ORIGINAL ARTICLE

Congolese and Somali Beliefs About Mental Health Services Linda Piwowarczyk, MD, MPH,* Hillary Bishop, MPH,Þ Abdirahman Yusuf, MPA,þ Francine Mudymba, BS,§ and Anita Raj, PhDÞ Abstract: Despite high levels of traumatic exposure, refugees often do not seek mental health services upon resettlement. The purpose of this study was to examine both concepts of mental illness in addition to attitudes and beliefs about treatment as well as potential barriers to accessing mental health services. To that end, qualitative research was done using focus groups with Congolese and Somali men and women in the United States (n = 48) in addition to a community survey with women from those communities (n = 296) administered by staff of a community-based organization. Mental health concerns, although identified, were often dealt with first in the communities themselves with the help of family or friends. Great emphasis was placed on their respective communities of faith. The actual role of mental health professionals was not well understood, and there was apparent hesitancy to use services, which also relates to issues of stigma. Key Words: Refugees, Somali, Congolese, mental health treatment, mental health services (J Nerv Ment Dis 2014;202: 209Y216)

A

ccording to the United Nations High Commissioner for Refugees (UNHCR, 2010), there are currently 43.3 million people under UNHCR’s mandate in more than 140 countries, of which 15.2 million are refugees. Eighty percent of the world’s refugees are in developing nations (UNHCR, 2010). A refugee is someone who has crossed his/her national border and is petitioning a third country to accept them (United Nations, 1951). Refugees who have resettled in western countries may be 10 times more likely than the general population in the resettled area to have posttraumatic stress disorder (PTSD; Fazel et al., 2005), which is often associated with cumulative trauma (Johnson and Thompson, 2008). A meta-analysis of 161 articles indicate that torture, cumulative exposure to potentially traumatic events, time since conflict, and assessed level of political terror were predictive of PTSD and number of potentially traumatic events, whereas time since conflict, reported torture, and residency status predicted depression (Steel et al., 2009). This study examines mental health concerns, inclusive of depression and PTSD symptoms, as well as attitudes toward mental health service acquisition among African immigrant and refugee adults in the United States. African immigrants and refugees in the United States, who now number more than 1.4 million, have seen their numbers almost quadruple since 1990 (Terrazas, 2009). Two particular countries that continue to be affected by war are the Democratic Republic of the *Boston Center for Refugee Health and Human Rights, Massachusetts; †Boston University School of Public Health, Massachusetts; ‡Somali Development Center, Boston, MA; and §Congolese Women’s Association of New England, Lynn, MA. Leadership team: Linda Piwowarczyk (PI), Anita Raj, Kelley Saia, and Sondra Crosby; Abdirahman Yusuf, Hiba Mohamoud Hashi, and Nimo Ibrahim Hashi of the Somali Development Center; and Francine Tshiwala Mudymba and Anne-Marie Wamba of the Congolese Women’s Association of New England. Send reprint requests to Linda Piwowarczyk, MD, MPH, Boston Center for Refugee Health and Human Rights, Boston Medical Center, 771 Albany St, Boston, MA 02118. E-mail: [email protected]. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0022-3018/14/20203Y0209 DOI: 10.1097/NMD.0000000000000087

