not have been possible. I wish them all the best in
the future.
I would also like to thank the staff at Foundation House, The Western English
Language School, MacKillop Family Services, The Napier Street Child and Family
Resource Centre, and Debney Meadows Primary School for their support, advice, and
assistance.
I would like to thank my supervisors, Dr Sophie Xenos and Dr Mervyn Jackson
for their patience, practical advice, and encouragement throughout this project. I
would also like to extend a special thanks to Dr John Reece who provided critical
advice and support during data analysis.
I thank all my family and friends, especially my mum for being the best mum
anyone could ask for, Linda and Tony for their generous support when times got
tough, Kylie for her kind words and patient ears, and of course Nari, Dave, Dan,
Kerrie, Holly, Marianne, Annaleise, Cath, Kath, Adam and Mary for their friendship
and for encouraging me to keep fit, healthy, and happy throughout this process.
Last but not least, I would like thank my wonderful partner Stephen for his
never-ending love, support, encouragement, and for keeping me sane every time my
computer refused to work properly. I could not have completed this thesis without
him – I love you lots.
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Table of Contents
Declaration of Authorship ....................................................................................................... ii
Acknowledgements ................................................................................................................. iii
Table of Contents ..................................................................................................................... iv
Index of Tables ......................................................................................................................... ix
Index of Figures ........................................................................................................................ xi
Glossary of Terms .................................................................................................................. xii

Abstract……... ........................................................................................................................... 1

CHAPTER 1. Introduction and Aims of the Current Research .......................................... 5
Introduction ............................................................................................................................ 5
Aim of the Current Research .................................................................................................. 6
Organisation of the Thesis...................................................................................................... 7

CHAPTER 2: Background Information about Refugees ...................................................... 9
The UNHCR‟s role and the Definition for Refugee .............................................................. 9
Refugees, asylum-seekers and illegal immigrants. ........................................................... 10
Refugees versus migrants. ................................................................................................ 11
The UNHCR and Australia‟s Humanitarian Program.......................................................... 11
Who are Australia‟s refugees? .......................................................................................... 13
Integrated Humanitarian Settlement Strategy (IHSS) ....................................................... 14
Three Phases of Traumatic Experiences .............................................................................. 15
Pre-flight. .......................................................................................................................... 15
Flight (or displacement). ................................................................................................... 16
Re-settlement. ................................................................................................................... 16
Resilience in Refugees ......................................................................................................... 18
Summary .............................................................................................................................. 19

CHAPTER 3: Literature Review - The Mental Health Impact upon Refugees ............... 21
Posttraumatic Stress Disorder .............................................................................................. 22
Depression ............................................................................................................................ 23
Controversy surrounding psychiatric diagnoses with refugee populations .......................... 23
Part I: Prevalence of Mental Health Issues in Refugee Adults ............................................ 26
PTSD in adult refugees. .................................................................................................... 26
Depression in adult refugees. ............................................................................................ 30
Other disorders in adult refugees. ..................................................................................... 31
Co-morbidity. .................................................................................................................... 36
Part I - summary. ............................................................................................................... 37
Part II: Prevalence of Mental Health Issues in Refugee Children........................................ 38
PTSD in refugee children. ................................................................................................. 39
Depression in refugee children. ........................................................................................ 43
Other disorders and problems in refugee children. ........................................................... 45
Co-morbidity. .................................................................................................................... 49
Part II - summary. ............................................................................................................. 49
Part III: Effects of the Refugee Experience on Families and Parenting............................... 50
Parenting and psychopathology. ....................................................................................... 51
Parenting in refugee families under stress. ....................................................................... 57
Refugee parenting needs after resettlement. ..................................................................... 58
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Part III - summary. ............................................................................................................ 65

