Trauma and Mental Health in Resettled Refugees: Mediating Effect of Host Language Acquisition on Posttraumatic Stress Disorder,Depressive and Anxiety Symptoms

Abstract

This study examined the relationship between traumatic exposure, host language acquisition and mental health (posttraumatic stress, depressive and anxiety symptoms) in long-term resettled refugees. Participants included a community sample of Bosnian refugees (N = 138, 55% male, mean age of 40 years old) that had resettled in Australia and Austria on average 18 years prior. Two mediation models were tested based on two competing theories. Model A examined whether language acquisition mediates the relationship between traumatic exposure and mental health problems experienced by refugees. Model B examined whether mental health symptoms mediate the relationship between exposure to traumatic events and the acquisition of host language. Model A fit the data well (CFI = 1.00, SRMR = .017, RMSEA < .001, χ² p = .526), while Model B was rejected as an acceptable model for the data (CFI = .556, SRMR = .136, RMSEA = .352). In Model A, the indirect pathway from trauma to mental health via language acquisition was significant for PTSD (β = .067, p = .028) and anxiety symptoms (β = .063, p = .026) but not depression symptoms (β = .048, p = .071). Intervention strategies aimed at improving host language acquisition may be important not only in successful adaptation to daily living in the host country, but also to improve the mental health of traumatized refugees.

Keywords

trauma war refugees language acquisition posttraumatic stress disorder depression anxiety migration

Introduction

Research focusing on refugees, asylum seekers and displaced populations has identified high prevalence rates of mental health disorders following exposure to traumatic war events (Fazel, Wheeler, & Danesh, 2005; Kirmayer et al., 2011), especially for those persons exposed to interpersonal and multiple traumas (Steel, Chey, Silove, Marnane, Bryant, & van Ommeren, 2009). In addition, research evidence identified that migratory factors associated with adapting to the host culture occupationally, socially and psychologically can exacerbate the mental health problems associated with exposure to traumatic experiences (Lindencrona, 2008; Porter & Haslam, 2005; Steel, Silove, Phan, & Bauman, 2002). Among migratory factors, host language acquisition is identified as a protective factor, buffering against the stress associated with adapting to the new environment and easing the process of completing daily living tasks (Beiser & Hou, 2001; UNHCR, 2001). On the other hand, inability to acquire the host language exposes refugees to additional stress, which negatively impacts their mental health (Robertson et al., 2006; Söndergaard & Theorell, 2004).

Research investigating host language acquisition has predominantly focused on non-refugee migrant populations. Less is known about the relationship between language acquisition and mental health among refugees and whether findings in non-refugee migrant populations are generalizable to refugees (van Tubergen, 2010). While there is robust evidence that past traumatic experiences commonly experienced by refugees affect mental health (Steel et al., 2009), little is known about the pattern and direction of the causal pathways between traumatic events, host language acquisition and mental health outcomes.

This study investigated two models used to investigate the relationship between traumatic events, host language acquisition and mental health in a sample of Bosnian refugees. The first model (Model A) proposes that while traumatic exposure has a direct impact on mental health, it also indirectly impacts mental health through its relationship with host language acquisition (see Figure 1). While there is no previous research into this proposed model, various studies provide support for the components of this model.

Figure 1.

Proposed models explaining the relationship between traumatic exposure, host language acquisition and mental health. Model (a): Language acquisition mediates the relationship between traumatic exposure and mental health; Model (b): Mental health mediates the relationship between traumatic exposure and language acquisition.

Trauma diminishes the capacity to deal with additional stress (Lindencrona, 2008), which indirectly increases vulnerability to stress related psychopathology (Matheson, Jorden, & Anisman, 2008; Schweitzer, Melville, Steel, & Lacherez, 2006; Steel, Silove, Bird, McGorry, & Mohan, 1999). Research indicates that language acquisition is an important stressor associated with the migratory process. Knowledge and familiarity with the host language is a major domain underpinning the process of acculturation that refugees go through during migration as they negotiate their participation in the new culture and maintenance of the origin culture and identity (Berry, 1997). The stress arising from this process associated with acquisition of host language is identified as a significant risk factor (Berry, 1997; Bogic et al., 2012; Ellis, MacDonald, Lincoln, & Cabral, 2008; Knipscheer & Kleber, 2006) predicting increased general distress, anxiety symptoms and even posttraumatic stress disorder (PTSD) symptoms (Beiser & Hou, 2001, 2006; Kartal & Kiropoulos, 2016; Schweitzer, Brough, Vromans, & Asic-Kobe, 2011; Silove, Steel, McGorry, & Mohan, 1998; Söndergaard & Theorell, 2004).

The second model (Model B) proposes that mental health symptoms associated with traumatic exposure affect the capacity to acquire the host language (see Figure 1). In this model, trauma exposure has an indirect relationship with host language acquisition, due to the direct relationship between trauma and mental health, and the subsequent relationship between mental health and language acquisition. Model B is supported by neurobiological research that finds that traumatic exposure alters the neural pathways in the brain that are associated with cognitive domains and executive functioning (Etkin, Gyurak, & O’Hara, 2013), with the largest effects on working and verbal memory, attention, learning and information processing (Bremner et al., 1993; Gilbertson, Gurvits, Lasko, Orr, & Pitman, 2001; Polak, Witteveen, Reitsma, & Olff, 2012; Scott et al., 2015; Shaw, Strother, McFarlane, Morris, Anderson, Clark, & Egan, 2002). These cognitive domains consequently play a role in second language acquisition. This proposition, however, has not been empirically tested. In addition, research in this area is predominantly conducted with veterans and the serving military, and hardly any studies have examined the impact of PTSD, depression or anxiety symptoms on executive functioning and language acquisition in refugees. Limited evidence suggested that traumatized refugees presenting with more severe PTSD symptoms acquire the host language at a significantly slower rate (Söndergaard & Theorell, 2004). This indicates that PTSD symptoms related to automatic processing problems, impairment in executive memory (Kanagaratnam & Asbjørnsen, 2007) and cognitive difficulties (Söndergaard & Theorell, 2004) may partially explain difficulties with acquisition of the host language.