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Congo (DRC) and Somalia. The Congolese population, especially in eastern Congo, has been traumatized by ongoing conflict, which has led to displacement and resettlement. A large cross-sectional survey completed in eastern Congo in 2007 found that 42% of the population had symptoms of PTSD, using the Posttraumatic Checklist, and approximately 32.8% had depression, using the Hopkins Symptom Depression Checklist (Pham et al., 2010). Another cluster survey in eastern Congo revealed that 67% of the households reported being exposed to human rights violations related to the conflict. Forty-one percent of those surveyed had symptoms consistent with major depressive disorder, and half of the sample had symptoms of PTSD (Johnson et al., 2010). In addition, it has been shown that Congolese with a history of internal displacement have greater exposure to violence and psychological distress (Mels et al., 2010). In Somalia, the population has been exposed to slaughter, rape, pillage of property and livestock, and the destruction of infrastructure (Koshen, 2007) during civil wars and inter- and intra-clan fighting. Ongoing conflict continues to displace Somali citizens (Infoplease, 2010). A clinic-based study comparing Somali (n = 600) versus non-Somali patients (n = 3009) using an outpatient clinic in Minnesota noted that although older men and most women tended to have PTSD and depression, almost half of the male patients were younger than 30 years and were approximately six times more likely than non Somali male patients in the same age cohort to have psychosis (80% vs. 13.7%; Kroll et al., 2011). Despite the cumulative trauma experienced by different African groups, studies in the United States and abroad suggest that refugees tend to be low utilizers of mental health services (Kinzie, 2006). This is also true for asylum seekers (Laban et al., 2007). Somali adolescent refugees exhibit low rates of mental health service use and are more apt to turn to religious and school personnel (Ellis et al., 2010). Although service utilization is low among children, those from refugee backgrounds may be at greater risk for mental health problems and have greater difficulty accessing services (de Anstiss et al., 2009). Somali refugees, after moving in the host country (secondary migration), tend to have disruptions in health care receipt (Warfa et al., 2006). Other Africans such as Ethiopian immigrants and refugees in Canada have been noted to be more likely to consult traditional healers than mental health professionals for mental health problems. Moreover, those with somatic complaints are greater utilizers of mental health services but primarily seek this care from family physicians (Fenta et al., 2006). Again, data on such health service utilization among Congolese and Somali adults in the United States are limited. Since 1992, excluding secondary migration, more than 200 individuals from the DRC and 3000 refugees from Somalia have been resettled in Massachusetts according to the Refugee and Immigrant Health Program Massachusetts Department of Public Health (2010). It is important to understand concepts of mental health, attitudes toward mental illness, and mental health service utilization within both populations given their potential exposure to trauma and potential need for services. The purpose of this study was to examine a) the conceptualization and experience of mental illness; b) the attitudes and beliefs toward mental health treatment; and c) the barriers to treatment utilization among Congolese and Somali refugees residing in Boston, Massachusetts. The current article is meant to serve

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as an overview that primarily focuses on the shared experiences and beliefs found within the two groups and does not describe or explore the inherent and large social/contextual differences between the two nationalities within the sample. Future publications will focus on exploring those differences between the two groups that are currently outside the scope of this article.

METHODS Data for this study were obtained from the African Women’s UJAMBO Good Health Project, which was designed to assess women’s health needs and beliefs within the Somali and Congolese communities of Greater Boston, with the goal of developing and pilot testing a DVD-based women’s health program. As part of the assessment process, the UJAMBO study included a qualitative component involving focus groups with female community members to obtain their health care acquisition knowledge, attitudes, and social norms related to general, reproductive, and mental health concerns. Additional focus groups were also conducted with the male Congolese and Somali community members to document different perspectives on the topics, which, however, are outside the scope of the current topic and will not be discussed in this particular article. The UJAMBO study also included a quantitative component involving an anonymous community-based survey with Somali and Congolese women in Greater Boston and Maine. The current study was conducted as a partnership between academics at Boston University School of Medicine/Boston Center for Refugee Health and Human Rights, Boston University School of Public Health, and two communitybased organizations serving African refugees in Greater BostonVthe Congolese Women’s Association of New England and the Somali Development Center. All study procedures were reviewed and approved by the Boston University Medical Campus institutional review board. Screening and verbal informed consent were obtained from each participant.

Qualitative Methods From June to July 2008, trained research staff from the partnering Somali and Congolese community organization recruited a convenience sample of eligible (i.e., aged Q18 years and not cognitively impaired) female community members at community events or within the Somali Development Center of Congolese Women’s Association of New England because it was felt to be the best form of accessing the relatively diffuse Somali and Congolese communities. Convenience or snowball sampling was necessary because of the limited numbers of eligible Somali and Congolese participants who met inclusion requirements and their limited experience in completing questionnaires. All recruited individuals were asked to attend the focus group at a designated day, time, and place. Immediately before focus group participation, verbal informed consent was obtained from each participant. Participation rates were not assessed during the recruitment process, but a series of six focus groups (n = 30) were conducted with the Somali and Congolese participants. Refreshments were provided to all group participants. As recommended by our partners, for each community, the women’s groups were divided by the following ages: 18 to 25 (two groups), 26 to 35 (two groups), and 36 years or older (two groups) to ensure comfort among peers. They felt that women in those similar age groups would be more likely to respond to sensitive questions especially related to reproductive health and sexual violence. All focus groups were led in English by study investigators, all of whom were physicians or doctoral-level researchers trained in qualitative data collection. The questions were posed initially in English. As needed, simultaneously translated discussions were done in one of three other languages per group: French, Lingala, or Somali. The groups ranged in duration approximately between 85 and 210

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195 minutes. Subsequent to completion of the group, the participants were given referrals to Boston Medical Center for health care and a $20 gift card for their time. For the purpose of data collection, detailed notes were taken in English by a designated notetaker and by the group leader. The notetaker then combined the notes and revised and refined them into a final document for data analysis. Audiotaping was not possible because of concerns that this would be uncomfortable for the participants.

