Abstract
Hazaras form an Afghan ethnic minority group in Australia who arrived as refugees and through humanitarian resettlement schemes over the past three decades. This qualitative study explored psychological distress in a community sample of young adult Hazaras with a refugee background. The aim was to contribute to a more detailed understanding of their mental health, coping, and help-seeking in Australia. Eighteen Hazaras, nine males and nine females aged 18–30 years (M = 22.39, SD = 3.35), in Perth, Melbourne, or Sydney, who had been living in Australia on average 7.17 years (range 1 to 16 years), participated in a semi-structured interview based on Kleinman's explanatory model framework. Participants described mental and physical health as interconnected and their explanatory models for psychological distress focused on their current difficult life experiences as refugees. Findings indicated noteworthy gender differences, with young women reporting less distress associated with adaptation than did young men. Some young people used positive coping strategies in the community, while others engaged with a variety of mental health services. Level of satisfaction with these services varied considerably, with satisfaction highest for services provided by multicultural centers. Generally, respondents were not focused on their past traumas, but more interested in planning for their futures in Australia. Key implications for culturally appropriate training and specialized interventions for use with young adult Hazaras from refugee backgrounds are discussed.
Introduction
Conflict and ethnic- and religion-based persecution over the past three decades have led 2.7 million Afghans to flee to countries such as the USA, Canada, Norway, and Australia (Mackenzie & Guntarik, 2015; Monsutti, 2007; UNHCR, 2015). In 2016 the Australian Afghanistan-born community totaled approximately 46,799 (Commonwealth of Australia, 2018). Of these, many tended to arrive on humanitarian, family, and skilled visas; approximately 11,146 were from the Hazara ethnic group. It is difficult to obtain exact numbers of Hazaras in Australia as ongoing safety concerns mean they are sometimes unwilling to reveal their ethnicity (Ibrahimi, 2012).
The average age of Afghanistan born people in 2016 was 31 years (Commonwealth of Australia, 2018). Despite high levels of resilience and agency, research has found that young adult refugees may experience ongoing physical and mental health difficulties due to exposure to premigration traumatic experiences, being unaccompanied by family, and experiences of discrimination and other post-displacement conditions in the settlement country (Fazel, 2018; Fazel et al., 2012; Montgomery, 2011; Vervliet et al., 2014; Ziaian et al., 2012).
A systematic review of research on mental health concerns affecting Afghan refugees found moderate to high levels of psychological distress (Alemi et al., 2014). An Australian study of adult Afghan refugees also reported moderate to high levels of depressive and traumatic stress symptoms in this refugee group (Sulaiman-Hill & Thompson, 2012). These authors found that Afghan women experienced higher levels of psychological distress compared to men because of family separation, discrimination due to wearing the hijab, and changing roles and expectations in Australia, consistent with previous research findings (Porter & Haslam, 2005; Schweitzer et al., 2006). These researchers suggest that future research should engage Afghans in the research process to facilitate the development of culturally sensitive intervention programs for this refugee group (Alemi et al., 2014).
Kleinman (1978) proposed that Western concepts of mental health and treatment reflected biomedical models of disease, focusing on treating the disease rather than helping patients to understand their illness as part of the healing process. Kleinman (1978) argued that patients and clinicians may hold different explanatory models (EMs) of illness and disease and that both EMs need to be understood to ensure best mental health outcomes. Research has supported this proposal that Western models of psychological distress may differ greatly from those in non-Western cultures where causes of mental illness are frequently defined in terms of cultural beliefs, religion, education, and experiences with illness (May et al., 2014).
Tempany (2008) adopted an interview method based on Kleinman's (1978) explanatory model (EM) framework to explore Sudanese Australian refugee youths’ EMs. The interviews explored beliefs about mental health, wellbeing, and causes of mental illness, and strategies used to support recovery. Tempany's (2008) findings indicated that interviewing young non-Western refugees can provide valuable insights into their mental health and wellbeing in Australia, and their beliefs regarding coping strategies and seeking professional help.