To better understand the relationship between trauma, mental health symptoms and host language acquisition, this study examined which of the two above-mentioned models better explained the relationship between these variables. In particular, we firstly examined if host language acquisition mediates the relationship between traumatic exposure and mental health problems experienced by Bosnian refugees (Model A). Secondly, we examined if mental health symptoms mediate the relationship between exposure to traumatic events and acquisition of the host language (Model B). Furthermore, because there is evidence to indicate that language acquisition is predicted by age (Flege, Yeni-Komshian, & Liu, 1999) and length of residence (Beiser & Hou, 2001) and that gender is a significant predictor of PTSD (Armour, Elhai, Layne, Shevlin, Duraković-Belko, Djapo, & Pynoos, 2011), we considered the potential confounding effects of these variables. Finally, we also tested if the models differed between Bosnian refugees resettled in two different countries.

War and resettlement experiences of Bosnian refugees

The last census conducted in Bosnia at the brink of the war (1991) indicated a population of 4.4 million, of whom 43.5% were Bosniaks (or Bosnian Muslims), 31.2% Bosnian Serbs, 17.4% Bosnian Croats, 5.5% Yugoslavs and 2.4% represented other ethnic groups (World Refugee Statistics, 1997). During the Bosnian war (1992–1995) about 2.2 million Bosnians were uprooted and driven away from their homes, about 200,000 were wounded and more than 250,000 were killed, with Bosniaks the main target ((World Refugee Statistics, 1997); World Bank Group, 1998). Brutal crimes and war strategies led not only to mass forced displacement, but also to the reappearance of concentration camps, systematic rape and executions and mass destruction of cultural and religious sites and monuments (Power, 2002). The escalating crisis led to a massive population movement and the biggest refugee crisis experienced post-World War II.

The huge influx of refugees to Europe in the 1990s had a major impact on admission processes and the provision of asylum. Instead of provision of humanitarian protection and permanent resettlement, Bosnian refugees that arrived in Austria were almost automatically provided with a temporary protection visa; were housed in temporary accommodations; and were denied the right to work, receive welfare benefits or reunite with family members outside of Austria – despite the persecution and atrocities they had experienced (Bauer, 2008; Franz, 2005). As a result, these de-facto refugees found employment on the black market, enabling them to move out of crowded, temporary housing, and eventually acquired working and residency permits (Krause & Liebig, 2011). Unfortunately, this process usually took years to achieve, exposing individuals and families to many years of stress associated with the migratory process. Currently there are about 150,000 Bosnians living in Austria (Statistics Austria, 2011).

Bosnian refugees resettled in Australia usually arrived under government-sponsored humanitarian programs. These refugees were identified by United Nations Higher Commission for Refugees (UNHCR) as the most vulnerable (UNHCR, 2011). In the 1990s, Bosnians were the largest group of refugees who received humanitarian sponsored visas and were permanently resettled in Australia (Jupp, 2002). As such, they immediately received permanent residency and unrestricted access to all services afforded to Australian citizens, including access to health services and welfare support, as well as additional services including language training, housing and vocational support. In addition, refugees resettled permanently in Australia had an option to reunite with their immediate family members and bring them to live in Australia (DIAC, 2009). Currently there are about 25,000 Bosnians living in Australia, with the majority resettled in Victoria and New South Wales (ABS, 2013). This description illustrates the differences in the resettlement experiences in the post-migratory environments that these two groups of refugees faced upon leaving their war-torn country.

Method

Participants and procedure

Participants were eligible for inclusion in this study if they were at least 18 years old, were exposed to war events in Bosnia during 1992–1995 and resided in Australia or Austria during data collection (2012–2014). Options used to recruit participants included snow-ball sampling, online recruitment, advertising in local media (Bosnian newspapers, radio and television) and recruitment through social clubs and associations. Participants responded in an anonymous self-report survey via an online hosted website or a hard copy of the survey which was returned anonymously in a prepaid envelope. More than half of the participants (n = 78, 57%) used a hard copy version. There were no statistical differences between those who filled a hard copy or an online version of the survey for any of the outcomes including levels of PTSD (χ²= 31.54; p = .29) depressive (χ²= 17.86; p = .53) or anxiety symptoms (χ²= 12.26; p = .66).

All measures used in the study were translated from English into Bosnian by the first author, who is a native speaker of the language, and then back-translated by an independent bilingual academic, so as to allow for comparison between the two translations. Any discrepancies in translation were resolved by discussion and mutual agreement between the first author and the bilingual academic. This study was reviewed and approved by the Monash University Human Research Ethics Committee certificate number CF09/32382009001758.

Measures

The questionnaire included a set of demographic questions (age, gender, education and marital status). Traumatic exposure was a cumulative measure assessed with a set of trauma history questions using yes/no answers assessing exposure to war-related (e.g., torture, concentration camp, killing) and other traumatic events (e.g., exposure to disasters, accidents and assaults) experienced during the participant’s lifetime. The information on trauma exposure was derived from assessment measures commonly utilized among refugee populations to assess war-related (i.e., Harvard Trauma Questionnaire, part 1 (Mollica, McInnes, Sarajlić, Lavelle, Sarajlić, & Massagli, 1999)) and life-time history of potentially traumatic events (CIDI (Kessler & Üstün, 2004)).

Posttraumatic Stress Diagnostic Scale

The Bosnian translation (Powell & Rosner, 2005) of the Posttraumatic Stress Diagnostic Scale (PDS; Part 3 only) (Foa, Cashman, Jaycox, & Perry, 1997) was used for the assessment of current PTSD symptomatology. This measure is based on the DSM-IV PTSD symptom criteria (APA, 2013) which included 17 items scored on a 4-point Likert scale (from 0 = not at all or only one time, to 3 = five or more times per week/almost always). The alpha coefficient for the current Bosnian version of the PDS was excellent (α = .97).

Depression and Anxiety Scale

The Depression Anxiety Stress Scale (DASS-21) is a 21-item self-report inventory designed to provide measures of the three related negative affective states of depression, anxiety, and stress (Lovibond & Lovibond, 1995). In the current study, only the depression and anxiety subscales were used to assess the presence of symptoms over the past two weeks. Items are measured on a 4-point Likert scale (0 = did not apply to me at all, and 3 = applied to me very much/most of the time). Alpha coefficients for the depression (α = .95) and anxiety (α = .92) subscales in the current sample were excellent.

Language acquisition

Language acquisition was assessed using a host language acquisition subscale from the Language, Identity, Behavioral Acculturation (LIB) scale (Birman, Trickett, & Vinokurov, 2002). Ratings are made on a 4-point Likert scale ranging from not at all to very well, like a native-speaker. The language acquisition subscale consisted of nine items asking participants to rate their ability to speak and understand the host language. The alpha coefficient in the current study (α = .95) was excellent.