CHAPTER 4: Study One – The Parenting Strengths and Difficulties of Recently-
Arrived Refugee Mothers in Melbourne ..................................................... 67
Study Aims….. ......................................................................................................................... 68
Method………. ......................................................................................................................... 68
Participants ........................................................................................................................... 68
Sampling............................................................................................................................... 69
Recruitment Settings ............................................................................................................ 70
The Napier Street Child and Family Resource Centre (Napier Street). ............................ 71
MacKillop Family Services (MacKillop). ........................................................................ 71
Debney Meadows Primary School (Debney Meadows). .................................................. 72
Design................................................................................................................................... 72
Procedure .............................................................................................................................. 74
Ethics approval. ................................................................................................................. 74
Recruitment of participants and associated ethical considerations. .................................. 74
Informed consent and associated ethical considerations. ................................................. 77
Focus group questions. ...................................................................................................... 80
Focus group procedure. ..................................................................................................... 81
Community and participant feedback. .............................................................................. 82
Analyses. ........................................................................................................................... 83
Results……….. ......................................................................................................................... 84
Section I: Roles, Duties, Goals, Joys, and Benefits of Parenting ......................................... 85
A parent‟s role and duty. ................................................................................................... 85
Aspirations and goals for children. ................................................................................... 86
Parenting joys and benefits. .............................................................................................. 88
Section II: Parenting Challenges .......................................................................................... 89
Main parenting challenges. ............................................................................................... 90
Other parenting challenges. ............................................................................................ 104
Section III: General Settlement Challenges/Difficulties and Other Issues ........................ 115
Unfamiliar environment. ................................................................................................. 115
Racism and discrimination. ............................................................................................. 117
Section IV: Other Results ................................................................................................... 118
Participant satisfaction and turnout. ................................................................................ 118
Community feedback on preliminary analysis results. ................................................... 118
Discussion…… ....................................................................................................................... 119
Summary of Major Findings .............................................................................................. 119
Positive aspects of parenting. .......................................................................................... 120
Challenges associated with parenting. ............................................................................ 121
Participant suggestions. ................................................................................................... 125
Practical Implications ......................................................................................................... 126
Cultural awareness. ......................................................................................................... 126
Intervention priorities. ..................................................................................................... 127
Other potential interventions. .......................................................................................... 130
Research method implications. ....................................................................................... 136
Theoretical Implications ..................................................................................................... 136
Limitations of the Study ..................................................................................................... 137
Resources, research design and research method. .......................................................... 138
Sample size and sample characteristics. ......................................................................... 139
Conclusions and Future Research ...................................................................................... 140
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CHAPTER 5: Literature Review - Interventions for Refugees ........................................ 142
Mental Health Treatment for Refugees in Resettlement Countries ................................... 142
Treatment of PTSD. ........................................................................................................ 143
Treatment of depression and other disorders. ................................................................. 148
Community-based models of intervention in resettlement countries. ............................ 150
School-based mental health services. ............................................................................. 152
Mental Health Promotion and Refugees in Resettlement Countries .................................. 154
Mental Health Prevention and Refugees in Resettlement Countries ................................. 157
Preventive family interventions. ..................................................................................... 158
School-based prevention programs. ................................................................................ 159
Chapter Summary ............................................................................................................... 165

CHAPTER 6: Study Two - Evaluation of the Rainbow Program .................................... 167
Study Aims….. ....................................................................................................................... 171
Study Hypotheses .................................................................................................................... 172
Method………. ....................................................................................................................... 173
Participants ......................................................................................................................... 173
Design................................................................................................................................. 174
Materials and Measures ...................................................................................................... 175
Intervention. .................................................................................................................... 175
Treatment integrity. ......................................................................................................... 177
Social validity measures. ................................................................................................ 177
Program effectiveness: Qualitative evaluations. ............................................................. 179
Program effectiveness: Quantitative evaluation. ............................................................ 179
Procedure ............................................................................................................................ 184
Ethics approval and organisation consent. ...................................................................... 184
Consent and associated ethical considerations. .............................................................. 184
Crisis care. ....................................................................................................................... 185
Implementation of Rainbow intervention. ...................................................................... 186
Collection of pre and post-intervention evaluation material. .......................................... 187
Data Analysis. ................................................................................................................. 188
Results……….. ....................................................................................................................... 195
Demographics..................................................................................................................... 195
Program integrity................................................................................................................ 198
Social Validity .................................................................................................................... 200
Social validity questionnaire (SVQ). .............................................................................. 200
Rainbow session feedback questionnaire (RSFQ). ......................................................... 201
Letters to the researchers. ............................................................................................... 203
Attendance rate. .............................................................................................................. 203
Participation rates. ........................................................................................................... 204
Researcher‟s reflection on social validity. ...................................................................... 204
Program effectiveness: Qualitative Evaluations ................................................................ 205
Letters to the researchers. ............................................................................................... 205
Participant progress. ........................................................................................................ 206
Program effectiveness: Quantitative Evaluations .............................................................. 209
Effect on self-esteem. ...................................................................................................... 209
Effect on adaptive functioning. ....................................................................................... 212
Effect on internalising, externalising and total problem behaviours. ............................. 214
Effect on depression. ....................................................................................................... 219
Effect on anxiety. ............................................................................................................ 221
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12-Month Follow-Up Data ................................................................................................. 228
Discussion…… ....................................................................................................................... 228
Summary of Results ........................................................................................................... 229
Program integrity. ........................................................................................................... 229
Social validity. ................................................................................................................ 230
Program effectiveness: Qualitative evaluations. ............................................................. 231
Program effectiveness: Quantitative evaluations. ........................................................... 233
Strengths and Limitations................................................................................................... 240
Practical Implications and Recommendations ................................................................... 244
Further Research and Recommendations ........................................................................... 245
Conclusion .......................................................................................................................... 247

