Mental and somatic health and pre- and post-migration factors among older Somali refugees in Finland.

Transcultural Psychiatry 2014, Vol. 51(4) 499–525 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1363461514526630 tps.sagepub.com

Article

Mental and somatic health and pre- and post-migration factors among older Somali refugees in Finland Mulki Mo¨lsa¨ University of Helsinki

Raija-Leena Punama¨ki University of Tampere

Samuli I. Saarni University of Helsinki

Marja Tiilikainen University of Helsinki

Saija Kuittinen University of Tampere

Marja-Liisa Honkasalo University of Turku

Abstract Mental and somatic health was compared between older Somali refugees and their pairmatched Finnish natives, and the role of pre-migration trauma and post-migration stressors among the refugees. One hundred and twenty-eight Somalis between 50–80 years of age were selected from the Somali older adult population living in the Helsinki area (N ¼ 307). Participants were matched with native Finns by gender, age, education, and civic status. The BDI-21 was used for depressive symptoms, the GHQ-12 for psychological distress, and the HRQoL was used for health-related quality of life. Standard instruments were used for sleeping difficulties, somatic symptoms and somatization, hypochondria, and self-rated health. Clinically significant differences in psychological distress, depressive symptoms, sleeping difficulties, self-rated health status, subjective quality of life, and functional capacity were found between the Somali and Finnish groups. In each case, the Somalis fared worse than the Finns. No significant differences

Corresponding author: Raija-Leena Punama¨ki, University of Tampere, Kalevankatu 5, FIN-33014, Finland. Email: [email protected]

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in somatization were found between the two groups. Exposure to traumatic events prior to immigrating to Finland was associated with higher levels of mental distress, as well as poorer health status, health-related quality of life, and subjective quality of life among Somalis. Refugee-related traumatic experiences may constitute a long lasting mental health burden among older adults. Health care professionals in host countries must take into account these realities while planning for the care of refugee populations. Keywords depression, mental health, psychological distress, refugees, Somali older adults, somatic health, war trauma

It has been estimated that 3.1% of the world population, or approximately 214 million people, have left their birth countries due to economic, political, or ecological reasons (IOM, 2010; UN, 2008). Refugees and asylum seekers who are forcibly displaced due to wars, persecution, and other dangerous circumstances are estimated to account for 11–13 million (UNHCR, 2010; USCR, 2005). For example, the civil war in Somalia, which has been ongoing since 1988, has resulted in a large migration into African, Middle Eastern, and Western countries. Over one million Somalis are believed to live outside Somalia (Sheikh & Healy, 2009). Whether forced or voluntary, migration is taxing on social, individual, and family resources. Older refugees may be especially vulnerable when resettling in counties that are culturally and geographically divergent from their own. The present investigation is focused on the mental and somatic health of older adult Somali refugees in Finland, and examines related pre- and post-migration factors in this population group.

Migration and mental health Previous research suggests that refugees and asylum seekers experience higher levels of mental and physical health problems than the general population in the host country (Fazel, Wheeler, & Danesh, 2005; Gerritsen et al., 2006a). The health of immigrants, on the contrary, has been found to be better than that of the host country population, particularly among newcomers to North America (Hyman, 2004; Kirmayer, et al., 2011). Adversity and persecution may be responsible for the health problems experienced among refugees and asylum seekers. These traumatic experiences are reflected in the high rates of trauma-related disorders such as post-traumatic stress disorder (PTSD), depression, pain, and somatic symptoms. A systematic review of 20 surveys (N ¼ 6743) showed that the high rates of PTSD may be approximately 10 times more likely among refugees than age-matched native populations (Fazel et al., 2005). The healthy immigrant effect thus reflects selection and filtering phenomena among those achieving an


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immigrant status (Hyman, 2004). Few studies compare mental and somatic health problems between immigrants, refugees, asylum seekers, and native populations in receiving countries. A Norwegian study confirmed that asylum seekers had a higher risk of hospitalization due to psychiatric disorders or mental illness than both immigrants and native citizens (Iversen & Morken, 2003). An epidemiological study found that both psychiatric disorders (depression and anxiety assessed by Hopkins Symptom Checklist, HSCL), as well as somatic complaints such as abdominal pain, abnormal blood pressure and various bodily pains (PAINS) were more prevalent among immigrants than among native Norwegians (Dalgard, Thapa, Hauff, McCubbin, & Syed, 2006). These findings did not support the healthy immigrant effect found in previous research. Similarly, a Finnish study found immigrants to be 1.5–2 times as likely to experience depression and insomnia as compared to the native population (Pohjanpaä¨, Paananen, & Nieminen, 2003). It is noteworthy that although the prevalence of psychoses is considered relatively stable across countries and cultures, elevated levels of schizophrenia have been documented among immigrants in western countries (Selten, Cantor-Graae, & Kahn, 2007; Sharpley, Hutchinson, Murray, & McKenzie, 2001). Gerritsen and colleagues (2006a) found that the prevalence of depression was 68% among asylum seekers and 39% among refugees in the Netherlands, suggesting that mental health problems may be more severe among asylum seekers. Levels of psychiatric distress among refugees are thus generally higher than in the native population. One study documented the prevalence for major depression to be between 6 and 11% and the prevalence of PTSD to be 3 to 8% among the general population (Kessler et al., 2005).