Statistical analyses

Descriptive and bivariate correlations were performed using SPSS version 22.0 (SPSS INC., 2013). Path analyses were performed in Mplus version 7.0.1 (Muthén & Muthén, 2010) testing direct and indirect effects. Gender and length of residence were identified as potential confounding covariates and were controlled in all analyses. Subgroup analyses were performed investigating the fit of the model based on the country of resettlement. We relied upon a variety of model fit indices including the chi-squared goodness of fit, comparative fit index (CFI) (Bentler, 1990), the root mean square error of approximation (RMSEA) (Steiger, 1990) and the standardized root mean square residual (SRMR) (Vandenberg & Lance, 2000). Interpretation of the model fit was based on appraising multiple fit indices (Hu & Bentler, 1998, 1999). If the CFI values were <.90 the model was rejected. RMSEA values <.05 were considered a close approximate fit, values between .05 and .08 were considered reasonable and values ≥.10, indicative of poor model fit. A SRMR value near .08 was considered to support the model well.

Results

Participant characteristics

The demographic characteristics of the sample are presented in Table 1. A total sample of 138 participants was recruited into the study with a mean age of 40.20 years (SD = 14.91, range from 18–80 years) with 55% being male. The average length of residence in the host country was 17.66 years (SD = 5.07). Group differences were identified for age (t(136) = 2.93, p = .004) and length of resettlement (t(136) = −3.173, p = .002). In particular, Australian Bosnians were older (M = 44.61(14.60) and reported shorter length of residence in host country (M = 16.05 (3.46) years) compared to Austrian Bosnians (age: M = 37.20(14.44), length of residence: M = 18.76 (5.69) years).

Table 1.

Socio-demographic Characteristics of Participants (N = 138).

	n	%
Gender
Male	76	55
Female	62	45
Country of residence
Australia	56	41
Austria	82	59
Marital status
Married	81	59
Single	28	20
In a relationship	18	13
Other	11	8
Education level
Tertiary or above	57	41
Advanced Diploma	28	20
High school or less	53	38
Religion
Islam	108	78
Atheist	12	9
Catholic	5	4
Other	1	1
Not declared	12	9
Ethnic background
Bosniak	110	80
Mixed ethnicity	5	4
Croatian Bosnian	2	1
Serbian Bosnian	1	1
Not declared	20	15

Table 2.

Exposure to Traumatic Events Reported by Bosnian Refugees (N = 138).

Traumatic event	n	%
Separation from immediate family	76	55
Direct bombardment or sniper fire	69	50
Lack of food, shelter, medicine	69	50
Other stressful event happened to family	56	41
Family member injured, killed or tortured	55	40
Other stressful or upsetting event	52	38
Life threatening accidents	41	30
Witnessed other people being harmed, tortured or killed	39	28
Serious physical attack or assault	34	25
Witnessed family injury, killing or torture	15	11
Fire, flood or natural disaster	14	10
Torture	12	9
Combat	10	7
Concentration camp	9	7
War-related serious injury	4	3

Eighty-two percent of the whole sample reported experiencing at least one traumatic event, while 70% reported experiencing three or more traumatic events in their life (M = 5.09, SD = 4.03, range 0–16). The most common experiences reported by participants include experiencing separation from immediate family members (n = 72, 42%), direct bombardment or sniper fire (n = 68, 46%) or lack of food, shelter or medicine (n = 68, 46%). There were no differences in traumatic exposure reported by men and women, but there were significant differences based on the country of resettlement with Australian Bosnians reporting more traumatic exposure M = 6.68 (4.00), than Austrian Bosnians M = 4.01 (3.70); t(136) = 4.02, p <.001.

Prevalence of Mental Health Outcomes

Table 3 presents the frequencies of self-reported PTSD, depression and anxiety symptoms. The mean score for posttraumatic stress was 8.58 (SD = 11.57), depressive symptoms, 3.76 (SD = 5.13) and anxiety symptoms, 3.41 (SD = 4.52), indicating relatively moderate levels of PTSD, depressive and anxiety symptoms. Utilizing the recommended cut-offs for severity scoring, results indicated that most participants reported normal levels of PTSD (66%), depression (70%) and anxiety (58%) symptoms. There were no significant differences reported by gender. However, there were significant differences in severity of anxiety and PTSD symptoms reported by country, with Bosnian refugees in Australia reporting more anxiety and PTSD symptoms than Bosnian refugees in Austria.

Table 3.

Severity of PTSD, Depressive and Anxiety Symptoms Across Bosnians in Australia and Austria.

Symptoms	Total Sample n (%)	Australian Bosnians n (%)	Austrian Bosnians n (%)	Group differences Fisher’s exact
Depressive symptoms				8.33, p = .071
Normal	89 (70)	29 (58)	60 (77)
Mild	7 (6)	2 (4)	5 (6)
Moderate	16 (12)	10 (20)	6 (8)
Severe	7 (6)	3 (6)	4 (5)
Extremely severe	9 (7)	6 (12)	3 (4)
Anxiety symptoms				9.74, p = .039
Normal	80 (58)	24 (48)	56 (72)
Mild	12 (9)	5 (10)	7 (9)
Moderate	16 (12)	9 (20)	7 (9)
Severe	7 (5)	3 (1)	4 (5)
Extremely severe	13 (9)	9 (2)	4 (5)
PTSD symptoms				14.89, p = .001
None/mild	83 (65.9)	27 (53)	56 (75)
Moderate	21 (16.7)	7 (14)	14 (19)
Moderate-severe	19 (15)	14 (27)	5 (7)
Severe	3 (2)	3 (6)	0 (0)

Note: Percentages do not always correspond to total N due to cases with missing data.

Association between language acquisition and mental health indices

Exposure to traumatic events was found to be positively associated with PTSD (.695), depressive (.600) and anxiety symptoms (.642) and negatively associated with host language acquisition (−.281). Furthermore, host language acquisition was found to be negatively associated with PTSD (−.411), depressive (−.296) and anxiety (−.359) symptoms.