Little research has explored coping or help-seeking for young Afghans from refugee backgrounds in Australia, especially those from the Hazara ethnic minority (Alemi et al., 2014, 2016). Barriers and facilitators to accessing mental health services for young refugees are also under-studied despite the importance of these issues for young people (Colucci, Minas et al., 2012; Colucci, Szwarc et al., 2012; Majumder et al., 2015). A systematic literature review of mental health service use by young people of refugee backgrounds in Australia (Colucci, Szwarc et al., 2012) identified 11 studies, of which only one explicitly examined service-related barriers for young refugees who had settled in Australia (de Anstiss et al., 2009). These authors also recommended that future research investigate how gender roles affect the uptake of mental health services by young refugees. One qualitative study of young refugee service users’ perceived barriers to mental health care found themes such as unfamiliarity with services, stigma, negative expectations about mental health professionals, structural obstacles, and social exclusion (Valibhoy et al., 2017b). These young participants expressed a need for autonomy over their mental health problems and they preferred to draw upon their social network of friends rather than receive help from health professionals.
Australian research on mental health service utilization by young refugees has tended to focus on either service providers or service users. For instance, an Australian research team conducted discussions with young people from refugee backgrounds (Centre for Multicultural Youth, 2011) and invited health professionals to discuss barriers and facilitators to accessing mental health services for young refugees (Colucci, Szwarc et al., 2012; Colucci et al., 2015). A major outcome of this study was the recommendation that young refugees who use mental health services and those who do not engage with these services should be interviewed about their views on mental health services.
Study aims
The current study aimed to explore barriers and facilitators to care with a community sample of young Hazara refugees in Australia. Four research questions guided the semi-structured interviews: How do these young people describe their mental health? What factors do they perceive contribute to or cause mental health problems? What strategies do they use to cope with mental health concerns? What interventions do they use to treat mental health problems?
Method
This qualitative study explored the beliefs of young adult Hazaras from refugee backgrounds about their psychological distress, coping strategies, and help-seeking in Australia. Ethics approval was obtained from Swinburne University of Technology Human Research Ethics Committee, approval file 2015/273. Senior members of the Hazara community were involved in developing the study aims, design, and content of interview questions to ensure these were culturally relevant, as suggested by Alemi et al. (2014). They provided suggestions about recruitment but were not involved in the qualitative analysis.
Participants
Participants were recruited via convenience and snowball sampling using contacts previously established through volunteer work and via community leaders’ advertisements in ethnic media and multicultural agencies. Seventy young Hazaras with refugee backgrounds completed an anonymous online survey (see Copolov et al., 2018). At the conclusion of this survey, respondents could express interest in participating in follow-up semi-structured interviews. Twenty-two young Hazaras (13 males; nine females) provided their contact information and the first author arranged and conducted interviews with each of them. Three male participants were not contactable and one male respondent's lack of English proficiency made him ineligible to participate, resulting in a final sample of 18 young Hazaras (nine males; nine females).
Participants self-identified as having a refugee background and were living in Perth (n = 9), Melbourne (n = 8), or Sydney (n = 1), Australia. They were aged 18 to 30 years (M = 22.39, SD = 3.35), had been living in Australia on average 7.17 years (range 1–16 years), were born in either Afghanistan or Pakistan, and identified as Shi’a Muslims. Nine participants were sponsored to Australia by their father or brother through family reunion, eight arrived in Australia as asylum-seekers prior to the government's policy changes towards processing and resettling asylum seekers offshore (see Australian Human Rights Commission, 2015), and one arrived with refugee status. Seven men and one woman had spent time in a detention center or camp. All of the men came to Australia unaccompanied by family and all of the women came with their families. Fifteen participants had completed high school, nine were currently studying at university and one had completed a university degree. Twelve participants were employed, five were not working because they were studying, and one was unemployed and looking for work. Three men and one woman were married.