Risk and protective factors among refugees Cultural and social issues surrounding the issue of immigrant somatic and mental health are complex and multifaceted (Kirmayer, 2001). Country of origin and socio-economic conditions in the host country have been found to impact the severity and manifestation of psychiatric distress. A Dutch study compared the prevalence of depressive and anxiety disorders including PTSD (assessed by clinical cut-offs of the GHQ-28 and the Harward Trauma Questionnaire, HTQ) according to the immigrants’ country of origin (Gerritsen et al., 2006a). Immigrants from Somalia experienced substantially lower levels of PTSD and depressive symptoms than immigrants from Afghanistan and Iran. However, another Dutch study showed that as many as 63% of Somali refugees suffered depression and a third suffered from anxiety disorders or PTSD (based on ICD classification) (Roodenrijs, Scherpenzeel, & de Jong, 1998). Yet, the corresponding prevalence rates were lower among Somali refugees settled in the United Kingdom, both approximately 25% (Bhui et al., 2006). The study by Bhui et al. revealed that compared to Bengali immigrants, Somalis suffer less from anxiety disorders. The authors attributed this to the existence of social and culturally-appropriate African healing networks. Although research is scarce, adaptation may be easier among immigrants settling in culturally similar countries than among those settling in countries that are


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culturally dissimilar to their own. A Norwegian community survey confirmed that non-western immigrants suffered higher levels of psychological distress (GHQ-28) than immigrants from western countries, whose distress level was equal to the native population (Dalgard et al., 2006). The duration of residence in the host country is expected to ease social adaptation and consequently improve mental health, but conflicting results have been found. Thapa, Dalgard, Claussen, Sandvik, and Hauff (2007) found that psychiatric distress, measured by the HSCL, decreased with time in Norway among men from Asian and African countries, but increased with time in Norway among women from the same countries. Some researchers argue that social and economic difficulties in receiving countries overshadow the refugee trauma. Some studies confirm that social alienation, racial oppression, and poverty are associated with psychiatric distress and disorders among immigrants (Bhui et al., 2003; Gerritsen et al., 2006b; Steel, Silove, Phan, & Bauman, 2002). For example, a study documented lower education and employment rates and limited access to social resources among Pakistani immigrants as compared to native Norwegians, and when controlling for these factors, no differences were found between the mental health of immigrant and native groups as assessed by the HSCL (Syed et al., 2006). The study also suggested that a decrease in post-migratory stress was correlated with a decrease in depression and anxiety symptoms among Pakistani immigrants (Syed et al., 2006). An Irish study found that severe mental health problems among asylum seekers, as compared to refugees, were due to their worse socio-economic conditions (Toar, O’Brien, & Fahey, 2009). There are also suggestions that negative socio-economic factors can accelerate the impact of pre-migration traumatic experience on refugees’ mental health (Steel, Silove, Bird, McGorry, & Mohan, 1999). A study found that negative impact of post-migration stressors on mental health diminished gradually with time, while the negative impact of severe past trauma on mental health tended to persist over time among Vietnamese refugees in Australia (Steel et al., 2002). The vast majority of available population-based studies of migration health show that women are more vulnerable to depression, anxiety, PTSD, and somatization symptoms (Gerritsen et al., 2006a; Thapa et al., 2007). Women generally experience higher rates of PTSD and depression (Olff, Langeland, Draijer, & Gersons, 2007), and gender differences are more acute in the face of traumatic stress (Punama¨ki, Komproe, Qouta, El Masri, & de Jong, 2005). This may offer an explanation for gender differences in the prevalence of mental health problems among refugee populations. Leaving home and resettling as a refugee may have gender-specific meanings and practical demands. For example, among immigrants from African and Asian countries in Norway, social integration was associated with good mental health in men, but not in women (Thapa et al., 2007). This may be due to the fact that men’s lives are more society focused, while women’s are more concentrated within the home. Yet, men tend to express their mental health problems with harmful actions, for example, through substance abuse and aggression, while females often express mental distress through anxiety and depression.


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An epidemiological study of Bosnian refugees showed violence-related mortality among men exceeded that of women (Mollica et al., 2001).