Path model analyses

Separate mediation analyses tested two competing models about the roles of trauma, mental health and host language acquisition in refugees. Table 4 shows the goodness of fit indices for each of the competing models. Model A generated fit indices indicative of a well-fitting model. Importantly the finding of a non-significant Chi-square test is a rare indicator of how well Model A represents the data. In comparison the fit indices generated by Model B fail to support this model as being an adequate representation of the data. Importantly, with language acquisition as the outcome variable, all primary variables in the model other than PTSD (β = .659, p = .02) were non-significant predictors of language acquisition: depression (p = .18), anxiety (p = .14), traumatic exposure (p = .64). The CFI, RMSEA and SRMR scores were all representative of a poor-fitting model. Furthermore, Model A is a better predictor of mental health (PTSD, depressive and anxiety) scores than Model B as indicated by the higher levels of explanatory power (variance explained) detailed in Table 4. Therefore, we selected Model A (represented in Figure 2) as the best conceptualization of the relationships between trauma, host language acquisition and mental health in refugees. However, as shown in Figure 2, significant paths indicated that levels of host language acquisition mediated the relationship between exposure to traumatic events and PTSD and anxiety, but not depressive symptoms. Specifically, indirect effects of traumatic exposure via host language acquisition were statistically significant and indicated that language acquisition at least partially accounted for the relationship between traumatic exposure and the severity of PTSD (β = .067, p = .028) and anxiety symptoms (β = .063, p = .026), but not depressive symptoms (β = .048, p = .071).

Figure 2.

Mediation Model A with the path relationship between trauma and mental health outcomes and mediated by host language acquisition. Significant parameters are indicated by black lines with standardized beta weights. The model controls for gender and length of residency. PTSD = Posttraumatic Stress Disorder.

Table 4.

Fit Indices for the Path Models of Relations Between Traumatic Exposure, PTSD, Depressive and Anxiety Symptom Severity and Host Language Acquisition.

	Model fit				Variance explained
	Chi-square (df), p	CFI	RSMEA	SRMR	Anxiety symptoms	Depressive symptoms	PTSD symptoms
Model A	1.283 (2), p = .526	1.00	<.001	0.017	.449	.381	.556
Model B	163.281 (9), p<.001	.556	.352	0.136	.405	.353	.474

Note: df = degrees of freedom; CFI = comparative fit index; RSMEA = root mean square error of approximation; SRMR = standardized root mean square residual.

We also considered the potential confound of age in the analyses and tested a moderated mediational model following the approach recommended by Hayes (2013). We observed that age did not moderate the mediation model we have tested and therefore we can conclude this is not an important confound to our analyses.

Subgroup analyses

Subsequently we explored whether the path coefficients found in Model A differed between participants resettled in Australia and Austria. While it is not within the scope of this paper to report the full post-hoc analyses, the results indicated a robust model fit for both subgroups [Australia model fit: (X²(2) = 2.097, p = 0.350, CFI = 0.999, RSMEA = 0.029, SRMR = 0.036, SS-BIC = 1230.990); Austria model fit: (X²(2) = 0.438, p = 0.804, CFI = 1.00, RSMEA = 0.00, SRMR =0.012, SS-BIC = 1741.871)] with one significant difference in the pathways identified. Specifically, Wald tests (p = .013) indicated that the path coefficient between traumatic exposure and PTSD was stronger in Austria (β = .659, p <.001) than in Australia (β = .606, p <.001), therefore indicating that trauma history is a stronger predictor of PTSD in Austria than in Australia. However, with a β > 0.5, both models still observe a large effect for traumatic exposure and PTSD.

Discussion

Bosnian refugees in this study reported high levels of traumatic exposure to war and other traumatic stressors. More than two decades after the war, these stressors were still associated with high severity of PTSD, depressive and anxiety symptoms. These findings are consistent with studies conducted with other refugee samples (Fazel et al., 2005; Silove et al., 1998) and with Bosnian refugee samples in other countries (Knipscheer & Kleber, 2006; Mollica, Sarajlić, Chernoff, Lavelle, Vuković, & Massagli, 2001; Momartin, Silove, Manicavasagar, & Steel, 2003). Significantly higher levels of trauma experienced and reported by Australian Bosnians could be explained by their older age, which has been associated with more mental health symptoms in refugees (Bogic et al., 2012; Porter & Haslam, 2015). Varying degrees of exposure found in Australian and Austrian Bosnians are consistent with prior research conducted with ex-Yugoslav refugees, including Bosnians, resettled in European countries that identified varying degrees of exposure and posttraumatic symptoms across samples resettled in different countries (Bogic et al., 2012). Different resettlement trajectories could explain this difference between the samples and the higher severity of posttraumatic symptoms identified in Australian Bosnians. In particular, Australian Bosnians went through resettlement under the UNHCR scheme, which granted resettlement and residence to the most vulnerable and those who experienced particularly traumatic ordeals during the war (UNHCR, 2011).

Analyzing the two different pathways proposed to underlie the relationship between traumatic exposure, mental health and host language acquisition, the results clearly supported Model A, indicating that the relationship between traumatic exposure and mental health was mediated by host language acquisition. Whereas in Model A all paths met criteria for significance, all primary variables in Model B, with the exception of PTSD, were non-significant predictors of language acquisition. Thus, there was no support for the hypothesis that mental health status affected the relationship between trauma and language acquisition. It is important to remember that in Model A the direct relationships between trauma and mental health are still very strong, thus suggesting that difficulties with language acquisition are not the sole reason for mental health problems, but are a mechanism that worsens these outcomes. On the other hand, in Model B, trauma did worsen language acquisition, but the associated mental health problems were not observed to be a mechanism that further inhibited this skill acquisition beyond the influence already observed for trauma.

This finding complements the established evidence base on the cumulative impact of post-migratory stressors (Beiser & Hou, 2001, 2006; Bogic et al., 2012; Schweitzer et al., 2011; Schweitzer et al., 2006; Steel et al., 1999) and language acquisition in particular (Kartal & Kiropoulos, 2016; Robertson et al., 2006; Söndergaard & Theorell, 2004) on mental health outcomes in refugees. However, while this finding was significant for posttraumatic stress and anxiety symptoms, it only approached significance for depressive symptoms, suggesting that the mediation effect of host language acquisition varies based on the type of psychopathology. One explanation for these findings might be the duration of residence in the host country. Longitudinal studies conducted with refugees have reported that depressive symptoms start to decrease after prolonged residence (i.e., more than 10–12 years), which suggests that the early stages of resettlement are highly stressful but a stage of adaption is reached when stress starts to decrease with increased length of stay in the host country (Fenta et al., 2004; Tran, Manalo, & Nguyen, 2007). These results are consistent with findings in the current sample (mean length of residence in host country: 17.66 years), where the migratory stressor of language acquisition did not significantly impact depressive symptoms.