CHAPTER 7: General Discussion ....................................................................................... 248
Summary of Findings ......................................................................................................... 248
Study One. ....................................................................................................................... 248
Study Two. ...................................................................................................................... 250
Methodological Challenges ................................................................................................ 252
Sample size, characteristics, and selection bias. ............................................................. 252
Quantitative and qualitative research measures. ............................................................. 252
Cultural validity of mental health constructs. ................................................................. 253
Resourcing issues. ........................................................................................................... 254
Theoretical Implications and Recommendations for Future Research .............................. 254
Practical Implications and Recommendations for Future Research................................... 255
Ethical considerations. .................................................................................................... 255
Recruitment issues. ......................................................................................................... 256
Other issues to consider. ................................................................................................. 257
Concluding Remarks .......................................................................................................... 258

References…... ....................................................................................................................... 259

Appendices…………………………………………...………………………………….….305
Appendix A: Ethics Approval from RMIT HREC – Focus Group Study .......................... 305
Appendix B: Ethics Approval from the DEECD - Focus Group Study ............................. 307
Appendix C: Ethics Approval from MacKillop Family Services – Focus Group
Study ............................................................................................................. 309
Appendix D: Permission to Conduct Research Forms – Focus Group Study .................... 310
Appendix E: Original RMIT HREC Plain Langauge Statement ........................................ 312
Appendix F: Original RMIT HREC Consent Forms ......................................................... 315
Appendix G: List of the Proposed Focus Group Questions ............................................... 316
Appendix H: Information Flyer for Focus Group Participants ........................................... 317
Appendix I: Coding Key Used to Develop Themes and Associated Subthemes .............. 318
Appendix J: Session by session Description of the Rainbow Program And Activity
Objectives ..................................................................................................... 320
Appendix K: Session Summary Worksheet (SSW) ............................................................ 324
Appendix L: Social Validity Questionnaire (SVQ) ........................................................... 325
Appendix M: Rainbow Session Feedback Questionnaire (RSFQ) ..................................... 325
Appendix N: Letter to the Researchers ............................................................................... 327
Appendix O: Questionnaire Package .................................................................................. 328
Appendix P: Ethics Approval from RMIT HREC – Rainbow Study ................................ 332
Appendix Q: Ethics Approval from the DEECD – Rainbow Study ................................... 334
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Appendix R: Consent for Research - Principal from WELS .............................................. 336
Appendix S: Consent for Research - VFST ....................................................................... 337
Appendix T: Plain Language Statement – Rainbow Study ................................................ 338
Appendix U: Consent Form – Rainbow Study ................................................................... 340
Appendix V: Letters to the Researchers ............................................................................. 341
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Index of Tables
Table 1 Demographic Data for Participants from Each Focus Group Setting ......... 69
Table 2 Main Parenting Challenges, Associated Subthemes and Suggestions
Provided to Address These Challenges ....................................................... 91
Table 3 Other Parenting Challenges, Associated Subthemes and Suggestions
Provided to Address these Challenges ...................................................... 105
Table 4 Reason for Participant Referral into the Rainbow Program ...................... 173
Table 5 Rainbow Program Implementation and Evaluation Schedule ................... 187
Table 6 Demographic Characteristics on Categorical Variables with
Corresponding Chi-square Analysis of Differences ................................. 196
Table 7 Demographic Characteristics on Quantitative Variables with
Corresponding Independent Sample t-test Analysis of Differences ......... 197
Table 8 Rainbow Program Agenda Items Implemented as Recorded on the SSW 198
Table 9 Overall Group Social Validity Results from the SVQ Conducted
Weekly ...................................................................................................... 200
Table 10 Session by Session Comparison of Group Feedback Responses about
their Positive Rainbow Program Experiences ........................................... 202
Table 11 Themes, Subthemes and Participant Quotes from the Letters to the
Researchers ............................................................................................... 206
Table 12 Summary of Changes Observed in Participant Behaviour over the
Duration of the Rainbow Program ............................................................ 208
Table 13 Comparison of CSEI Scores by Group at Pre-test and Post-test .............. 209
Table 14 Cohen‟s d and the 95%CI for Self-Esteem Representing the Amount of
Change between Pre-test and Post-test for the Rainbow and Control
Groups ....................................................................................................... 212
Table 15 Comparison of Adaptive Functioning Scores by Group at Pre-test and
Post-test ..................................................................................................... 213
Table 16 Cohen‟s d and the 95%CI for Adaptive Functioning Representing the
Amount of Change between Pre-test and Post-test for the Rainbow and
Control Groups .......................................................................................... 214
Table 17 Comparison of TRF Problem Behaviour Scores by Group at Pre-test
and Post-test .............................................................................................. 215
Table 18 Cohen‟s d and the 95% Confidence Interval for the Teacher Report
Form Representing the Amount of Change between Pre-test and Post-
test for the Intervention and Control Groups ............................................ 218
Table 19 Comparison of Mean, Standard Deviation and Range Scores by Group
at Pre-test and Post-test for the Children‟s Depression Inventory-Short
Form .......................................................................................................... 219
Table 20 Cohen‟s d and the 95%CI for the Children‟s Depression Inventory
Representing the Amount of Change between Pre-test and Post-test for
the Rainbow and Control Groups ............................................................. 221