Older Somali refugees Older immigrants and refugees are regarded as particularly vulnerable to mental and somatic health problems (Silveira & Ebrahim, 1995, 1998; Wrobel, Farrag, & Hymes, 2009), although empirical investigations of age-specific mental health manifestations are rare. A meta-analysis revealed that old age (> 65-years) represented a high risk factor for refugee mental health problems, exceeding as the effect of low economic status or war experience (Porter & Haslam, 2005). A study showed that mood and anxiety disorders (SAD: Symptoms of Anxiety and Depression Scale) were substantially higher among older Somali and Bengali immigrants in the UK than among the general population (Silveira & Ebrahim, 1995). However, potential confounders were not controlled for in this particular study. A combination of factors may contribute to the increased vulnerability of older refugees. These factors include the scarcity of accessible resources needed to meet new social and cultural demands (Silveira & Allebeck, 2001), narrowing social networks, and difficulties in social integration, including proficiency of local language and participation in native institutions and friendships (Gele & Harsløf, 2012). An ethnographic study of aging male Somali immigrants in the UK identified loneliness, inadequate access to health services, homesickness, and low levels of family support as the main contributors to decreased life satisfaction and increased levels of depression. This relationship was found to be especially acute in cases of physical disability. Family support was the main buffer against depression, and religious practices and reliance on Somali peer support were perceived as the main coping resources (Silveira & Allebeck, 2001). Similarly, a Norwegian study reported that mental health problems among older immigrants are due to the accumulation of stressors resulting from a paucity of culturally appropriate resources to meet daily needs (Gele & Harsløf, 2012). The high comorbidity between mental health problems and neurological problems in old age is also worth considering (Shah, 2009). The emergence of somatic illnesses can weaken psychological well-being especially among older adults, and their acculturation process is slower than that of young refugees and immigrants. Higher prevalence of mental health problems among older immigrants has also been attributed to a lack of culturally sensitive and readily accessible services available to this group. Qualitative analyses reveal that older refugees refrain from seeking help because they feel alienated by the western biomedical conceptualization of mental distress. The health care system ignores their holistic experiences of social suffering and culturally-bound symptom manifestation, and often fails to listen to spiritual, historic, and culturally unique illness explanations that could serve as a basis for healing and provide a sense of security (Groleau & Kirmayer, 2004; Mo¨lsa¨, Hjelde, & Tiilikainen, 2010). Previous research confirms that mental health services lack culturally insightful healing practices for refugees,


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for example, in the UK (McColl & Johnson, 2006; Shah, 2009) and the Netherlands (Gerritsen et al., 2006b). A US study found that due to institutional barriers, even mentally ill older immigrants can receive less care than the healthy native population (Jackson et al., 2007).

Culture and health Study participants were Somali refugees and matched-pair Finnish natives over 50 years of age. The participants embody collectivist African Islamic (Somali) and individualist Nordic Protestant (Finnish) cultures. Somali and Finnish cultures differ in many ways, for example, in meaning given to religion, valuation of collective and individual responsibilities, as well as in conceptualization of health and illness (Kuittinen et al., 2014; Tiilikainen & Koehn, 2011). Among Somalis, Islamic customs and values shape daily life. Social networks, helping behaviors, and collective harmony are highly valued (Laitin & Samatar, 1987). Christianity and the secular traditions that characterize Finnish society emphasize achievement and independence. Finnish conceptualizations of mental health reflect individualistic values while Somali conceptualizations of mental health reflect collectivist values. For instance, in Finnish culture, depressive symptoms typically involve self-accusations and feelings of guilt. Mental health problems are considered an individual’s own responsibility and failure (Holma, Holma, Melartin, Rytsa¨la¨, & Isometsa¨, 2011; Kuittinen et al., 2014). In Somali culture, mental distress is associated with disturbed social relations, malevolent spirits, and improper conduct in the social realm (Mo¨lsa¨ et al., 2010). Finland was a relatively isolated country with a very small migrant and refugee population until the 1990s. Since then, the number of foreign-language speakers has increased almost tenfold reaching 224,388 persons in 2010, and currently constituting over 4% of the Finnish population (Statistics Finland, 2011). Somalis constitute the fourth largest immigrant group in Finland, approximately 12,985 in 2010 (Statistics Finland, 2011). The prevalence of mental disorders in the Finnish general population has been the subject of a number of epidemiological surveys (Pera¨la¨ et al., 2007; Pirkola et al., 2005), while research on immigrants and refugees is scarce. The present study is the first comparative study of the prevalence of mental health problems among older Somali refugees and Finnish natives.