Inclusion criteria for participants comprised: (a) Hazara ethnicity; (b) between 18 and 30 years of age; (c) residing in Australia; (d) conversational English capabilities; (e) access to telephone or Skype; (f) consent for their interview to be audio-recorded and transcribed. To maximize participation and following suggestions from leaders in the Hazara community, the age range of 18–30 years was selected for the current study. Data were collected between December 2015 and January 2016.
Data collection
A qualitative semi-structured interview was chosen because of its flexible and exploratory approach, and because it can elicit experiences from people who have had limited opportunity to give voice to these experiences (Alemi et al., 2014; Weisner & Fiese, 2011). An adapted version of Tempany's (2008) interview schedule based on the EM framework (Kleinman, 1978) was used to explore subjective mental health, beliefs about causes of mental health concerns, coping strategies, and help-seeking. An example question for subjective mental health is, “What does mental health mean to you?” An example question for causes of mental health concerns is, “What do you think causes mental health problems?” and for coping strategies is, “What do you do when you feel sad?” An example question for help-seeking is, “If one of your friends or family had mental health issues, can you list some services they could access?” The interviews were conducted by the lead author and although the topics were the same for all interviews, the order in which they were discussed varied according to the participants’ train of thought.
Procedure
Respondents were given full information about the study and their rights as research participants and then responded to the semi-structured interview. Gaining informed consent in a non-intrusive manner (i.e., verbally) is suggested as best practice with Afghan refugees (Smith, 2009). A gift card was provided as an appreciation for their participation. Interviews were conducted by the lead author via Skype or telephone depending on the interviewee's choice; interviews lasted from 60 to 90 min and were audio-recorded after verbal consent to the procedure.
Data analysis
Audiotaped interviews were transcribed verbatim by the lead author. NVivo software (Version 10) was used for data management and coding. Data were analyzed using deductive thematic analysis in line with the modified Tempany (2008) interview schedule but included an inductive component based on participants’ unprompted responses (Braun & Clarke, 2006, 2013). Consultation with community leaders made it clear that it was culturally inappropriate to identify participants by pseudonyms. Instead, respondents were assigned labels of male respondent (MR) 1–9 and female respondent (FR) 1–9 with their corresponding ages.
Thematic analysis was conducted in stages based on Braun and Clarke's (2006, 2013) six-step process, and was informed by other qualitative studies that used similar data analysis techniques (Earnest et al., 2015; McGregor et al., 2016). After familiarization with the dataset, initial codes were generated as they related to the aims and research questions of the study and the wider literature. The coded information was then collated and organized into potential themes and subthemes based on similarities between groups of codes, generating a thematic ‘map’ of the analysis. Ongoing refinements were made to the names and definitions of themes and subthemes and a final review was conducted in relation to the overall story identified in the analysis. Consensus on the themes and subthemes was reached via discussion between first and second authors (Olszewski et al., 2006).
Results
Themes that emerged from the data analysis were grouped into eight broad categories: Gender Roles; Family Separation; Stigma of Mental Illness; Religious Practices; Substance Use; Patterns of Use; Barriers and Facilitators to Accessing and Engaging with Mental Health Services; and Satisfaction with Services. The participants had a shared cultural and religious background and there was general correspondence between men's and women's responses. However, differences between male and female participants were found, especially in relation to psychological distress, coping strategies, and help-seeking.
Beliefs about psychological distress and possible causes
Psychological distress
Most participants viewed their mental health as interconnected with their physical health and their environment. They explained that good wellbeing meant being “active,” “healthy,” and “educated,” whereas depression happened when things “were not going your way” or “you were experiencing too much pressure.” In an interview, FR6 (24 years) noted: “If you are physically well then we are mentally well. If you are not mentally well then you are not physically well.” Participants also expressed concern over community members’ downplaying the importance of mental health. For instance, FR9 (22 years) reported: “I know generally mental health is not seen as being as important as physical health, but I do think it's really quite important, especially your mental health as a child.”