Qualitative Data Analysis The notes were then analyzed by the research team using the grounded theory approach (Glaser and Strauss, 1967; Strauss, 1987; Strauss and Corbin, 1990). Specifically, a research coinvestigator worked with two coders to identify mutually exclusive but possibly linked codes or themes across focus groups. The two, both of whom were trained graduate students of public health, then worked independently on different text files to code all data. Additional codes and subcodes were identified iteratively in this coding process and reapplied to previous groups as needed. Intercoder reliability across coding was reached via a standard approach (Carey et al., 1996). Specifically, the coders came to agreement on all codes; if agreement was unable to be reached, a decision will be made by the lead investigator who was overseeing the coding process. A manual coding process was used to sort coded data into health domains, and then, within each domain, coded and subcoded themes and related data were placed. During the coding process, tree diagrams were also constructed to depict study domains, codes specific to these domains, and subcodes within each code. These diagrams were developed using the same iterative process as that used for study coding as a whole. Final domains identified through this process included a) sexual violence, b) obstetrics-gynecology health care seeking/utilization, c) barriers and facilitators to mammography and breast cancer health care seeking, d) general health and health care seeking/utilization, and e) mental health and mental health care seeking/utilization. The current study focuses on the domain of mental health and the themes of a) definitions of mental health problems, b) causes of mental health problems, c) beliefs regarding treatment of mental health issues, and d) barriers to seeking professional mental health services.

Quantitative Methods From May to October 2010, surveys (n = 296) were administered by community based organization (CBO) staff to female members of the Somali and Congolese community living in Greater Boston (inclusive of Maine), as part of the evaluation of the UJAMBO DVD program. Women were considered eligible if they came from these two communities; ranged in age from 25 to 64 years, with a history of childbirth; and were able to speak Somali, French, Lingala, or English. Baseline surveys of both the intervention and control participants are included in the current analyses. We chose this age range to target women who had likely given birth and also to make the group more similar. Other questions in the surveys related to reproductive health beliefs and practices. Given the differential comfort levels discussing these topics culturally, this age range was recommended, and the groups were divided as recommended by CBO colleagues. As with the qualitative research, convenience sample procedures were used because of access to limited numbers of eligible women in the Boston area. Women were recruited at each agency, at church functions, at community gatherings, and through a local Congolese-owned business. Immediately before survey assessment, verbal informed consent was obtained from all participants. For the UJAMBO workshop participants, surveys were administered individually or, if the woman could self-administer the survey, in a group * 2014 Lippincott Williams & Wilkins

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setting shortly before the workshop and in a specified private location. For the remaining participants, individual surveys were conducted, either self-administered or, in situations of low literacy, by the interviewer. Immediately after survey or evaluation study completion, the participants were informed about the availability of care at Boston Medical CenterVa local hospital with refugee care contracts, and they were provided with a $5 gift card for their time. Relevant sections of the Behavioral Risk Factor Surveillance System Survey (Centers for Disease Control and Prevention, 2010) used included questions on demographics (age, nativity, years in the United States, language/literacy, and education), general health, access to health care, and mental health and mental health services. Knowledge and behavioral intentions related to three target services (mammograms, Papanicolaou tests, and mental health services) were assessed as the primary outcome variables for the UJAMBO intervention. The survey itself was embellished to also assess reproductive health issues as well as prevalence and attitudes toward disclosure of sexual violence, blaming, and potential benefit of seeking mental health services, which is beyond the scope of this article.

Quantitative Data Analysis Descriptive statistics were conducted on demographic and mental healthYrelated variables. Mean values were computed for continuous variables such as age, years in the United States, number of children, and number of days experiencing sadness or worry. Frequencies were used to quantify categorical demographic variables as well as mental health treatment utilization and attitudes toward mental health treatment and mental illness.

RESULTS Demographics of Focus Group Participants Thirty-one women participated in the focus groups: 15 from the DRC and 16 from Somalia. The mean ages of both groups were comparable: the Somali women had a mean age of 34.1 years (range, 18Y59) and the Congolese women were 34.5 years (range, 18Y50). Sixty percent of the Congolese women had attended a university (partial or full), in contrast to only 12.5% of the Somali women. The Somali women mostly identified with being refugees or US citizens, unlike the Congolese women, who were generally asylum seekers/ asylees or US citizens. Eighty percent of the Congolese women said that they read English very well or somewhat well, in contrast to only a quarter of the Somali women. Eighty-six percent of the Congolese women also described themselves as writing, speaking, or understanding English very well or somewhat well, whereas less than one fifth of the Somali women did so (18.7%). Most of the Congolese women were employed (86.6%). Four Congolese women owned their own home and three rented. Six of the Congolese women stayed with someone or moved from place to place. Roughly three of five Somali women worked (61.9%). Most rented homes (81.2%), and the remaining lived in a shelter or moved from place to place. Marital status was comparable across both groups.