Study aims The purpose of this study is to investigate mental and somatic health among older (> 50 years) refugees. First, we compare levels and clinical severity of depressive and psychological distress symptoms, somatic complaints and somatization, hypochondriasis, sleep problems, health-related quality of life, and self-rated health between older Somali refugees and pair-matched Finnish controls. The role of gender and age in the two cultural groups is analyzed, followed by how migrantrelated risk factors such as past trauma and current social integration (language


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proficiency and duration of residence) are associated with mental and somatic health in the Somali group.

Methods Participants and procedure Eligible participants were over 50 years old, born in Somalia, and currently living in the Helsinki Metropolitan area in Finland. Commonly, “older adults” is defined as individuals older than 60 or 65 years old age (often > 65). Yet, our characterization of older adults follows the WHO’s inclusion criterion for the African context, which is 50 years of age or older (WHO, 2010). The Population Register Center documented 307 older Somalis fulfilling the criterion in 2006, and study participants were drawn from this group. Of the 307 eligible participants approximately every second person was sent a letter including the study information and affirmation of anonymity and voluntary participation. Further requirements included satisfactory health status and sufficient cognitive ability to participate in the interview. The sample excluded institutionalized individuals. Of the 155 chosen participants, two had died and 15 were excluded due to hospitalization or absence, leaving a sample of 138. Ten declined to interview (three for health reasons, seven for other reasons), and thus the final sample was 128 Somalis. The response rate was 93% of contacted participants. The Finnish matched controls were selected from the Health 2000 survey conducted in 2000–2001. The methods and results of the survey are described in detail elsewhere (Aromaa & Koskinen, 2004; Heistaro, 2008) and can be retrieved from www.terveys2000.fi. For each Somali participant, a matched counterpart was selected from the Finnish study by gender, age (5-year categories), vocational education (categorized as none, various courses, vocational school, polytechnics, or university), and marital status (categorized as married, divorced, widow, or single). In both groups, participants were between 50–80 years of age (M ¼ 57.90, SD ¼ .50). We used the questionnaire from the Health 2000 survey in an interview setting among the Somalis. The interviews were carried out in 2007 by eight Somali-speaking interviewers, three women and five men. They were trained and supervised by the first author. Oral consent was obtained from each participant. Reaching older Somalis by phone and mail was challenging. In addition to phone calls and sending mail to listed home addresses, participants were located through social networks and unofficial inquiries. They included mosques, cultural centres, Somali associations, and language classes in the Helsinki Metropolitan area, as well as Somali general stores and coffee shops. The majority of Somali women were interviewed in their homes, whereas men often preferred to be interviewed in one of these public places. The interview lasted approximately two hours. Interviewing was chosen as a method of surveying participants because almost half were analphabetic (n ¼ 62). In previous studies, the number of Somalis responding to written surveys


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has been very low, which was an additional reason for choosing the interview method. The questionnaire was first translated from Finnish into Somali by a professional translator and was then double checked by three Somali linguists. No back translations were conducted. Special attention was paid to semantic and cultural meanings of symptom descriptions. To ensure the cultural appropriateness of the questionnaire, the pilot testing of the interview protocol was conducted with 10 older Somali volunteers. The first author supervised the work of the interviewers and pilot testing was conducted with volunteers. However, while Somali elders were interviewed, the native Finns completed the questionnaires themselves.

Measures Background information included age, vocational education (none, various courses, vocational school, polytechnics, university), marital status (married, divorced, widow, single), work status (home, permanent full-time job, part-time job, retired), and income (categorized as less than 500, 500-1500, and more than 1500). Post-migration variables were recorded in the Somali group. These variables included date of arrival to Finland, residence permit type (permanent, asylum seeker, Finnish nationality), and Finnish language proficiency (complete, satisfactory, does not speak Finnish). Somali participants were asked about their warrelated traumatic events using a 10-item Harvard trauma questionnaire (Mollica et al., 2001). Examples of war-related traumatic events included being wounded in shelling/bombardment, being detained, home demolition, or witnessed killing (1 ¼ yes; 0 ¼ no). Depressive symptoms were assessed by Beck’s Depression Inventory, BDI (Beck, Erbaugh, Ward, Mock, & Mendelsohn, 1961) consisting of 21 questions about feelings of low mood, hopelessness, irritability, cognitions of guilt and punishment, and somatic symptoms such as fatigue and weight loss. Participants were asked to estimate their feelings according to a set of four possible alternatives ranging in intensity (e.g., “I do not feel sad”, “I feel sad”, “I am sad all the time, and I can’t snap out of it”, “I am so sad or unhappy that I can’t stand it”). The responses were scored on a scale of 0 to 3, and the total sum ranged from 0–63. The internal consistency was high (Chronbach’s a: .89). BDI sum was also categorized to indicate clinically significant cut-off points: (0) less than 9/10 indicate no depression, (1) score of 10–18 is interpreted as mild depression, and (3) scores above 18 indicate moderate or severe depression. Psychological distress was measured using the General Health Questionnaire GHQ-12, consisting of 12 questions which assess the situation over the past few weeks (Goldberg, 1972; Goldberg et al., 1997). The participants responded on a 4-point scale. However, the sum variable was constructed by dichotomizing the values (presence of absence of symptoms). The sum variable ranged from 0–12, with higher scores indicating worse conditions. The GHQ-12 was also dichotomized using a cut-off point of 3/4, with scores above 3 suggesting high probability