Importantly, subgroup analyses for country of resettlement found support for the mediating role of host language acquisition in both Australian and Austrian Bosnian samples. While there were differences in the direct relationship between trauma and PTSD, the overall findings suggest Model A is robust across different cultural approaches to migration. Indeed, language acquisition difficulties form significant psychological and social barriers to the adaptation and integration of refugees, difficulties that are often intensified by the wider host society. The process of segregation based on competence in the host language can lead to social exclusion and discrimination (Correa-Velez, Gifford, & Barnett, 2010; Sorgen, 2015), which have been associated with poor mental health outcomes (Aichberger et al., 2015; Ellis et al., 2008).

The importance of language acquisition and its effect on mental health and integration of refugees cannot be underestimated. Barriers to communication not only exacerbate the symptoms associated with pre-migratory traumas, but also limit adaptation and social integration (UNHCR, 2001), daily functioning (Beiser & Hou, 2001), participation in the employment market and job satisfaction (Birman, Simon, Chan, & Tran, 2014; Chiswick, Lee, & Miller, 2004). Therefore, difficulty with host language acquisition not only aggravates pre-existing psychopathology of refugees, but also inhibits adaptation to the new cultural landscape.

The impact of language acquisition difficulties on refugee mental health is also an important clinical issue. Inability to understand or communicate appropriately with mental health providers not only impairs the communication itself, but is also a barrier to access and utilization of services (Crosby, 2013). In Australia alone, linguistic barriers are associated with inaccurate diagnosis of mental illness, low hospitalization rates, longer hospitalization duration, and greater rates of involuntary admissions (Cross & Singh, 2012; Pirkis, Burgess, Meadows, & Dunt, 2001). Language also influences the effectiveness of treatment (Miller, Martell, Pazdirek, Caruth, & Lopez, 2005) as it shapes understandings and expressions of distress and mental health symptomatology (Hollifield et al., 2002) and influences the establishment of rapport and trust (Miller et al., 2005). Assisting refugees in acquiring the host language would assist with adaptation to migration and with recovery from mental health problems associated with pre-migratory traumatic exposure.

While language class provision may already be part of the resettlement policies for refugees, previous research indicates that only providing language training opportunities is not enough. Refugees experience access barriers due to social, gendered and cultural issues and potentially even lack of pre-migration education and literacy (Watkins, Razee, & Richters, 2012). Limitations in the accessibility, availability and quality of education in service provision also compound these problems (Watkins et al., 2012). This is particularly an issue if refugees are resettled in rural areas, where student retention challenges and restricted or lack of professional development for educators can be experienced by educators with regard to refugee education (Major, Wilkinson, Langat, & Santoro, 2013).

More can be done to address these barriers and enable refugees to access language services and successfully acquire host language skills. This may include creating culturally responsive education by offering different types of learning opportunities such as activity- or visually-based learning for illiterate students (Maher, 2006), training bilingual refugees as educators (McKay, 2008) and providing home-based learning (Watkins et al., 2012). Finally, informing educators about the possible mental health issues that may be present in refugees is also important, given that exposure to pre-migratory traumatic events is strongly related to disturbed cognitive functioning and learning ability in individuals experiencing posttraumatic symptoms. Enabling and supporting refugees’ adaptation to the host-country environment may best be achieved by implementing resettlement policies that provide multidisciplinary provision of services such as access to social services, health, education, language and vocational training.

Limitations

There are several methodological limitations with this study. First, the study included a relatively small sample of refugees who were recruited via community associations, events and online forums. While this strategy enables data collection from a broader section of participants, the sample of refugees in this study may be more open to reporting their distress than the refugees who did not take part in the study. In addition, the small sample size limits the power of the analyses and comparisons between the two countries in particular. Hence, all conclusions from this study should be interpreted with caution. Secondly, we recruited participants from two countries, and while the refugees targeted may share similar cultural backgrounds, they may also differ in their pre- and post-migration experiences, as indicated by group differences identified in this study. Such differences may reflect recruitment bias, hence limiting the generalizability of these findings to the broader Bosnian refugee population and to other refugee groups in other countries. Thirdly, the current study relied on self-report measures and retrospective reporting, which may present a risk of recall bias and inaccurate measurement of symptoms. Fourthly, prior psychiatric history and presence of mental health symptoms associated with other mental health disorders (i.e., not just PTSD, anxiety and depression) were not assessed in this study. Finally, the psychometric properties of some of the measures used in this study have not been validated in Bosnian refugee populations.

Future directions

Future research should employ a larger sample to replicate these results. Furthermore, longitudinal multi-ethnic and multi-national research is needed to test whether the proposed model fits with other refugee groups and other cultures. Such research should start when refugees arrive in the host country and investigate if the provision of language classes assists in the wellbeing of refugees. Moreover, such studies should be conducted across different refugee groups and resettlement countries, as prior research has indicated that resettlement context impacts on how refugees acculturate into the host society (Berry, 1997). Attention should be given to subgroup differences, such as exposure to trauma, age, gender and length of resettlement, but also differences inherent in the origin culture. Despite the limitations, this study is the first to report on the effects of host language acquisition on the relationship between traumatic exposure and symptoms of PTSD, depression and anxiety among refugees.

Conclusion

Building on our understanding of the risk factors and challenges facing refugees, these findings indicate that more could be done to address the long-term effects of traumatic exposure in refugees and the associated mental health problems. Assisting refugees in the acquisition of the host language could benefit their adaptation to the new environment and lead to improvements in mental health. The findings of the current study draw attention to the proximal environmental settings crucial to recovery (Miller & Rasmussen, 2010). While trauma-related migratory factors are increasingly the target of recovery programs offered to asylum seekers and refugees, health programs implemented in resettlement societies also need to incorporate educational and language acquisition programs aimed at lessening the impact of post-migration stressors.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Dzenana Kartal, PhD, is a research fellow at Phoenix Australia-Centre for Posttraumatic Mental Health at the University of Melbourne. She completed her PhD at Monash University investigating the influence of war-related traumatic exposure, acculturative stress and acculturation on the mental health of long-term resettled refugees in Australia and Austria. Her research experience lies within the area of posttraumatic mental health of including refugees, migrants and asylum seekers and veterans. Her published works focuses on the mental health services research investigating psycho-social vulnerabilities among refugees, implementation and evaluation of evidence-based treatments for PTSD and evidence synthesis including systematic reviews and meta-analyses.

Nathan Alkemade, PhD, is a senior clinical psychologist at Monash Health. He researches the psychological impacts of trauma on a variety of populations including refugees, traumatic brain injury, severe physical injury, natural disasters, military and veterans. His published works focus on accurate psychiatric diagnosis post injury along with the longitudinal effects of trauma on psychological distress and the role of various mediating factors.

