Migration Stressors, Psychological Distress, and ...

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Abstract Each refugee community experiences specific migration experiences. The migration journey of Sri Lankan Tamil refugees are marked by exposure to ...
Int. Migration & Integration DOI 10.1007/s12134-014-0404-y

Migration Stressors, Psychological Distress, and Family—a Sri Lankan Tamil Refugee Analysis Miriam George & Jennifer Jettner

# Springer Science+Business Media Dordrecht 2014

Abstract Each refugee community experiences specific migration experiences. The migration journey of Sri Lankan Tamil refugees are marked by exposure to multiple pre- and post-migration traumatic events. A two-group, cross-sectional design was used to identify the relationship among migration stressors, family presence, and number of children based on refugee theory. The results of the study indicate that refugees in India have higher psychological distress than refugees in Canada, and the number of children had a positive relationship with psychological distress. Findings from the study will help in the adaptation of culturally and contextually relevant settlement programs to improve the quality of life for refugees and to reduce the cost of settlement programs provided by host countries. Keywords Refugee trauma . Refugee theory . Refugee settlement programs . Sri Lankan Tamils . Refugee policies Forty-two million refugees around the world have been forcibly uprooted from their country of origin (UNHCR 2011). The effects of pre- and post-migration traumatic experiences on refugees are long lasting and shattering to both their inner and outer selves (Steel et al. 2006). Civil wars, torture, shortage of food, being lost, and close to death create significant psychological risk for trauma for many refugees during their pre-migration period (Bhui et al. 2003). Refugees who have already survived premigration traumatic events in their country of origin also often face challenging experiences during the resettlement period. Loss of own culture, nostalgia, loneliness, depression, anxiety, guilt, anger, and frustration may be so severe that many refugees want to go back to their country of origin, even though they fear the violent consequences (George 2012). There are often intergenerational struggles at home because of the uncertainty about how to adapt to the new culture (George and Tsang 2000). In the 30 years of scholarly research on refugee migration, only a few researchers have M. George (*) : J. Jettner School of Social Work, Virginia Commonwealth University, P.O. Box 842027, Richmond, VA 23284, USA e-mail: [email protected]

M. George, J. Jettner

attempted to empirically identify the factors that distinguish refugee families. The etiology of conflict in refugee families is thus cloudy. The objective of this paper is to examine the relationship between pre-migration stressors, daily stressors, psychological distress, family presence, and the number of children among Sri Lankan Tamil refugees whose traumatic experiences are understudied in the scientific literature.

Uprooted Sri Lankan Tamil Refugees The extreme violence unleashed against Sri Lankan Tamils during the civil war between the Liberation Tigers of Tamil Eelam (LTTE) and the Government of Sri Lanka resulted in three waves of forced migration by Sri Lankan Tamil refugees since 1984 (George 2009). The largest concentrations of Sri Lankan Tamils outside of Sri Lanka are in Canada and in India (George 2010a). India’s close proximity to Sri Lanka and Canada’s special Tamil immigrant supportive (1983–2005) migration programs are the reasons for having high number of Sri Lankan Tamil refugees in these countries (Amarasingam 2013). Today, over 125,000 of Sri Lankan Tamil refugees live in India, with 90,000 living in refugee camps (OfERR 2012). There is an estimate of between 200,000 and 300,000 Tamil refugees in Canada (Wayland 2004). As Wayland suggest, this estimate may not be accurate. Canadian statistic is based on community estimates, media estimates, and old statistic Canada numbers that are problematic. The pressures on refugees do not remain constant over time; they change as refugees undergo the process of integration. Refugee-host relationships can create an atmosphere that either aids or hinders the post-migration daily stressors of refugees (George 2010b). The migration journey of many Sri Lankan Tamil refugees is marked by sustained exposure to these multiple traumatic events, during both the pre-migration and post-migration periods (Tambiah 1992). During the pre-migration period, many Sri Lankan Tamil refugees continued to live in war zone areas in Sri Lanka (Grønseth 2006; Somasundaram 2007) and were faced with lack of food, water, shelter, access to medical care as well as sexual and physical assault (Weaver 2005; Somasundaram 2007). Exposure to traumatic experiences usually did not end once Sri Lankan Tamils left Sri Lanka. Sri Lankan Tamil refugees continue to face difficulties in refugee camps, as well as in their new host countries, where their lives often remain in limbo until they receive residency status (Weaver 2005). Experiences of ill health, loss, bereavement, and violence have resulted in psychological distress among Sri Lankan Tamil refugees (Somasundaram 2007). The situation has become more complex as some Sri Lankan Tamil refugees are forced to repatriate now that the civil war has ended (George 2009). This population was forced to adapt to a new life away from their homeland during the war and, in doing so, had children born in exile. However, due to repatriation efforts, these children now face the difficulty of adapting to their parents’ native country. In addition, complex migration policies of host countries like India and Canada not only create challenging experiences for Sri Lankan Tamil refugee families, but also affect the ways in which they settle into their new countries. India was not a signatory to the UN Convention on refugees (OfERR 2012). Indian-based Sri Lankan Tamil refugees have no social or political rights in India (George 2012). The rationale for the Indian government to refuse any rights is its expectation that Sri Lankan Tamil refugees would return to Sri Lanka once the war ended (George 2010a). Shortly after the war, India began a program