Mental health was described as being kept in a person's “heart or brain.” Some men described their poor mental health as an “illness of thoughts” that manifested itself as headaches, red eyes, disturbed sleeping, or sleeping a lot, and which needed to be “released.” These thoughts were described as having cognitive and emotional components, including rumination and intense feelings of sadness.
Gender roles
The young people described feeling “pressures” associated with trying to re-establish traditional gender roles in Australia and with accommodating new gender roles. These pressures came from their families, their communities, and from themselves. Traditional gender roles for men included expectations that they would be financially responsible for their families, whether living overseas or in Australia. Eight of the nine young men described feeling pressure to find a job, and had put their studies on hold because of this expectation to look after their families. Participants described this obligation as very “stressful” as they were trying to re-establish their lives in Australia. MR1 (20 years) commented: I have more responsibilities as an older family member to help support my family back in Afghanistan and to cope with my life here. They [family] are going to keep annoying me saying, “Send me money, send me money, send me money.” I need the money here as well. I always felt this form of anxiousness that I am not doing enough … I have a lot of opportunities here … I think I was always in fear that the time was too quick for my steps, that it was moving faster than me.
Family separation
Five men were separated from their immediate family overseas; no women were separated from their immediate family. The men had all arrived in Australia as unaccompanied minors. They reported feeling considerable distress, worrying about their family's safety. Most participants, both men and women, expressed concerns about the mental health of unaccompanied minors whose families remained overseas. They believed that unaccompanied minors might have difficulties adjusting to life in Australia without the support of their family, as MR1 (20 years) explained: “They [unaccompanied minors] do get a lot of psychological problems here because they stress out about their family, they stress out about their health, they stress out about financial problems.” Unlike the men, the women all had their immediate family with them. They said they missed their extended family but had adjusted to being restricted to electronic contact with these family members. Most women expressed concerns for their mothers’ mental state and isolation because their mothers lacked English proficiency, but otherwise did not consider family obligations or expectations a major cause of psychological distress.
Stigma of mental illness
Most participants mentioned that there were differences in opinion between young Hazaras and their elders about acknowledging mental health concerns. For example, five participants described their concerns over recent suicides in their communities and said that if mental health concerns were recognized by community elders, then people might feel more understood and able to request help: There are a lot of Hazara youths and … adults who do suffer from mental health especially the younger ones who are new to the country or are on Bridging Visas or Temporary Protection Visas. There are many who have committed suicide …. I don’t think they [elders] even recognize what it is, the fact that it is a form of sickness, that could be cured; they see it as a state that must be there for the time being. [FR5, 20 years old] My older sister she's got anxiety … She just can’t get out of bed, but she's never been to the doctors to find out what it is because we don’t talk about our feelings … going to a doctor is a very big thing especially about your mental health.
Beliefs about coping strategies
Respondents reported that the coping strategies they used to deal with psychological distress were primarily social support (family and friends), sports activities, and self-help strategies. There were gender differences for some coping strategies. Women described relying on religious practices, whereas men described substance use as a coping strategy for dealing with psychological distress.
Religious practices
Five women (but none of the men) described using religious practices to deal with psychological distress. For these women, religion played a crucial role: They “felt at peace” when they prayed and it gave them a sense of hope that they could deal with personal difficulties. Religion was described as a “good escape” and a support system during hardships, especially reading the Quran, praying, and speaking to God about their problems. FR1 (18 years) commented: “God is near … you can talk to him about anything … he isn’t going to get angry or leave you.” Some of the women mentioned that not having a Shi’a Mosque in their city meant it was difficult to get spiritual help. FR1 noted: “In my city we don’t have a lot of cultural practices since we don’t have a mosque so it's very hard to seek advice from a religious scholar.” Instead, the women said their families encouraged them to read duas (a call out or summoning to God) when they needed to do well at university or to reach their goals. FR2 (22 years) explained the purpose of reading duas: “If I want to pass uni but I am really afraid that I might fail an exam or something … you just pray once or twice and then it helps you kind of pass that.”