Definitions of Mental Health Problems (Focus Groups) Mental health concerns in these communities are identified only in very extreme situations, in which people are engaging in erratic or noticeable behaviors such as ‘‘removing their clothing’’; only in these types of situations would help be acquired. ‘‘Don’t believe in it [mental health problems] until you start taking your clothes off’’ (Congolese woman, Q36 years). * 2014 Lippincott Williams & Wilkins

Refugee Beliefs About Mental Health

‘‘They think the mental illness is serious because if you see a woman depressed, isolated, very worried, not eating I they need to go to the hospital, see a doctor’’ (Congolese woman, Q36 years). According to the Somali CBO staff, there was some confusion within the community itself regarding which Somali word to use when describing mental distress. The world Qulub was used to describe psychosis when in fact Waali is the more appropriate word for psychotic symptoms. Qulub is more appropriate when referring to serious depression.

Causes of Mental Health Problems (Focus Groups) Both communities associated a rise in incidence of emotional problems with conflict. There were a paucity of words to describe these problems in the past and, generally, a denial of the existence of emotional difficulties except to describe those with serious mental illness. Many difficulties were placed in the context of ordinary life or related to the immigration experience. ‘‘Psychiatric problems are not accepted, if you have psychiatric problems it is because you are a bad person or ‘crazy’’’ (Congolese woman, 26Y35 years). ‘‘Stress, adaptation, coming from different areas’’ (Congolese female, Q36 years). ‘‘It is witchcraft or a bad spirit. Go to church, see the pastor, and wait for it to pass’’ (Congolese female, Q36 years).

Barriers to Receiving Professional Mental Health Services (Focus Groups) a. Turning to family or friends for support rather than acquiring formal services For many people, it is expected that with the help of family, friends, or community elders, someone can cope with the hardship/ stress and its mental health consequences that are simply a part of life. ‘‘People don’t believe in mental health. They might talk about problems to a close friend or family. The close friend might say this is how it is and you have to deal with it. So you deal with it. Most family/friends will tell ‘you to deal with it’’’ (Congolese woman, 26Y35 years). ‘‘Community should be involved. Friends and family’’ (Somali woman, Q36 years). b. Utilizing traditional ways of healing in coping with stress and depression There are traditional ways within the community of dealing with mental health problems. People are expected to turn to families, friends, and religious leaders. There will be pressure from the community not to seek formal mental health services. It is expected that one will turn to wise people in the community. Psychiatric services are not routinely sought in their countries of origin. ‘‘In order to stop thinking about it [your mental trauma], you must pray or meditate to move on, accept it and pray to forget’’ (Congolese woman, 25Y36 years). ‘‘Africans usually do not seek psychiatric care. We look for other ways. We talk to elders I. If mental illness, they will try herbs’’ (Somali woman, Q36 years). c. Turning to religion The Congolese also emphasized praying first and waiting for God to work. One is expected to accept the trauma in one’s life and pray to move on. If it is a bad spirit, one is expected to pray with one’s pastor for alleviation. One’s pastor is felt to be trustworthy, confidential, and affirming. The Somalis also spoke about turning to religious leaders as well. There do not appear to be specific religious prohibitions from seeking mental health services. www.jonmd.com