Migration Stressors, Psychological Distress, and Refugee Families

of “voluntary” repatriation and more than 50,000 Sri Lankan Tamil refugees were repatriated to Sri Lanka without international supervision (Giammatteo 2010). According to media reports, refugees coming back to Sri Lanka have found their homes destroyed; roads and water systems inoperable; and schools, health clinics, and hospital facilities shut down (Giammatteo 2010). Thus, Sri Lankan Tamil refugees reported feeling in “limbo” and were unsure of what would become of their lives due to the lack of repatriation support from both Indian and Sri Lankan governments. Both of these governments’ consistent attitude of it is “their” problem, not “ours” has created a distorted view that is unaware of its own culpability in perpetuating the violation of human rights (George 2010a). In many host countries, refugees’ higher psychological distress levels may also be attributed to the lack of cultural sensitivity among refugee review boards and other refugee policy-making bodies (Rousseau et al. 2002). For instance, Rousseau et al. (2002) found a lack of tolerance in Canadian host country refugee policies. Many of this host countries’ policies are highly Eurocentric and are not applicable to the diverse cultural, social, and political nature of refugees (George 2010b). Traumatic experiences are heightened by the burden of proof policy, whereby during the process of determining eligibility the onus is on the refugee to provide a medical certificate to prove their claims of having been physically, mentally, or sexually abused (Rousseau et al. 2002). Often refugee review board members’ lack of knowledge of international refugee law, ambivalence toward traumatization, ignorance regarding trauma, and lack of understanding of refugees’ historical, social, cultural, and political backgrounds adversely affect the decisionmaking process (Rousseau et al. 2002). These factors may affect Sri Lankan Tamil refugees during their post-migration period, leading to increased psychological distress. Given the high degree of pre-migration trauma and the contextual complexity in understanding post-migration stressors and its influence on psychological distress, how does one begin to understand and intervene with refugee families? There is limited data on the salience of intergenerational conflict in community samples of refugees. Heightened family conflict, poor communication, and lack of parental responsiveness all contribute to complex refugee family dynamics (Fazel et al. 2005; Fernando et al. 2010; Miller et al. 2009). The twin stressors of poverty and differential rates of acculturation between parents and youths are common among refugee families, and evidence for intergenerational conflict related to these stressors is present among refugees (Portes 2001). Among Cambodian and Hmong refugee youths in the Portes (2001) study, almost a third (32 %) reported being embarrassed because of their parents. However, these findings stand in contrast to the less than 17 % among immigrant youths in Portes (2001) study who were not from regions plagued by political violence. While this observation may be tempered by inter-group cultural differences, it does seem to suggest that exposure to political violence may explain some proportion of the variance in intergenerational conflict. Alternatively, a history of hardship may be associated with positive adaptive outcomes among refugee children of those persecuted. Somasundaram (2007) found that Sri Lankan Tamil internally displaced children reported to develop resilience and survival skills from their pre-migration traumatic experiences. Grønseth (2006) research with Sri Lankan Tamil refugees in Norway produced similar results where the focus of refugees was on “being in the present world.” Western research process and conceptualizations have been primarily individualistic in orientations (George, M. Ethical lessons learned from conducting refugee-based research in an Indian refugee camp. Under review).

M. George, J. Jettner

However, in collectivistic, co-operative societies, there is a need to go beyond the individual to the family, community, and social levels to more fully understand what is going on in the individual prior to developing settlement interventions. In light of these findings from the literature, the main objective of this paper is to analyze the interaction of pre- and post-migration stressors and family for designing the most effective interventions for Sri Lankan Tamil refugees.