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of psychiatric problems (Holi, Marttunen, & Aalberg, 2003). The GHQ-12 is a well-established screening instrument for psychiatric problems, and in this data the Chronbach’s a value of .95 indicated high internal consistency. Sleeping difficulties were assessed by two questions concerning the difficulty to fall asleep and maintain sleep. Responses were recorded on a 4-point Likert scale of how often they had difficulties falling asleep, woke up in the night or early morning (1 ¼ no problem 4 ¼ nearly always). An averaged sum variable of these three items was constructed. Somatization was assessed by the 13-item scale of SCL-90 (Derogates, 1992). The symptoms included faintness or dizziness, muscle soreness, and a lump in the throat. Participants estimated the extent to which they suffered from the listed symptoms during the past month on a 5-point Likert scale (1 ¼ not at all to 5 ¼ very much). The averaged sum variable was constructed, showing high reliability (Chronbach’s a ¼ .87). Somatic complaints and troubles were measured by 10 symptoms and disturbances developed for the Health 2000 research (Heistaro, 2008), including fast heartbeat, swollen feet, lethargy, moodiness, depression, irritability, anxiety, sweaty palms, sleeping difficulties, poor concentration, and memory problems. Participants recorded their symptoms during the past month on a 5-point Likert scale (1 ¼ not at all to 5 ¼ very much). The averaged sum variable was constructed, showing high reliability (Chronbach a ¼ .82). Hypochondriac health attitudes were measured based on a modified 7-item version of the Whiteley Index, which measures health-related concerns (Pilowsky, 1967). Questions included “Do you worry much about your health?” and “Is it difficult for you to believe when your doctor says you are healthy?” In the original index response, the scale was dichotomous, but in the current study participants responded on a 5-point Likert scale (1 ¼ not at all to 5 ¼ very much). The averaged sum variable was constructed, showing sufficient internal consistency (Chronbach’s a ¼ .77). Health-Related Quality of Life (HRQoL) measurement is based on the EuroQoL EQ-5D instrument (www.euroqol.org). It conceptualizes HRQoL based on five dimensions: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression. Three responses were available: no problems, some or moderate problems, or extreme problems. Responses were dichotomized as no problems vs. some to extreme problems. Self-rated health (SRH) was determined based on current health status, subjective quality of life, and illness-related disability on 10-point scales, where 0 represented the worst possible condition, and 10 represented the best possible condition. For health status, 0 represented the worst imaginable health status, while 10 represented the best imaginable health status. For subjective quality of life, 0 represented the worst imaginable quality of life, while 10 represented the best imaginable quality of life. For disability due to illness, 0 represented no hindrance caused by illness on home, work, and leisure time, while 10 represented the worst possible hindrance. Finally, presence of chronic illness was recorded (0 ¼ no, 1 ¼ yes).


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Statistical methods To compare mental and somatic health between the Somali and Finnish groups, we applied two (Group: Somali vs. Finnish) X 2 (Gender) X 2 (Age: 50–64 vs. 65–80) ANOVAs using depressive symptoms, psychological distress, sleeping difficulties, somatization symptoms, somatic complaints and hypochondria, current health status, subjective quality of life, and illness-related disability. We used 2 statistics to compare the occurrence of clinically significant depression and psychological distress between the two cultural groups. A linear multiple step-wise regression analysis was conducted to analyze the effect of pre- and post-immigration issues on mental and somatic health in the Somali group. Background variables were entered as control variables (gender, age, monthly income, employment). Postimmigration variables were then entered (duration of stay in Finland, residence status as dummy variable for Finnish nationality), followed by traumatic events, to indicate the pre-emigration characteristics. A significance level of .05 was used as a criterion for variables in the regression model. The sufficiency of the sample sizes for two-way ANOVAs was calculated by the Power for Comparing Two Means (Rosner, 2006), and for linear stepwise regression models by the equation presented by Tabachnick and Fidell (2007). Data analysis was performed using SPSS version 15 for analysis of statistical data (SPSS Inc. IBM).