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‘‘Church [is the answer to dealing with mental illness]’’ (Congolese woman, Q36 years). ‘‘It is witchcraft or a bad spirit. Go to church, see the pastor, and wait for it to pass’’ (Congolese woman, Q36 years). ‘‘People are more likely to talk with their pastor regarding problems. Turning to your pastor for counseling is socially acceptable; these conversations are held confidential. The pastor is always thought to be trustworthy and usually supports you; he trusts in God and makes you believe in yourself’’ (Congolese woman, 25Y36 years). ‘‘Counsel in each other. Look to friends, family, religious leaders. Take children for her so she can rest’’ (Somali woman, Q36 years). It can be confusing when there is a conflict between what the pastor recommends and what one’s physician recommends. People will often defer to the pastor and wait for an answer to prayer rather than seek health services. ‘‘You are between the doctor and the community. You don’t know what to do about it’’ (Congolese woman, 18Y25 years). ‘‘Going to the doctor, some say ‘you want to bring yourself a disease. As long as you pray you will be fine’’’ (Congolese woman, 18Y25 years). d. Western mental health services and mental health needs from a western perspective are not understood The actual role of mental health professionals and particularly psychiatrists is not well understood. It is not clear what symptoms can be actually treated. The participants also indicated that they had limited insight as to their mental health needs. ‘‘Depends on who you talk to. If you know a person will help you, go to them. We don’t seek care. In our community, they don’t know about psychiatric. They will take you as a crazy woman’’ (Congolese woman, 18Y25 years). e. Negative attitudes toward medication There is ambivalence in the community regarding taking medication. It is associated with both positive and negative expectations. ‘‘If she is suffering, she may take the medicine and continue with the pastor’’ (Congolese woman, 25Y36 years). ‘‘Taking medications will not help, only hurts’’ (Somali woman, Q36 years). There may be pressure from the environment including from both family and clergy to stop medication, even if these are prescribed. ‘‘When they prescribe meds. People close to you discourage you from taking medication. You need support. Some people will discourage you. May you feel you don’t want to go back. You stop seeking help, especially from doctors’’ (Congolese woman, 18Y25 years). ‘‘May be given meds, you get side effects. It makes you more crazy. People at home discourage you to take it’’ (Congolese woman, 18Y25 years). ‘‘If a doctor says you need medication, and the pastor says no. You won’t take it’’ (Congolese woman, 25Y36 years). f. Desire not to disclose private information to strangers The idea of talking to a stranger, not from the culture, is difficult to accept and generally frowned upon. ‘‘If you go, your husband or boyfriend will discourage you. You don’t go to strangers to talk about something shameful’’ (Congolese woman, 18Y25 years). ‘‘Most would not go to a psychiatrist, don’t want to talk to outsiders’’ (Somali woman, 18Y25 years). 212

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‘‘Some would go [to a psychiatrist] but most would think it strange to talk with an outsider; not part of culture to speak openly with a stranger’’ (Somali woman, 18Y25 years). g. Stigma related to mental illness There is significant stigma in the community related to both having a mental health problem and seeking treatment. An association is often made to the country of origin in terms of how and for whom mental health services are delivered. As a result, people may not disclose to others about their suffering. ‘‘Psychiatric problems are not accepted, if you have psychiatric problems it is because you are a bad person or ‘crazy’’’ (Congolese woman, 25Y36 years). ‘‘In old days, used to lock up. I saw a man locked up’’ (Congolese woman, Q36 years). This stigma can also be held by family members. If it is found out that someone is seeking mental health services, he/she may be ostracized. However, social ostracism is not universal. ‘‘In our community, seeking psychiatry is not to be ashamed or ‘crazy.’ Something will help you’’ (Congolese woman, 18Y25 years). ‘‘[husbands think] The same thing (as community responses to seeking help for mental health), that ‘she’s losing it’’’ (Somali woman, 25Y36 years).

Quantitative Results Sample Characteristics (Survey) The mean age of the total sample was 40.40 (SD, 9.60) years. Fifty percent of the women were married, whereas 24% of the women were divorced, widowed, or separated. The mean number of children was 2 (SD, 1.79), with the children ranging in age from infancy (0 years) to 10 years. The women had been living in the United States for a mean of 7.95 (SD, 4.58) years. Of the women reporting English proficiency, 24% had little or no speaking ability, 15.2% reported fair speaking ability, 27% reported good speaking ability, and 20.6% were fluent. A significant number of women (23%) reported never attending any formal education/school, whereas 27% had completed high school, and more than 31% had attended some college or higher. The most commonly reported type of employment was employment for wages (49%), with the second most frequently reported employment being a homemaker (33.4%). Fifty-three percent of the sample reported an annual income of less than $25,000, and 12.8% reported having an annual income of less than or equal to $10,000. Finally, 80.8% of the women rented an apartment for housing, with 7.1% reporting that they lived with family or friends and 3.7% staying at shelters or on the street (Table 1, sample characteristics of the Somali and Congolese participants).

Mental Health Concerns (Survey) Mental health was assessed with items determining the number of sad or worried days in the past month. Few women reported any days of sadness, and 24% of the sample reported that they did not know or were unsure how many days they felt sad in the past month. Similarly, few women reported any days of worry, whereas 23.6% reported that they did not know or were unsure of how many days they felt worried. However, for the women who did report sadness, the mean number of sad days was 11.42 (SD, 10.38). For those reporting worries, the mean number of worried days was 13.09 (SD, 11.12; Table 2, women’s symptomatic days in the last month).