Theoretical Analysis Based on Refugee Theory This paper is examining the context of Sri Lankan Tamil refugees through the lens of refugee theory which will help us to analyze refugee settlement structures and refugee behaviors (Kunz 1973, 1981). One of the refugee theorists, Paludan (1974), proposed a typology of refugee settlement that distinguishes between a “new refugee settlement” and a “traditional refugee settlement.” The key differences between new and traditional refugee settlements are that the new refugee settlement is culturally, racially, and ethnically vastly different from their country of origin, and refugees are likely to lack family or potential support groups in their country of resettlement. In contrast, traditional refugee settlements are culturally, linguistically, and ethnically similar to their country of origin and are likely to be welcomed and assisted by family and friends who speak their language and can cushion their adjustment (Paludan 1981; Stein 1986). Examples of these types of refugee settlements are Sri Lankan Tamil refugees who have resettled in the state of Tamil Nadu in India and Sri Lankan refugees who have resettled in Canada. Sri Lankan refugees in Tamil Nadu (traditional refugee settlement) live in the same cultural, social, and linguistic environment as they did in Sri Lanka. Sri Lankan Tamil refugees in Canada (new refugee settlement) live in a culturally, socially, and linguistically different environment. The behavioral and material aspects of Western culture are alien to refugees in a new settlement (Weaver 2005), and they may experience more traumatic post-migration experiences as a result. Paludan asserts that differences between new and traditional refugee settlements can influence certain patterns of behavior by refugees during their host country resettlement (1981). Examining the utility of these theoretical concepts and linking these concepts to Sri Lankan Tamil refugee context may provide diverse perspectives on their resettlement.

Research Questions 1. Do refugee pre-migration and daily stressors predict their psychological distress? 2. Is this prediction moderated by typology of refugee settlement, family presence, and the number of children?

Methodology Research Design A two-group cross-sectional design was selected to determine the factors that impact refugee traumatic events and psychological distress. The outcome

Migration Stressors, Psychological Distress, and Refugee Families

variable (psychological distress) and predictor variables (pre-migration traumatic events and daily stressors) are both continuous variables. The moderators—typology of refugee settlement and family presence—are categorical variables, while the number of children is a continuous variable. Study Measures The Harvard Trauma Questionnaire (HTQ), the Post-Migration Living Difficulties Questionnaire (PMLDQ), and the Symptoms Check List - 90R (SCL-90R) were used in this study. Pre-migration stressors: Harvard Trauma Questionnaire (HTQ) is probably the most commonly used tool for assessing refugee pre-migration/migration stressors (Weaver 2005; Mollica et al. 1992). The scale was developed from clinical samples. HTQ is a self-report questionnaire with three parts. HTQ administered in the South Asian population (Mollica et al. 1992) and the Tibetan population (Lhewa et al. 2007). Weaver (2005) developed a Tamil version (HTQ-T), with input from the Tamil community and also from health-care professionals who work with the Tamil community, to ensure criterion validity and to specifically tailor the questions to address the common experiences of Tamil refugees (2005). This study is the first to use the HTQ-T. Part 1 of HTQ-T (“Things That Happened”) was considered as questions about premigration events. Part I contains a list of 24 traumatic events using Likert scaling (no= 0, witnessed=2, experienced=3) to assess respondent’s pre-migration traumatic events. Three open-ended questions were dropped from the scale, resulting in 21 items. Scoring was calculated by summing the number of pre-migration traumatic events experienced (M=23.20, SD=7.45, Cronbach’s alpha=0.83). Post-migration stressors: Daily stressors were measured by the post-migration living difficulties (PMLD) scale. The scale consists of 24 items on a five-point Likert scale where 0 indicated “no problem” and 4 indicated “a very serious problem.” One item was dropped due to the request of community partners resulting in a 23-item scale (M=27.47, SD=20.56; Cronbach’s alpha=0.96). Psychological distress: Psychological Distress was measured by the Symptoms Checklist 90R (SCL). There are 90 items on a five-point Likert scale (0=not at all, 4=extremely). It is designed to provide an overview of a patient’s symptoms and their intensity at a specific point in time. By providing an index of symptom severity, the assessment helps to facilitate treatment decisions and to identify patients before problems become acute. Overall distress was calculated by a sum of each individual item, with higher values reflecting greater psychological distress (M= 110.87, SD=57.60; Cronbach’s alpha=0.98). Measurement Translation In recognition of the significant traumatic events experienced by Sri Lankan Tamil refugees and the importance of employing culturally appropriate assessment to obtain in-depth information on the struggles during their pre- and postmigration periods, these study instruments were culturally and linguistically adapted by the researcher. Translations were completed by a research advisory body that included social workers and Sri Lankan Tamil refugee community members using a traditional forward and back translation and comparing versions maximizing technical, semantic, content, and conceptual equivalence (Flaherty et al. 1988). Translation procedure was followed to address concerns over the additional stress potentially caused by language difficulties common among refugees living in a host country (Wenzel 2002) and concerns expressed by those who criticize the limited attention paid by researchers to non-war-related traumatic experiences of refugees (Hollifield et al. 2002).