Substance use
Four of the men (but none of the women) reported turning to alcohol, smoking, and, in some cases, illicit drug use to deal with their psychological distress. The young men said that many things were out of their “control” so they used substances to minimize feelings of distress. MR1 (20 years) described his friend who passed the time by smoking because he had lost his job and felt depressed: “He had family problems, money problems, accommodation problems … living problems.” However, MR1 thought his friend could use other ways of “getting rid of his depression,” such as exercising or writing down his thoughts.
Beliefs about help-seeking experiences
While this was a community sample, eight out of the 18 participants described seeking help from health professionals when they experienced psychological distress. They identified barriers and facilitators to accessing and engaging with mental health services and, without prompting, mentioned their satisfaction with the services they received.
Patterns of use
Six men had visited a health professional to deal with mental health concerns. Four men had initially presented physical symptoms to a doctor but did not want to take the medication the doctor prescribed to treat these symptoms. MR3 (23 years) said that he did not want to take medication because he knew “friends in detention center who became addicted to sleeping tablets.” The doctors thought their physical symptoms were related to mental health concerns and provided the option of seeing a psychologist. MR3 described his experience: All night I could not sleep, I was just thinking, thinking and then I went to GP because I was feeling unwell and GP said, “Do you want to take medicine?” I said, “I’ll be addicted to medicine” so I said it's better to see psychologist. When I went there [psychologist] for four or five sessions, I could not find it helpful. They just make me sad.
Two women participants had sought formal help for their psychological distress. FR1 (18 years) had seen a health professional at a mental health center to “just talk about everything” and FR4 (19 years) had visited a university counsellor a few times after seeing “media misrepresentations of asylum seekers.” FR4, who was the only female participant who had spent time in a detention center with her family, said that she was not able to tell her parents about her decision to see a university counsellor in case they became worried.
Barriers and facilitators to accessing and engaging with mental health services
Participants who said they had accessed services for psychological distress, or had tried to, were asked, “Was it easy to access services? Why/Why not?” Respondents said that cultural influences and service-related factors were barriers to accessing and engaging with mental health services, whereas learning about psychology in high school or at work was described as facilitating service access and engagement.
Participants described language as a key service-related barrier. They reported that Hazaras who lacked English proficiency required interpreters or health professionals who spoke their mother tongue to engage in health services. Frequently, however, interpreters were not available. For example, MR4 (30 years) explained that when he first arrived in Australia and visited a doctor, he required a professional interpreter, but they “didn’t bring the interpreter as most of the doctors don’t have [make use of them].” Most participants said they were unaware of any Dari- or Hazaragi-speaking health professionals nearby. As a result, many could not access health services without friends, family, or community members acting as interpreters for them. MR4 added, “Now that I know English, I am going to help my friends and I am saying, ‘I’m [an] interpreter and I want to speak with you [doctor] and with my friend to solve the problem’.”
Another service-related barrier described by participants was cost and ease of access to health services. They explained that seeing a health professional could become very costly if they required specific treatments or were not covered by Medicare. MR2 (24 years) said: “With regard to help it is very expensive here and sometimes people keep [delay] … their treatment to travel back to Afghanistan or Pakistan and then go to the doctor.” Participants lived in three major Australian cities. They reported that service availability and accessibility was much better in two of these cities than in the third city. The Hazara community was aware of these service-related differences through the widespread use of electronic communication within the community.
FR1 (18 years) described a cultural and service-related barrier to accessing mental health services for Hazara women who had experienced domestic violence. These women felt they could not trust health professionals to maintain confidentiality. FR1 said she knew of Hazara women who did not want to talk to health professionals about issues related to family violence or domestic abuse, as they believed these professionals had a “duty of care to take action and do something about it.” The women also feared that they or their families would be deported as a result. Moreover, the women felt that if this information should become publicly known, they might be compromised, as participant FR1 explained: “In our community, reputation is a very big thing.”