Results Descriptive results There were no differences in gender, age, marital status, or level of education between the Somali and Finnish groups due to pair-matching (see Table 1). The sample population consisted of 41% men and 59% women. The majority (61%) was 50–59 years of age. Relatively few (5%) belonged to the oldest age group of > 70 years. The majority (62%) was married and a quarter (26–27%) was widowed. As groups were matched according to Somali education level, the percentage of uneducated participants was high (63–66%), and polytechnic or university education was relatively rare (13%). This does not correspond to the distribution of education levels in the general Finnish population. Significant group differences between Finns and Somalis were found in monthly income and employment. The Finns had substantially higher income levels than the Somalis (2 ¼ 133.15, p < .0001; df ¼ 2, N ¼ 248). Two thirds of the Somalis (67.2%, n ¼ 84) and 1.6% (n ¼ 2) of the Finns earned less than 500 a month, whereas 68.3% (n ¼ 84) of the Finns and 9.6% (n ¼ 12) of the Somalis earned more than 1500. Somalis were more likely to have unstable work (2 ¼ 80.64, p < .0001; df ¼ 8, N ¼ 238). Approximately a third (28.2%; n ¼ 31) of Somalis and three fourths of the Finns (78.1%; n ¼ 100) were currently employed fulltime. The Somalis were often self-employed or entrepreneurs. The unemployment rate during the last five years was 59.4% (n ¼ 76) in the Somali group and 12.5%


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Table 1. Background variables in the Somali and Finnish groups. Somalian

Gender Woman Men Age 50–59 years 60–69 70–80 Civic status Married Divorced Widow Single Education No education Various courses Vocational school Polytechinic school University Other

Finns

%

N

%

N

58.6 41.4

75 53

58.6 41.4

75 53

60.9 33.6 5.5

78 43 7

60.9 34.4 4.7

78 44 6

62.2 9.4 26.0 2.4

79 12 33 3

61.7 9.4 26.6 2.3

79 12 34 3

65.6 8.6 9.4 7.8 5.5 3.1

84 11 12 10 7 4

62.5 13.3 7.8 7.8 5.5 3.1

80 17 10 10 7 4

(n ¼ 16) in the Finnish group (2 ¼ 61.08, p < .0001; df ¼ 1, N ¼ 256). Income level and employment status could not be included as covariates in the analyses due to their skewed nature, but the analyses were re-run using them as between-subject variables. Some background variables were analyzed only among the Somalis. Nearly half (47.7%) had a permanent residence permit in Finland and 18.6% were Finnish nationals. The rest had a family member status (7%) or a residence permit by humanitarian law (15.6%). The duration of residence in Finland varied from one to 19 years. Forty-one and a half percent had been in the country 10 years or more and 15.7% had arrived during the past three years.

Mental and somatic health problems Means and standard errors in the Somali and Finnish groups, as well as ANOVA results for group differences in mental health problems and somatic complaints are presented in Table 2. Levels of BDI-depressive symptoms, GHQ-psychological distress, and sleeping difficulties were higher in the Somali group than in the


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Table 2. Mental and somatic health problems by cultural group, gender and age: Means (M), standard error (SE) and ANOVA results.

Scale

Depressive symptoms

Psychological distress

Sleeping difficulties

Somatization symptoms

Somatic complaints

Hypochondriac health concerns

0–21

0–12

1–4

1–5

1–5

1–5

M

SE

M

SE

M

SE

M

SE

M

SE

M

SE

Somali

9.10

.73

5.29

.43

1.63

.08

1.92

.07

1.95

.06

1.75

.07

Finns F (1, 250)

7.06 3.89*

.73

1.39 .08 4.79*

1.89 0.60

.07

1.91 0.17

.06

2.02 8.55**

.07

Cultural group 1.58 .44 36.54****

Gender Women

9.95

.63

4.00

.38

1.72

.07

2.06

.06

2.07

.05

1.94

.06

Men

6.20

.76

2.86

.45

1.29

.08

1.75

.07

1.80

.06

1.83

.07

F (1, 250)

16.05****

4.14*

19.37****

12.12***

11.09***

1.76

Age 50–65 yrs

8.00

.55

3.83

.33

1.51

.06

1.91

.05

1.92

.05

1.95

.05

66–80 yrs F (1, 250)

8.15 0.02

.87

3.04 1.71

.51

1.50 0.01

.09

1.90 0.01

.08

1.94 0.01

.07

1.82 1.83

.08

*p < .05. **p < .01. ***p < .001. ****p < .0001.