Utilization of Mental Health Services and Attitudes Toward Utilization of Mental Health Services (Survey) Most of the women (88.7%) had never sought help from a mental health professional, and roughly forty-two percent were unsure * 2014 Lippincott Williams & Wilkins

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Refugee Beliefs About Mental Health

TABLE 1. Sample Characteristics of Congolese and Somali Participants (N = 296) Total

Somali

Congolese

n = 294

n = 146

n = 148

40.40 (SD, 9.60) (range, 25Y60) n = 252 149 (59.1%) 24 (9.5%) 12 (4.6%) 35 (13.9%) 32 (12.7%) n = 276 1.98 (SD, 1.79) (range, 0Y10) n = 285 7.95 (SD, 4.58) (range, 0Y30) n = 257 71 (27.6%) 45 (17.5%) 80 (31.1%) 61 (23.7%) n = 295 68 (23%) 29 (9.8%) 24 (8.1%) 80 (27.1%) 68 (23%) 26 (8.8%) n = 292 145 (49.7%) 16 (5.5%) 13 (4.5%) 4 (1.4%) 99 (33.9%) 10 (3.4%) 1 (0.3%) 4 (1.4%) n = 287 38 (13.2%) 40 (13.9%) 39 (13.6%) 40 (13.9%) 62 (21.6%) 34 (11.8%) 6 (2.1%) 28 (9.8%) n = 293 22 (7.5%) 239 (81.6%) 21 (7.2%) 11 (3.7%)

39.49 (SD, 9.59) (range, 25Y60) n = 140 111 (79.3%)a 13 (9.3%) 4 (2.9%) 11 (7.9%) 1 (0.7%) n = 140 2.62 (SD, 1.97) (range, 0Y10) n = 145 7.76 (SD, 4.54) (range, 0Y30) n = 147 70 (47.6%) 30 (20.4%) 22 (15.0%) 25 (17.0%) n = 147 68 (46.2%) 27 (18.4%) 16 (10.9%) 13 (8.8%) 6 (4.1%) 17 (11.6%) n = 147 36 (24.5%) 7 (4.8%) 8 (5.4%) 4 (2.7%) 81 (55.1%) 8 ( 5.4%) 1 (0.7%) 2 (1.4%) n = 147 35 (23.8%) 37 (25.2%) 27 (18.4%) 18 (12.2%) 8 (5.4%) 7 (4.8%) 6 (4.1%) 9 (6.1%) n = 148 17 (11.5%) 112 (75.7%) 8 (5.4%) 11 (7.4%)

41.31 (SD, 9.55) (range, 25Y60) n = 112 38 (33.9%) 11 (9.8%) 8 (7.1%) 24 (21.4%) 31 (27.7%) n = 136 1.32 (SD, 1.29) (range, 0Y7) n = 140 8.16 (SD, 4.62) (range, 0Y25) n = 110 1 (0.9%) 15 (13.6%) 58 (52.7%) 36 (32.7%) n = 148 0 (0%) 2 (1.4%) 8 (5.4%) 67 (45.3%) 62 (41.9%) 9 (6.1%) n = 145 109 (75.2%) 9 (6.2%) 5 (3.4%) 0 (0%) 18 (12.4%) 2 (1.4%) 0 (0%) 2 (1.4%) n = 140 3 (2.1%) 3 (2.1%) 12 (8.6%) 22 (15.7%) 54 (38.6%) 27 (19.3%) 0 (0%) 19 (13.6%) n = 145 5 (3.4%) 127 (87.6%) 13 (9.0%) 0 (0%)

Characteristic

Age Marital status Married Widow Separated Divorced Never married No. children Years in US English speaking Not at all Fair Good Fluent Educational level Never attended Grades 1Y8 Grades 9Y11 High school graduate Some college College graduate or higher Employment Employed for wages Self-employed Out of work Q1 yr Out of work G1 yr Homemaker Student Retired Unable to work Household income e$10,000 $10,000Y15,000 $15,000Y20,000 $20,000Y25,000 $25,000Y35,000 $35,000Y50,000 $50,000Y75,000 Do not know Housing Own home Rent an apartment Stay with family or friend Shelter or on the street a

Culturally, among the Somalis, if someone is physically separated from his/her spouse (regardless of the cause), one will likely still identify as married.

whether they would seek help if they felt very depressed. Approximately one third of the women indicated that they would not seek help from a mental health professional if they ever experienced depression. In addition, 28.4% of the women strongly agreed that treatment could help those with mental illness lead normal lives, whereas * 2014 Lippincott Williams & Wilkins

32.1% agreed slightly. A total of 26.7% of the women indicated that they were unsure whether treatment could help people with mental illness live normally. Finally, 33.8% of the women strongly agreed that people were sympathetic to those with mental illness, whereas 30.7% slightly agreed. A significant number of women (16.4%) were unsure www.jonmd.com