Respondents who had learnt about psychology in high school or at work said this had helped them become aware of how to access mental health services. For example, MR1 (20 years) explained that young people learn about available mental health services at school and those who had dropped out of school (to financially support their family) may feel “stressed” because they have not been taught how to access available services. He used a metaphor to illustrate this point: If you go to a beach and if there are no signboards, obviously you are going to jump in the shallow water and break your neck, as there are not any signboards about the dangers of the beach, about what to do and what not to do. If they had been told about this, they would have been all right.
Satisfaction with services
Several of the unaccompanied young men who had seen a health professional expressed concerns about the effectiveness of these services. The first concern raised by the men was that the mental health services were not culturally relevant or useful. Three of the unaccompanied young men who had been referred to a psychologist reported they did not find Western psychological therapies helpful. Participant MR3 (23 years) was referred to a psychologist who suggested he try mindfulness strategies: They [the psychologist] said, “You have to think that you are in a park and you are sleeping under the tree and you are feeling that a few birds are there and listen to them.” She said, “When you want to sleep, you have to count your fingers and toes, you have to count them like 100 times and it makes you sleep” … and it was not helping me. She [the psychologist] asks a lot of questions about my family and my past but I don’t have any problem with my family, I just had my hand damaged so I’m not sure why I’m seeing a psychologist … for three months she is asking me about my background … I do want to be … a good patient so that's why I just answer …. Once I asked her, why she was focusing on my past and she's saying, “it's a part of our job.” In the beginning of this year, I applied [for university] but I didn’t have very stable accommodation … it was a bit difficult you know to find the right direction …. I talk with some of them [university counsellors], they give advice but that didn’t help me. I had an appointment a couple of times with the doctor and I said, “look, our mental health is not for money, our mental health is not for business, our mental health is about our future here” … the doctor said, “just drink yoghurt and do something physical,” look I said, “my job is all physical, you said just drink a cup of yoghurt and I’m drinking a liter, two liters of yoghurt but you can’t help me, you can’t help me because they are not our problem.” I’m homesick and sometimes I’m really sad and I’m talking with her [the doctor], sharing my story with her to see if she can feel me or just walk in my shoes … and she just says, “look, this is not my business,” and I say “alright, that's okay.” I don’t think any of them can help me ‘cause I’m not a crazy or silly man. I’m a homesick man.
In contrast, two men who had accessed multicultural centers felt listened to by the social workers, counsellors, and psychologists working there, and found they helped reduce their psychological distress because they provided health and settlement assistance. MR9 (25 years) described his experience at a multicultural center as very positive because the social worker listened to what he had to say, checked in on him regularly (by telephone), and put him in contact with other young people to play soccer. He said, “Everything was stuck in my inside and I just wanted to get it out. I just wanted to talk, and they listened.” MR8 (25 years) also described his positive experiences after receiving psychological help at a multicultural center, as the staff understood how to help young people from refugee backgrounds: I think it is easy because they [the multicultural centre] deal with … people coming from a refugee background and they know very well what are the issues, what are the opportunities, and because they listen to us and then they give their advice and that is kind of helpful.
Discussion
A major finding from the current study was that these young adults believed their mental health, physical health, and environment were interconnected and they expressed concern that older members of their community did not think addressing mental health concerns was as important as addressing physical health. Differences in beliefs about mental illness between younger and older Afghan community members may be attributed to beliefs that mental illness symptoms are normal responses to difficult lived experiences and circumstances within Afghan populations. Research by Ventevogel and Faiz (2018) explored similar notions and argued that findings from mental health surveys with Afghan populations may more accurately show indicators of non-disordered psychosocial distress rather than of a mental disorder. The authors encourage researchers to consider the role of gender, culture, and context when interpreting somatic presentations of mental illness within Afghan populations (Ventevogel & Faiz, 2018).