Finnish group. However, health attitudes indicating hypochondria were more common among the Finns. No group differences were found in levels of somatization or somatic complaints. Clinically significant level of psychological distress (GHQ-12) was significantly higher among the Somalis (85.3%) than the Finns (14.7%) (2 ¼ 157.12, p < .0001, df ¼ 1,237). Rates of clinical depression did not differ between the two groups (2 ¼ 2.32, p ¼ ns, df ¼ 1,256). The rate of moderate or severe depression was 21.1% among Somalis and 14.1% among Finns. Table 2 further demonstrates the increased vulnerability of women to both mental health problems (depressive symptoms, psychological distress, and sleeping problems) and somatic symptoms. Age was not a significant determinant of either mental or somatic health in the studied older adults. The Gender X Group and Age X Group interaction effects were non-significant on all mental health and somatic variables, indicating a similar role of gender and age in both groups. As indicated in Table 3, the Somalis had lower self-reported health status and quality of life than the Finns. They also perceived the symptoms and illnesses as causing more harm to their functioning in home, work, and leisure activities. In terms of health-related quality of life, group differences were found in self-care (2 ¼ 6.59, p < .01, df ¼ 1,235), pain/discomfort (2 ¼ 6.04, p < .02, df ¼ 1,243), and anxiety/depression (2 ¼ 146.03, p < .0001, df ¼ 1,229). Anxiety/depression levels were higher among Somali elders (96.5%) than among Finns (17.2%). Somalis reported higher levels of moderate or severe problems in daily self-care


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Table 3. Current health status, subjective quality of life and harm of illness on everyday functioning by cultural group, gender and age: Means (M), standard error (SE) and ANOVA statistics.

Scale Cultural group Somali Finns F (1, 250) Gender Women Men F (1, 250) Age 50–65 yrs 66–80 yrs F (1, 250)

Current health status

Subjective quality of life

Harm of illness on function

0–10a

0–10a

0–10b

M

SE

M

SE

M

SE

6.33 6.92 4.55*

.20 .19

6.56 7.31 7.99**

.19 .19

3.66 2.20 12.99***

.29 .29

6.13 7.12 15.28***

.17 .20

6.62 7.25 6.61**

.16 .20

3.27 2.58 3.49+

.25 .30

6.85 6.40 2.79+

.15 .23

7.12 6.75 2.79+

.14 .22

2.77 3.08 0.58

.22 .34

Note. aHigher scores indicate good health status and high quality of life; bHigher scores severe harm on functioning. +p < .10, *p < .05, **p < .01.

(24.1%) than Finns (11.4%). However, pain or discomfort was more common among Finns (58.2%) than among Somalis (43.8%); 56.3% of Finns reported chronic illnesses, compared to 40.6% of Somalis (2 ¼ 6.26, p < .01, df ¼ 1,256). Significant Group X Gender interaction effects were found in current health status (F(1,232) ¼ 5.00, p < .03) and subjective quality of life (F(1,233) ¼ 3.85, p < .05). Figures 1 and 2 indicate that women in the Somali group reported poorer current health and quality of life than their male counterparts, whereas no gender differences were found in the Finnish group. Further, significant Group X Age interaction effects were found on self-care (F(1,229) ¼ 12.83, p < .0001) and on usual activities (F(1,234) ¼ 5.88, p < .02). As Figure 3 demonstrates, older age (> 65 years) was associated with increased vulnerability among Somali refugees. This is demonstrated by the lower capacity for self-care (e.g., feeding, dressing) and lower ability to conduct daily activities, as compared to the younger Somalis or the older Finns. In order to examine group differences regarding the effect of economic and employment stability on mental and somatic health, we re-ran ANOVAs, including monthly income (> 1000 and > 1000) and unemployment during the last five years


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8

Health status

7

6

Women Men

5

4 Somali refugees

Finnish natives

Figure 1. Association between culture and current health status according to gender.

8

Quality of life

7

6

Women Men

5

4 Somali refugees

Finnish natives

Figure 2. Association between culture and subjective quality of life according to gender.

(no; yes) separately as between group variables. We were interested in the interaction between group and economic indicators because they can neutralize the documented group-related health differences and reveal group-specific associations. The results sustained the main group effects on depression, psychological distress, sleeping difficulties, and hypochondriac health attitudes. Significant Group X


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1.5

1.4

Self care

1.3 50-65 years 66-85 years

1.2

1.1

1 Somali refugees

Finnish natives

Figure 3. Association between culture and self-care indicating health-related quality of life according to age.