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TABLE 2. Women’s Symptomatic Days in the Past Month* (N = 31) Mental Health Symptom

Sadness (average days)

Worry (average days)

Total

Somali

Congolese

N = 31 11.42 (s = 10.39) (r = 1Y30) N = 43 13.09 (s = 11.12) (r = 1Y30)

n =13 17.31 (s = 12.88) (r = 2Y30) n = 20 18.45 (s = 12.71) (r = 2Y30)

n =18 7.17 (s = 5.24) (r = 1Y20) n = 23 8.43 (s = 6.91) (r = 1Y30)

*Table refers to women who reported at least one day of sadness or worry within the past month.

whether people were sympathetic to individuals with mental illness (Table 3, women’s utilization of mental health services and attitudes toward service utilization).

DISCUSSION This study documents that although emotional distress is recognized in the Somali and Congolese communities in the United States, it is largely associated with severe mental illness. Other forms of distress are thought to be related to the stressors of daily life. There was some confusion within the Somali community on how to describe problematic behavior within their own language. This reflects work with Somalis in New Zealand that described two major categories of mental health problems (Guerin et al., 2004). The first

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category they described is related to madness or what might be mania or schizophrenia and is characterized by being mad, throwing stones, yelling, eating out of dumpsters, or walking naked. Such people in Somalia were thought to be a danger to themselves and were often hospitalized or restrained. The second category was the absence of well-being, mild or moderate depression, or anxiety whose origin was thought to be social in nature. Past work has also shown that symptoms are not really thought to be a problem unless these actually interfere with life. For example, frequent crying, insomnia, and headaches might be viewed as simply a part of life and not something to access help for (Guerin et al., 2004). Our current findings support this past research as well, with the participants primarily associating mental illness and the need for treatment with more severe symptoms such as psychosis. Although there was some belief that mental illness was related to supernatural causes, experiences related to civil war and postmigration stressors were also thought to be contributory. This supports previous findings in which major causes of emotional distress included ‘‘shock and devastation of war, dead, missing, or separated family members, and spirit possession or a curse’’ (Carroll, 2004). The qualitative data also support past findings on the use of spirituality, religion, and traditional healers as methods of treatment of distress. For example, some Congolese are suspicious of western medicine and turn first to traditional healers ufumu or sorcerers ulonzi (who can be the same person). ‘‘In Christian circles, the benefits of ufumu healing are rarely acknowledged outside of academic discussion, though it is an undeniable fact that patients often use it’’ (Kwon, 2009). Similarly, Somalis often look first to a sheik healer to provide guidance from writings in the Koran and may also seek the help of a traditional healer called a minga or waddad (Scuglik et al.,

TABLE 3. Women’s Utilization of Mental Health Services and Attitudes Toward Service Utilization (N = 296) Utilization

Total

Somali

Congolese

Have you ever sought treatment from a mental health professional? n = 293 n = 146 n = 147 Yes 16 (5.5%) 12 (8.2%) 4 (2.7%) No 260 (88.7%) 130 (89.0%) 130 (88.4%) Do not know 17 (5.8%) 4 (2.7%) 13 (8.8%) If you were very depressed, would you seek help from a mental health professional? n = 289 n = 142 n = 147 Yes 77 (26.6%) 53 (37.3%) 24 (16.3%) No 91 (31.5%) 41 (28.9%) 50 (34.0%) Do not know 121 (41.9%) 48 (33.8%) 73 (49.7%) Treatment can help people with mental illness lead normal lives. Do you agree slightly or strongly or disagree slightly or strongly? N = 296 n = 148 n = 148 Agree strongly 84 (28.4%) 53 (35.8%) 31 (20.9%) Agree slightly 95 (32.1%) 49 (33.1%) 46 (31.1%) Neither agree nor disagree 18 (6.1%) 16 (10.8%) 2 (1.4%) Disagree slightly 11 (3.7%) 7 (4.7%) 4 (2.7%) Disagree strongly 9 (3.0%) 9 (6.1%) 0 (0%) Do not know/not sure 79 (26.7%) 14 (9.5%) 65 (43.9%) People are generally caring and sympathetic to people with mental illness. Do you agree slightly or strongly or disagree slightly or strongly? n = 293 n = 147 n = 146 Agree strongly 99 (33.8%) 46 (31.3%) 53 (36.3%) Agree slightly 90 (30.7%) 36 (24.5%) 54 (37.0%) Neither agree nor disagree 21 (7.2%) 16 (10.9%) 5 (3.4%) Disagree slightly 20 (6.8%) 18 (12.2%) 2 (1.4%) Disagree strongly 15 (5.1%) 14 (9.5%) 1 (0.7%) Do not know/not sure 48 (16.4%) 17 (11.6%) 31 (21.2%)