In line with both Ventevogel & Faiz's (2018) research and a study of Somali refugees in Norway (Markova & Sandal, 2016), participants in the current study described their psychological distress as thoughts made up of cognitive and emotional components located in physical parts of their body, such as in their heart or brain. Also consistent with Ventevogel and Faiz's research, there were gender differences in somatic explanations of poor mental health. Some of the men described poor mental health as an illness of thoughts that manifested as somatic symptoms. The men explained that ill thoughts needed to be released from their body to deal with distress. This finding differs from earlier research with Afghan and Kurdish refugees in Australia and New Zealand (Sulaiman-Hill & Thompson, 2012) which found that women were more likely to attribute their mental health symptoms to a physical problem compared to men, and from the wider literature on gender differences in somatization for immigrants from various ethnic groups (Aragona et al., 2008).
Participants’ explanatory models (Kleinman, 1978) of the causes of psychological distress were reflected in how they believed such distress should be managed. According to some of the young Hazaras, psychological distress was not a disease needing professional treatment, but instead was a condition caused by emotional reactions to difficult life situations (e.g., isolation caused by family separation), gender role pressures (e.g., financial responsibilities), and stigma about mental illness. Receiving social support from family and friends, self-help strategies, and participating in sports were viewed as effective coping strategies outside of formal psychological treatment, supporting earlier research with similar refugee groups (Sulaiman-Hill & Thompson, 2012).
Gender differences also emerged in relation to coping strategies. A number of the unaccompanied men who were separated from their immediate families or who had to take unskilled work to support their families rather than continue their education turned to substance use to cope with psychological distress, as found in previous research (Posselt et al., 2014). In contrast, while most of the young Hazara women described experiencing pressures related to their expanded gender roles in Australia, they typically described embracing these new opportunities. Most used religious practices to cope with pressures associated with these changes, supporting previous research that found religious practices to be one of the most important coping strategies for Afghan refugee women (Sulaiman-Hill & Thompson, 2012; Welsh & Brodsky, 2010).
In contrast to Sulaiman-Hill & Thompson's (2012) findings, the young Hazara women in the current sample reported coping well with changes to their traditional gender roles and they welcomed the possibility of continuing their education and delaying marriage. This may be a result of the age differences between the samples. Sulaiman-Hill and Thompson's sample ranged between 18 and 70 years of age and included older pre-literate women from traditional backgrounds who may have found it difficult to make adaptative changes in Australia and New Zealand. This possibility is supported by the finding that the young Hazara women in the current sample were concerned about their mothers’ psychological distress due to difficulties adapting to life in Australia.
The third major finding from the study was that this sample of young people who were not selected as users of mental health services nevertheless perceived barriers and facilitators in accessing and engaging with mental health services. These barriers included the influence of cultural context on service use, and the concern that mental health services were highly stigmatized in their communities, as well as the cost and location of services.
Concerningly, the Hazara women described issues of trust and confidentiality as potential barriers to accessing mental health services due to the fear that domestic violence would become public and affect their reputation in the community or their visa status. Many refugees have had experiences that have made them feel suspicious and it is essential that health professionals clearly explain the rules of clinical confidentiality, when it may need to be breached, and how this would be done (Colucci et al., 2017). The young Hazaras said that learning about mental health services at school or work meant they were aware of services but this did not necessarily increase engagement with services.
While some studies have reported barriers and facilitators to accessing and engaging with mental health services for young people of diverse refugee backgrounds, little research has investigated satisfaction with services from the perspective of young Afghan refugees (Alemi et al., 2016; Valibhoy et al., 2017a). The young Hazaras who had accessed a mental health service said that when services were ineffective or irrelevant, this increased their distress. They suggested that health services could be improved by ensuring professionals listened, were non-judgmental, and showed warmth, respect, understanding, and compassion. It is noteworthy that some of the young Hazaras said their satisfaction was highest for services provided by multicultural centers where they felt listened to and which used interventions they found relevant and helpful.