Litza Kiropoulos, PhD, is a senior lecturer in clinical psychology in the Melbourne School of Psychological Sciences at the University of Melbourne. She also works part-time as a senior clinical psychologist at various hospitals. Some of her research interests include immigrant and refugee mental health, affective and anxiety disorders, underlying mechanisms involved in the development and maintenance of affective and anxiety disorders and the development and evaluation of specialized and early tailored psy-chological interventions for affective and anxiety disorders in clinical, medically ill and immigrant populations.

References

ABS. (2013). 2011 quickstats country of birth - Bosnia and Herzegovina. Australian Bureau of Statistics Retrieved from http://www.abs.gov.au.

Aichberger

M. C.

Bromand

Rapp

M. A.

Yesil

Montesinos

A. H.

Temur-Erman

Schouler-Ocak

(2015) Perceived ethnic discrimination, acculturation, and psychological distress in women of Turkish origin in Germany. Social Psychiatry and Psychiatric Epidemiology, 1–10. doi: 10.1007%2Fs00127-015-1105-3.

APA (2013) Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Washington, DC: American Psychiatric Association.

Armour, C., Elhai, J. D., Layne, C. M., Shevlin, M., Duraković-Belko, E., Djapo, N., & Pynoos, R. S. (2011). Gender differences in the factor structure of posttraumatic stress disorder symptoms in war-exposed adolescents. Journal of Anxiety Disorders, 25(4), 604–611. doi: 10.1016/j.janxdis.2011.01.010.

Bauer

W. T.

(2008) Zuwanderung nach Österreich (immigration to Austria), Wien, Austria: Österrechische Gesllschaft fur Politikberatung und Politikentwiklung. Retrieved from http://www.forschungsnetzwerk.at/downloadpub/zuwanderung_nach_oesterreich_studie2008_oegpp.pdf.

Beiser

Hou

(2001) Language acquisition, unemployment and depressive disorder among southeast Asian refugees: A 10-year study. Social Science & Medicine 53(10): 1321–1334. doi: 10.1016/s0277-9536(00)00412-3.

Beiser

Hou

(2006) Ethnic identity, resettlement stress and depressive affect among southeast Asian refugees in Canada. Social Science & Medicine 63(1): 137Ö150. doi: 10.1016/j.socscimed.2005.12.002.

Bentler

P. M.

(1990) Comparative fit indexes in structural models. Psychological Bulletin 107(2): 238.

Berry

J. W.

(1997) Immigration, acculturation, and adaptation. Applied Psychology: An International Review 46(1): 5Ö34. doi: http://dx.doi.org/10.1111/j.1464-0597.1997.tb01087.x.

10.

Birman

Simon

C. D.

Chan

W. Y.

Tran

(2014) A life domains perspective on acculturation and psychological adjustment: A study of refugees from the former Soviet Union. American Journal of Community Psychology 53(1–2): 60–72. doi: 10.1007/s10464-013-9614-2.

11.

Birman

Trickett

E. J.

Vinokurov

(2002) Acculturation and adaptation of Soviet Jewish refugee adolescents: Predictors of adjustment across life domains. American Journal of Community Psychology 30(5): 585–607. doi: 10.1023/A:1016323213871.

12.

Bogic

Ajdukovic

Bremner

Franciskovic

Galeazzi

G. M.

Kucukalic

Schützwohl

(2012) Factors associated with mental disorders in long-settled war refugees: Refugees from the former Yugoslavia in Germany, Italy and the UK. The British Journal of Psychiatry 200(3): 216–223. doi: 10.1192/bjp.bp.110.084764.

13.

Bremner

J. D.

Scott

T. M.

Delaney

R. C.

Southwick

S. M.

Mason

J. W.

Johnson

D. R.

Charney

D. S.

(1993) Deficits in short-term memory in posttraumatic stress disorder. American Journal of Psychiatry 150(7): 1015–1019. doi: 10.1176/ajp.150.7.1015.

14.

Chiswick

B. R.

Lee

Y. L.

Miller

P. W.

(2004) Immigrants’ language skills: The Australian experience in a longitudinal survey. International Migration Review 38(2): 611–654. doi: 10.1111/j.1747-7379.2004.tb00211.x.

15.

Correa-Velez

Gifford

S. M.

Barnett

A. G.

(2010) Longing to belong: Social inclusion and wellbeing among youth with refugee backgrounds in the first three years in Melbourne, Australia. Social Science & Medicine (1982) 71(8): 1399–1408. doi: 10.1016/j.socscimed.2010.07.018.

16.

Crosby

S. S.

(2013) Primary care management of non-english-speaking refugees who have experienced trauma: A clinical review. Journal of the American Medical Association 310(5): 519–528. doi: 10.1001/jama.2013.8788.

17.

Cross

Singh

(2012) Dual vulnerabilities: Mental illness in a culturally and linguistically diverse society. Contemporary Nurse: A Journal for the Australian Nursing Profession 42(2): 156–166. doi: 10.5172/conu.2012.42.2.156.

18.

DIAC. (2009). Refugee and humanitarian issues: Australia’s response. Department of Immigration and Citizenship. Australian Govenment. Retrieved from www.dss.gov.au/sites/default/files/documents/01_2014/refugee-humanitarian-issues-june09_access.pdf.

19.

Ellis

B. H.

MacDonald

H. Z.

Lincoln

A. K.

Cabral

H. J.

(2008) Mental health of somali adolescent refugees: The role of trauma, stress, and perceived discrimination. Journal of Consulting & Clinical Psychology 76(2): 184–193. doi: 10.1037/0022-006x.76.2.184.

20.

Etkin

Gyurak

O’Hara

(2013) A neurobiological approach to the cognitive deficits of psychiatric disorders. Dialogues in Cinical Neuroscience 15(4): 419.

21.

Fazel

Wheeler

Danesh

(2005) Prevalence of serious mental disorder in 7000 refugees resettled in western countries: A systematic review. Lancet 365(9467): 1309–1314. doi: 10.1016/S0140-6736(05)61027-6.

22.

Fenta

Hyman

Noh

(2004) Determinants of depression among ethiopian immigrants and refugees in toronto. Journal of Nervous and Mental Disease 192(5): 363–372. doi: 10.1007/s00127-003-0596-5.

23.

Flege

J. E.

Yeni-Komshian

G. H.

Liu

(1999) Age constraints on second-language acquisition. Journal of Memory and Language 41(1): 78–104. doi: 10.1006/jmla.1999.2638.

24.