M. George, J. Jettner

Recruitment and Sampling The study received institutional review approval from University of Toronto where the researcher/first author was situated. Data was collected from participants in the city of Toronto, Canada during July to October of 2008 and from the city of Chennai, Tamil Nadu, India during November to January of 2009. For this study, the selection of these locations substantiated one of the study moderators: typology of refugee settlement by refugee theory. Toronto, Canada represents a new settlement based on the new culture/language/social practices, and Tamil Nadu, India represents an old settlement based on the similar language/culture/social practices. Participants had to be living in their respective host countries—Canada or India—for at least 12 months. All participants were 18 years of age or older. Exclusion criteria limited participation to one member per family. The study used convenience sampling method to recruit 50 Sri Lankan Tamil refugee participants residing in Toronto, Canada, and 50 Sri Lankan Tamil refugee participants residing in Chennai at the Indian state of Tamil Nadu. Sampling continued until target numbers were reached. To obtain a community sample from Toronto and Chennai, flyers were distributed during various community events. Interested individuals contacted the researcher using local phone numbers in Toronto and Chennai. The researcher/first author explained the study in Tamil or English, depending on the caller’s preference, and screened potential participants. The researcher/first author then contacted eligible participants to set up a date and time to sign the Tamil-translated consent form and conduct the face-to-face interview in a mutually acceptable location. In recognition of participants’ time commitment, the researcher provided a 20 Canadian dollar honorarium for Canadian participants, while participants from India received 200 Indian rupees based on the local rate for such research honoraria. All interviews in both Canada and India were conducted by the researcher, who is proficient in Tamil.

Data Analysis The data were analyzed by multiple regression using the Enter Method with SPSS 21. Seventeen cases were deleted for missing 20 % or more of data, resulting in an analytic sample of N=83. No significant demographic differences were found between deleted and non-deleted cases. We handled the remaining missing data (5 % or less per case) in two ways. A zero was imputed for missing values for the pre-migration measure (HTQ part 1), since it is essentially a checklist of various traumatic events. The corrected item mean was substituted for missing values for the post-migration (PMLD) and psychological distress (SCL) scales. Values were imputed for practical and theoretical reasons. On the practical side, we opted to impute values to retain the largest sample size possible in this preliminary study, rather than delete entire cases or utilize pairwise deletion in the analyses. Further, Schafer and Graham (2002) argue that when using a scale, pairwise deletion can reduce the reliability of the scale as well as introduce bias since non-responses are technically counted as “0” when summing or averaging the scale. We chose the corrected item mean substitution method to impute values since this method accounts for both the average response to an item and also the person’s overall response set for that scale (Huisman, 2000). This method has been found to perform as well as multiple imputation methods in terms of reducing bias (Huisman, 2000;

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Kadengye et al. 2012). No problems with outliers, linearity, and multicollinearity were noted. Based on previous analyses, we had determined that daily stressors partially mediated the effects of pre-migration trauma on psychological distress. Further, we had determined that psychological distress significantly differed within our sample based on host country and refugee status (George, M. & Jettner, J. Impact of Daily Stressors on Psychological Distress: A Sri Lankan Tamil Refugee Analysis. Under review). We had not controlled for these variables in our previous models, although we had suggested that the context and specific aspects of daily stressors, in this case family presence, may help explain the relationship between pre-migration and daily stressors on psychological distress. In order to assess this, we built models that assessed the influence of the control variables (model 1), the control variables and pre-migration trauma (model 2), and the full model, which added daily stressors in model 3 (Table 1). In model 1, host country, family presence, and number of children were regressed on psychological distress. The model was not statistically significant (F3,82 =2.049, p=0.114). In model 2, the control variables as well as pre-migration trauma were regressed on psychological distress. The model was statistically significant (F4,82 =4.431, p=0.003) and explained 14.3 % of the variance. The number of children had a statistically significant relationship with psychological distress where, as the number of children increased, psychological distress decreased by 9.685 units (p=0.043). Pre-migration trauma was also a significant predictor of psychological distress, where for each traumatic event experienced, psychological distress increased by 2.707 units (p