Limitations
This qualitative study is based on a small, English-speaking, young adult sample of individuals who have resettled in a high-income country. In the semi-structured interview, questions relating to participants’ pre-arrival experiences were avoided, and memories of their past were only discussed if raised by the participants themselves. It was deemed unethical to ask about past traumatic experiences through a phone or Skype interview. The recruitment process and interview methodology may have resulted in a sample of participants with more advanced English literacy skills than other young Hazaras in Australia, and findings cannot be generalized to other young refugee groups. Future research could use purposive sampling to recruit a more diverse sample of young adult Hazaras of refugee background to expand the study findings.
Conclusion
This study examined beliefs about causes of psychological distress, coping, and help-seeking in a community sample of young adult Hazara refugees in Australia. Participants focused on holistic explanations of psychological distress. They described using both positive (social support) and negative (substance use) coping strategies in the community and reported barriers and facilitators to accessing and engaging with mental health services. Despite being a community sample, some participants had accessed a service and their levels of satisfaction with these services varied considerably. Satisfaction was highest for services provided by multicultural centers.
The results have implications for mental health service development in Australia and can inform health professionals working with this ethnic group and age group. First, findings support the value of qualitative research with relatively homogeneous refugee samples. The EMs for psychological distress of these young English-speaking Hazara refugees, while similar to other non-Western EMs of psychological distress (May et al., 2014), were also frequently described by the young participants as differing considerably from the EMs of psychological distress held by their Hazara community elders. The young adults understood these generational differences as reflecting their experiences in Australia both in education and work. Findings imply that understanding EMs of young adult Hazaras may inform the development of culturally sensitive interventions to address psychological distress in this age group (Alemi et al., 2014). Positive coping strategies, such as social support, sports, and use of self-help strategies were often perceived as more effective than seeking help from a health professional. This suggests interventions that would benefit young Hazara men and women in building resilience and autonomy. Existing health services may need to develop culturally sensitive interventions for effective work with this client group.
Results showed significant gender differences for coping strategies. Unaccompanied Hazara men may need assistance with developing social and employment networks in Australia, as well as engaging with pre-existing networks overseas. This may mitigate the use of more negative coping strategies such as substance use. The young Hazara women indicated the usefulness and positiveness of religious beliefs and practices for dealing with their psychological distress. All young Hazaras may benefit from places of worship being available in their city of residence so that they can practice their religion and access advice from religious scholars in times of need.
The current study demonstrates that we could gain valuable insights from asking community samples of young people with refugee backgrounds about perceived barriers and facilitators in engaging with mental health services, regardless of whether they had or had not accessed a service. In this community sample, most of the young Hazara men and two of the young Hazara women had accessed a mental health service. A major concern of the young Hazaras was that negative hearsay within their community about non-culturally specialist mental health services is damaging. Services may need to anticipate rumors and proactively manage this by enhancing formal communications about their services. On a positive note, findings suggest that multicultural centers can successfully support young adult Hazaras with refugee backgrounds by providing relevant and tailored services. This is a promising area that merits further exploration.
These young refugees did not focus on their past traumas. They preferred to think about, and plan for, their futures in Australia. This highlights the importance of specialized training for mental health professionals which does not focus exclusively on past trauma, and does not assume that this is the only reason young people of refugee backgrounds seek help. Health professionals need to be open to hearing their clients’ concerns and adopting relevant interventions which directly address adapting to life in their settlement country. Building on suggestions made by the young Hazaras, interventions to alleviate psychological distress might be more successful if they take a holistic approach by providing support psychologically, educationally, financially, and socially while maintaining refugees’ cultural beliefs and norms (Murray et al., 2010).
Footnotes
Acknowledgements
We thank Professor Sandra Gifford and Dr. Jonathan Kingsley for assistance in preparing the manuscript, and acknowledge the young people who kindly gave their time to participate in the study.