Foa

Cashman

Jaycox

Perry

(1997) The validation of a self-report measure of posttraumatic stress disorder: The posttraumatic diagnostic scale. Psychological Assessment 9(4): 445–451. doi: 10.1037/1040-3590.9.4.445.

25.

Franz

(2005) Uprooted and unwanted: Bosnian refugees in Austria and the United States, College Station: Texas A & M University Press.

26.

Gilbertson

M. W.

Gurvits

T. V.

Lasko

N. B.

Orr

S. P.

Pitman

R. K.

(2001) Multivariate assessment of explicit memory function in combat veterans with posttraumatic stress disorder. Journal of Traumatic Stress 14(2): 413–432. doi: 10.1023/A:1011181305501.

27.

Hayes

A. F.

(2013) Introduction to mediation, moderation, and conditional process analysis: A regression-based approach, Guilford Press.

28.

Hollifield

Warner

T. D.

Lian

Krakow

Jenkins

J. H.

Kesler

Westermeyer

(2002) Measuring trauma and health status in refugees: A critical review. Journal of the American Medical Association 288(5): 611–621. doi: 10.1001/jama.288.5.611.

29.

L.-T.

Bentler

P. M.

(1998) Fit indices in covariance structure modeling: Sensitivity to underparameterized model misspecification. Psychological Methods 3(4): 424. doi: 10.1037/1082-989X.3.4.424.

30.

L.-T.

Bentler

P. M.

(1999) Cutoff criteria for fit indexes in covariance structure analysis: Conventional criteria versus new alternatives. Structural Equation Modeling: A Multidisciplinary Journal 6(1): 1–55. doi: 10.1080/10705519909540118.

31.

Jupp

(2002) From white Australia to Woomera, the story of Australian immigration, Cambridge: Cambridge University Press.

32.

Kanagaratnam

Asbjørnsen

A. E.

(2007) Executive deficits in chronic PTSD related to political violence. Journal of Anxiety Disorders 21(4): 510–525. doi: 10.1016/j.janxdis.2006.06.008.

33.

Kartal

Kiropoulos

(2016) Effects of acculturative stress on PTSD, depressive, and anxiety symptoms among refugees resettled in Australia and Austria. European Journal of Psychotraumatology 7. . doi: 10.3402/ejpt.v7.28711.

34.

Kessler

R. C.

Üstün

T. B.

(2004) The world mental health (wmh) survey initiative version of the World Health Organization (WHO) composite international diagnostic interview (cidi). International Journal of Methods in Psychiatric Research 13(2): 93–121.

35.

Kirmayer

L. J.

Narasiah

Munoz

Rashid

Ryder

A. G.

Guzder

Pottie

(2011) Common mental health problems in immigrants and refugees: General approach in primary care. Canadian Medical Association Journal 183(12): E959–E967. doi: 10.1503/cmaj.090292.

36.

Knipscheer

J. W.

Kleber

R. J.

(2006) The relative contribution of posttraumatic and acculturative stress to subjective mental health among Bosnian refugees. Journal of Clinical Psychology 62(3): 339–353. doi: 10.1002/jclp.20233.

37.

Krause, K., & Liebig, T. (2011). The labour market integration of immigrants and their children in Austria. Oecd social, employment and migration working papers no. 127. (1815–199X). Directorate for Employment, Labour and Social Affairs, OECD Publishing Retrieved from http://www.oecd.org/migration/49205671.pdf.

38.

Lindencrona

F. S. E.

(2008) Mental health of recently resettled refugees from the Middle East in Sweden: The impact of pre-resettlement trauma, resettlement stress and capacity to handle stress. Social Psychiatry & Psychiatric Epidemiology 43(2): 121–131. doi: 10.1007/s00127-007-0280-2.

39.

Lovibond

P. F.

Lovibond

S. H.

(1995) The structure of negative emotional states: Comparison of the depression anxiety stress scales (dass) with the beck depression and anxiety inventories. Behaviour Research And Therapy 33(3): 335–343. doi: 10.1016/0005-7967(94)00075-U.

40.

Maher, S. (2006). Community adult education based setdement programs for newly arrived african women on humanitarian and women at risk visas Retrieved 27 September 2016, from https://www.churchilltrust.com.au/media/fellows/MAHER_Sara_2006.pdf.

41.

Major

Wilkinson

Langat

Santoro

(2013) Sudanese young people of refugee background in rural and regional australia: Social capital and education success. Australian and International Journal of Rural Education 23(3): 95.

42.

Matheson

Jorden

Anisman

(2008) Relations between trauma experiences and psychological, physical and neuroendocrine functioning among somali refugees: Mediating role of coping with acculturation stressors. Journal of Immigrant & Minority Health 10(4): 291–304. doi: 10.1007/s10903-007-9086-2.

43.

McKay

(2008) Refugees, recent migrants and employment: Challenging barriers and exploring pathways, New York, Abingdon: Routledge.

44.

Miller

K. E.

Martell

Z. L.

Pazdirek

Caruth

Lopez

(2005) The role of interpreters in psychotherapy with refugees: An exploratory study. American Journal of Orthopsychiatry 75(1): 27. doi: 10.1037/0002-9432.75.1.27.

45.

Miller

K. E.

Rasmussen

(2010) War exposure, daily stressors, and mental health in conflict and post-conflict settings: Bridging the divide between trauma-focused and psychosocial frameworks. Social Science & Medicine 70(1): 7–16. doi: 10.1016/j.socscimed.2009.09.029.

46.

Mollica

R. F.

McInnes

Sarajlić

Lavelle

Sarajlić

Massagli

M. P.

(1999) Disability associated with psychiatric comorbidity and health status in Bosnian refugees living in Croatia. JAMA: The Journal of The American Medical Association 282(5): 433–439.

47.

Mollica

R. F.

Sarajlić

Chernoff

Lavelle

Vuković

I. S.

Massagli

M. P.

(2001) Longitudinal study of psychiatric symptoms, disability, mortality, and emigration among Bosnian refugees. JAMA 286(5): 546–554. doi: http://dx.doi.org/10.1001/jama.286.5.546.

48.

Momartin

Silove

Manicavasagar

Steel

(2003) Dimensions of trauma associated with posttraumatic stress disorder (PTSD) caseness, severity and functional impairment: A study of Bosnian refugees resettled in Australia. Social Science & Medicine 57(5): 775–781. doi: 10.1016/S0277-9536(02)00452-5.

49.

Muthén

L. K.

Muthén

B. O.

(2010) Mplus user’s guide: Statistical analysis with latent variables, Muthén & Muthén.