Unemployment interaction effects on psychological distress (F(1,235) ¼ 5.46, p < .02) indicates that unemployment was associated with high levels of psychological distress only in the Somali group. Unemployment was not significantly associated with mental and somatic symptoms. Monthly income did not have either main or interaction effects with the cultural group on any mental and somatic symptoms. Concerning the health-related quality of life, significant Group X Monthly income interaction effects on self-care (F(1,230) ¼ 7.08, p < .008) and usual activities (F(1,230) ¼ 3.62, p < .05) indicate that low income was associated with poor quality of life especially in the Somali group. Low income was also directly associated with poor quality of life, indicated by significant main effects on movement (F(1,230) ¼ 5.81, p 50 years) residing in the Helsinki Metropolitan area (N ¼ 307) would have been ideal in order to maximize the sample size and guarantee representativeness. In addition, a multi-informant setting would have strengthened our results, and clinical interviews or observations would have allowed for verification of the applied self-reports. Third, although the same questionnaires were used for data collection in both cultural groups, the Somalis were visited by interviewers who recorded their responses, while the Finns completed the questionnaires themselves. Home visits were necessary for the Somali group in order to guarantee a representative sample and a high response rate. Illiteracy among the Somali participants was also a consideration. It is difficult to predict the effects of the different data collection procedures on our results. Finally, pre-immigration traumatic events were recalled retrospectively. There is, however, some evidence that refugees report key traumatic events consistently over time (Herlihy, Scragg, & Turner, 2002), although others have remarked that recall of traumatic memories is particularly difficult for Somali refugees (Kroll et al., 2011).

Key messages Further research is needed in the area of culture-specific resilience and vulnerability factors among older refugees. It is of utmost importance to both recognize psychological problems as well as to identify strengths among older refugees. Our data supports the view that refugees from African cultures express mental distress in varied and complex ways. Awareness of the impact of traumatic experiences on the psychological and somatic health of older refugees should be an essential component for health care services to meet the needs of these populations in their host countries. Funding This study was financed by the Academy of Finland. The first author received financing from the Finnish Cultural Foundation, Uusimaa Regional Fund, Finnish Psychiatry Association, the City of Helsinki.

Acknowledgments The authors are grateful to all the Somali participants who shared their personal experiences with our research team as well as to the Finns who participated in the Health 2000 study. We are thankful for the volunteers who made the study possible by assisting with data collection tool translation.


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Mulki Mo¨lsa¨, MD, is a doctoral student at the University of Helsinki, focusing on health and mental health of Somali seniors in Finland. She works as a medical officer at the HUS—The Hospital District of Helsinki and Uusimaa, Department of Psychiatry, as a visiting researcher at the National Institute for Health and Welfare (NIHW), Helsinki, Finland and as a consultant on immigrant health issues. At the NIHW she is studying immigrants’ health, well-being and use of services, as well as the living conditions in Finland. She has also conducted research on female genital cutting and worked as a sub-investigator on vaccine clinical trials at the University of Tampere. Her research interests include cross-cultural psychiatry, migration and health, and ageing. Raija-Leena Punama¨ki, PhD, is a psychologist and professor at the University of Tampere, Finland, and received her PhD from the University of Helsinki. Her research has focused on child development and mental health in conditions of war and military violence, as well as rehabilitation of victims of torture and human right abuse. Her current research focuses on preventive interventions among war traumatized children, and mother–child interaction in life-endangering conditions. She is a member of Finnish Psychologists for Social Responsibility, the European Society for Study Traumatic Stress Studies, and the Finnish Academy of Science and Letters.


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Samuli I. Saarni, MD, PhD, is a psychiatrist and adjunct professor of social psychiatry in the University of Helsinki, Finland. He is currently working as chief medical officer at the Helsinki University Central Hospital, Department of Psychiatry and as a senior researcher at the National Institute for Health and Welfare, Helsinki, Finland. His research interests include psychiatric epidemiology, quality of life research, and health care ethics. Marja Tiilikainen, PhD, is an adjunct professor in comparative religion and Academy Research Fellow at the Department of Social Research, University of Helsinki. Her mulidisciplinary research focuses on everyday Islam, cultural dimensions of health, illness and healing, and life of immigrant women and families. She has conducted long-term research on Somali migrants and carried out ethnographic research in Finland, Northern Somalia, and Canada. Her main publications include Medicine, Mobility and Power in Global Africa (2012). Saija Kuittinen, MA, is a psychologist and a doctoral student at the University of Tampere and National Doctoral Programme of Psychology, Finland. Her Master’s thesis focused on cultural aspects of depression and antecedent risk factors, and PhD thesis on parenting practices among immigrants living in Finland and families living in war-zones. Her research interests are cultural differences and similarities related to mental health, development and parenting practices. Her aim is to combine cross-cultural psychology with psycholinguistics. She is a member of the International Association of Cross-Cultural Psychology and the Nordic Network for Research on Refugee Children. Marja-Liisa Honkasalo, MD, PhD, is a medical anthropologist and professor at the University of Turku, Finland. Her search interests concern the relationship between nature and culture, including topics of illness, the body, and death, as well as semiotics and cultural meanings of women’s symptoms. She has also published a series of articles on the experience of chronic pain. Dr Honkasalo received the Steve Volgar Professional Prize from the American Anthropological Association for the best article in 2009. Her edited volume Culture, Suicide, and the Human Condition (with Miira Tuominen) is being published by Berghahn in 2014.


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