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2007). Youths have been shown to also turn to religious figures or school personnel (Ellis et al., 2010). Finally, a study by Carroll (2004) found that people will turn to a spiritual leader, religious/ cultural doctor, group ceremony, or reading the Koran for treatment. Our work not only supported these past findings for Somalis but also illustrated the extent to which the predominantly Christian Congolese turn to their faith and spiritual leaders with signs of emotional distress. The current findings documented numerous potential barriers to care including a lack of understanding of the western perspective of mental health treatment, differences in the understanding of mental illness and treatment, hesitancy to disclose private information to strangers, stigma toward mental illness, lack of awareness of one’s emotional needs, and logistical obstacles. The ideas of stigma toward mental illness and the hesitancy to disclose information to a stranger outside the community have been documented in past studies. For example, although there may be some opening to counseling especially through the venue of school, many Somali adolescents considered therapy not only culturally unacceptable and a stigma but also ‘‘‘not Somali’ especially for the older generation’’ (Ellis et al., 2010). Our quantitative findings also revealed that a large number of women would not seek mental health services or were unsure whether they would seek services, even if they were very depressed. This hesitancy to utilize services may be influenced by a combination of the barriers described in the focus groups. Large numbers of women also reported that they were unsure whether treatment could help those with mental illness lead normal lives, indicating a potential disjunct in the understanding of mental illness and its subsequent treatment methods. This study has two notable limitations. Convenience sampling procedures were used to recruit participants for the focus groups, the intervention, and the surveys. Considering that this procedure did not include an element of randomization, it is less likely that these results can be effectively generalized to the broader Somali and Congolese refugee communities in Boston, Massachusetts, or the United States. For example, the prospect of recruiting Congolese participants from a Congolese business (both employees and customers) may have inadvertently biased the Congolese sample toward higher income and/or employment levels. However, given the small and relatively diffuse concentration of these populations, convenience sampling was considered to be the most effective, practical, and appropriate method for achieving a sample size large enough to facilitate quantitative analysis. Second, self- report surveys were used, which introduces potential recall bias. Recall bias may have been introduced when the participants could not accurately recall information or if they purposefully altered their answers in an attempt to give a more socially acceptable answer. The pressure to give socially desirable answers may have been exacerbated for those participants who completed the surveys with the assistance of a translator/interviewer. Given the low English literacy levels of these particular populations, it was felt that utilizing a bilingual interviewer to administer the surveys was the only way to effectively include participants from across the English proficiency spectrum and therefore improve the external validity of the study findings. Despite the limitations introduced by convenience sampling and self-report data, and the exclusive focus on women, the limited availability of quantitative data on these populations in the United States suggests that the results of this study will still provide useful, scientific information on mental health service utilization and beliefs in African refugee communities. The findings of this study speak to the importance of communitybased programming in an effort to reach refugee populations that are reluctant to use mainstream mental health services. Varying definitions of mental illness as well as cultural and logistical barriers to care seeking are potential factors that may influence treatment utilization. Further education must take place within communities * 2014 Lippincott Williams & Wilkins

Refugee Beliefs About Mental Health

regarding concepts of trauma and depression because individuals may not articulate their feelings or draw the connection between past traumatic events and current symptom presentation. Local communities of faith may be important gateways to access individuals who are suffering but have not sought western medical treatment. Providers should be educated on the prevailing health beliefs within African refugee populations and the primacy that these populations place on faith and prayer. The current study also speaks to the need for collaboration between mental health providers and the leaders of faith communities who greatly influence health care utilization. Both the quantitative and qualitative data highlight the need for education within the community, as well as among spiritual leaders, on the role that western medicine may have in the healing process. Future studies and research should focus on teasing apart the various cultural nuances for different African refugee populations so that mental health interventions and services can be better tailored to each community’s needs. Additional in-depth work on social support structures and other community assets may also be beneficial in highlighting community resources that may be beneficial for individuals with mental illness. ACKNOWLEDGMENTS The authors thank Jessica Ruhlman, Devon Larkin, and Emily Lilo for their contributions to the study and the Somali and Congolese communities for their participation in the focus groups and surveys.

DISCLOSURES This study was supported by Office of Minority Health grant number BBCMP1002A. The authors declare no conflict of interest.

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Congolese and Somali beliefs about mental health services.

Despite high levels of traumatic exposure, refugees often do not seek mental health services upon resettlement. The purpose of this study was to exami...
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