50.

Pirkis

Burgess

Meadows

Dunt

(2001) Access to Australian mental health care by people from non-English-speaking backgrounds. Australian and New Zealand Journal of Psychiatry 35(2): 174–182. doi: 10.1046/j.1440-1614.2001.00882.x.

51.

Polak

A. R.

Witteveen

A. B.

Reitsma

J. B.

Olff

(2012) The role of executive function in posttraumatic stress disorder: A systematic review. Journal of Affective Disorders 141(1): 11–21. doi: 10.1016/j.jad.2012.01.001.

52.

Porter

Haslam

(2005) Predisplacement and postdisplacement factors associated with mental health of refugees and internally displaced persons. JAMA 294(5): 602. doi: 10.1001/jama.294.5.602.

53.

Powell

Rosner

(2005) The Bosnian version of the international self-report measure of posttraumatic stress disorder, the posttraumatic stress diagnostic scale, is reliable and valid in a variety of different adult samples affected by war. BMC Psychiatry 5: 11–10. doi: 10.1186/1471-244X-5-11.

54.

Power

(2002) A problem from hell: America and the age of genocide, New York: Harper Collins.

55.

Robertson

C. L.

Halcon

Savik

Johnson

Spring

Butcher

Jaranson

(2006) Somali and Oromo refugee women: Trauma and associated factors. Journal of Advanced Nursing 56(6): 577–587. doi: 10.1111/j.1365-2648.2006.04057.x.

56.

Schweitzer

Brough Vromans

Asic-Kobe

(2011) Mental health of newly arrived burmese refugees in australia: Contributions of pre-migration and post-migration experience. Australian and New Zealand Journal of Psychiatry 45(4): 299–307. doi: 10.3109/00048674.2010.543412.

57.

Schweitzer

Melville

Steel

Lacherez

(2006) Trauma, post-migration living difficulties, and social support as predictors of psychological adjustment in resettled Sudanese refugees. Australian & New Zealand Journal of Psychiatry 40(2): 179–187. doi: 10.1111/j.1440-1614.2006.01766.x.

58.

Scott

J. C.

Matt

Wrocklage

Crnich

Jordan

Southwick

Schweinsburg

(2015) A quantitative meta-analysis of neurocognitive functioning in posttraumatic stress disorder. Psychological Bulletin 141(1): 105–140. doi: 10.1037/a0038039.

59.

Shaw, M. E., Strother, S. C., McFarlane, A. C., Morris, P., Anderson, J., Clark, C. R., & Egan, G. F. (2002). Abnormal functional connectivity in posttraumatic stress disorder. Neuroimage, 15(3), 661–674. doi: 10.1006/nimg.2001.1024.

60.

Silove

Steel

McGorry

Mohan

(1998) Trauma exposure, postmigration stressors, and symptoms of anxiety, depression and post-traumatic stress in tamil asylum-seekers: Comparison with refugees and immigrants. Acta Psychiatrica Scandinavica 97(3): 175–181. doi: 10.1111/j.1600-0447.1998.tb09984.x.

61.

Söndergaard

Theorell

(2004) Language acquisition in relation to cumulative posttraumatic stress disorder symptom load over time in a sample of re-settled refugees. Psychotherapy & Psychosomatics 73(5): 320–323. doi: 10.1177/0020764007075025.

62.

Sorgen

(2015) Integration through participation: The effects of participating in an English conversation club on refugee and asylum seeker integration. Applied Linguistics Review 6(2): 241–260. doi: 10.1515/applirev-2015-0012.

63.

Statistics Austria. (2011). Census 2011 Austria. Retrieved 22 April 2017, from https://www.statistik.at/web_en/publications_services/Publicationsdetails/index.html?includePage=detailedView&sectionName=Population&pubId=685.

64.

Steel

Chey

Silove

Marnane

Bryant

R. A.

van Ommeren

(2009) Association of torture and other potentially traumatic events with mental health outcomes among populations exposed to mass conflict and displacement: A systematic review and meta-analysis. Journal of the American Medical Association 302(5): 537–549. doi: 10.1001/jama.2009.1132.

65.

Steel

Silove

Bird

McGorry

Mohan

(1999) Pathways from war trauma to posttraumatic stress symptoms among tamil asylum seekers, refugees, and immigrants. Journal of Traumatic Stress 12(3): 421–435. doi: 10.1023/A:1024710902534.

66.

Steel

Silove

Phan

Bauman

(2002) Long-term effect of psychological trauma on the mental health of vietnamese refugees resettled in Australia: A population-based study. Lancet 360(9339): 1056–1062. doi: 10.1016/S0140-6736(02)11142-1.

67.

Steiger

J. H.

(1990) Structural model evaluation and modification: An interval estimation approach. Multivariate Behavioral Research 25(2): 173–180.

68.

Tran

T. V.

Manalo

Nguyen

V. T. D.

(2007) Nonlinear relationship between length of residence and depression in a community-based sample of vietnamese americans. International Journal of Social Psychiatry 53(1): 85–94. doi: 10.1177/0020764007075025.

69.

UNHCR (2001) Chapter 2.6: Fostering independent communication: Language training programs for adult resettled refugees. In refugee resettlement: An international handbook to guide reception and integration, Geneva: UNHCR.

70.

UNHCR (2011) Unhcr resettlement handbook – revised edition, Geneva: United Nations High Commissioner for Refugees. Division of International Protection Retrieved from http://www.unhcr.org/46f7c0ee2.pdf.

71.

van Tubergen

(2010) Determinants of second language proficiency among refugees in the Netherlands. Social Forces 89(2): 515–534. doi: 10.1353/sof.2010.0092.

72.

Vandenberg

R. J.

Lance

C. E.

(2000) A review and synthesis of the measurement invariance literature: Suggestions, practices, and recommendations for organizational research. Organizational Research Methods 3(1): 4–70.

73.

Watkins

P. G.

Razee

Richters

(2012) ‘I’m telling you … the language barrier is the most, the biggest challenge’: Barriers to education among Karen refugee women in Australia. Australian Journal of Education 56(2): 126–141. doi: 10.1177/000494411205600203.

74.

World Bank Group. (1998). The world bank group countries: Bosnia and Herzegovina. Retrieved from http://www.Worldbank.Org/html/extdr/offrep/eca/.

75.

World Refugee Statistics. (1997). World refugee survey Washington, DC: US Committee for Refugees. Immigration and Refugee Services of America. Retrived from: http://www.refworld.org/docid/3ae6a8b220.html.