african refugees in durban: discrimination, food insecurity and mental health prof jonathan burns...
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African refugees in Durban: discrimination, food insecurity
and mental health
Prof Jonathan BurnsHead of Department of PsychiatryNelson R Mandela School of MedicineUniversity of KwaZulu-NatalDurban, South Africa
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The epidemiology of migration – Humans have been migrating for millions of years
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The epidemiology of migration –Human migration during the 20th Century
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The epidemiology of migration –20-30 million internally displaced people
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Migration is associated with an increased risk for mental disorders
• Anxiety & Depression In the UK, Asian & Afro-Caribbeans (especially women) are 1.5-2.5 times more likely to be diagnosed with anxiety disorder or depression (Bhugra & Jones 2001)
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• Post-traumatic stress disorder – high rates of PTSD in refugees from El Salvador, Tibet, Khmer, China, Ethiopia, Kosovo (Fazel et al 2005) – mean prevalence of 9% (highest: 44% Cambodian & 38% Kosovan refugees)
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• Suicide & attempted suicide – elevated rates in S. Asian female diaspora globally, especially aged 18-25yrs. Factors: males – socio-economic status; females – cultural transitions & tensions (Bhugra & Jones 2001)
• Substance abuse
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Increased prevalence of schizophrenia in migrants
• Afro-Caribbeans in UK and Netherlands have increased rates of schizophrenia (range from 2-16 x local white population).
• Systematic review (Cantor-
Grae & Selten 2005) – 3x risk.
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Reasons for increased prevalence of schizophrenia in migrants
1. Higher rates in countries of origin – NO
2. Schizophrenia predisposes to migration – NO
3. Misdiagnosis in ethnic minorities – NO
4. Stress of migration itself – evidence shows that onset of schiz is usually 10-12 yrs post-migration and is increased in 2nd generation.
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Reasons for increased prevalence of schizophrenia in migrants
Ethnic density & perceived discrimination:
• Rates are increased where the individual’s ethnic group is significant minority in community
• Perceived racism and discrimination correlates with increased risk for schizophrenia
Boydell et al 2001
Veling et al 2006
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Stages of Migration• Pre-migration• Migration• Post-migration
Reasons for migration• Political• Economic• Educational
Migrate singly or en masse
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Important pre-migration factors
• Reasons for migrating• Alone or with family/group• Personality of individual• Trauma, persecution• Prepared or sudden• Degree of control over
migration
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Important migration factors
• Traumas experienced• Vulnerable groups
(women, children, elderly)• Alone or with family/group• Legal illegal/asylum• Host country response
(eg immigration policies)• Financial means• ‘cultural bereavement’
(loss/grief reaction) – normal response
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Vulnerable groups
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Host country response/policies
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Important post-migration factors
• Aspirations & expectations versus achievement
• Acculturation & adjustment• Cultural identity shifts• Culture shock• Ethnic conflict, xenophobia• Ethnic density, networks,
support• Unemployment, housing• Legal problems, detention
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Cultural bereavement- Loss of social structure,
supports, economic worth, language, culture, values, identity, etc
- A normal grief reaction
Culture shock- Transition from eg. Socio-
centric society to an Ego-centric society
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Cultural identityContact may lead to:- Assimilation- Rejection- Integration- Deculturation
Cultural congruity- Socio-centric vs ego-
centric societies- Individual personality
(socio- vs ego-centric)- Adjustment varies
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Ethnic density
• Size of ethnic group in proportion to total pop in a region
• Increased ED may be protective, supportive
• But increased ED may delay adjustment and increase stress in eg. ego-centric individuals
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Refugees, migration and xenophobia
• SA: 2001 census: > 1 million refugees from within Africa (probably higher: ½-1million current from Zimbabwe)• Internal migration/urbanization (mines, etc)• May 2008 – xenophobic attacks (>70 killed, 10s of 1000s displaced and homeless); again in 2015
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Durban Migrant Mental Health Study
• Dennis Hurley Centre – FBO• 6 months in early 2014• 335 adult refugees/migrants• Socio-demographics• Pre/Migration/Post factors• Food security• Discrimination• PTSD symptoms (Harvard Trauma Questionnaire)• Anxiety & depression (Hopkins Symptom Checklist-25)• Life Events Checklist
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Demographics % %
Male 53
DRC 48
Zimbabwe 34
Burundi 14
Married/partner 57
Mean age (years) 33
Mean years of schooling 11
Occupation: before vs after migration: - unemployed - student - teacher/professional - artisan/labourer - part-time
Before
143123150
After
306112711
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Pre-migration/migration factors %
Reason for leaving: - To escape war, violence, danger, arrest - To seek employment, study - To join relatives, friends
70282
Forced to leave suddenly or quickly 70
Traveled to SA: - alone - with family - with friends - with strangers
6119126
Substance use: - alcohol - cannabis
231
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Post-migration factors %
Currently living alone 7
Mean number of people living in home 5
No income or less than $100/month 29
Last 12 months, not enough food to eat: - often - sometimes
2338
Have you felt discriminated against? 71
Where? - home country only - both home country and in SA - in SA only
72370
Family separation since being in SA 33
No social support 23
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Trauma exposures
Trauma % Trauma %
Lost a child 17 Sexual assault 5
Natural disaster 28 Combat/exposure to war
57
Fire/explosion 16 Captivity or hostage 12
Transport accident 39 Life-threatening illness or injury
28
Physical assault 67 Sudden death of loved one
68
Assault with weapon 46 Torture 13
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Mental health outcomes
Outcome %
HSC anxiety score ≥ 16 50.3
HSC depression score ≥ 24 53.9
HTQ PTSD score ≥ 60 25.9
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Anxiety Depression PTSD
Nationality - Zimbabwe - DRC - Burundi
17.916.815.3
29.726.623.4
54.249.343.6
Household income ($/m) <100 100-250 250-500 500-1000 >1000
19.417.616.414.314.2
31.128.825.722.222.2
58.752.446.741.539.8
Last 12 months, not enough food-Yes-No
18.414.8
29.922.8
55.141.7
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Anxiety Depression PTSD
Forced to leave family behind - Yes - No
18.216.4
29.925.9
56.047.1
Discrimination in SA - Yes - No
18.716.1
30.025.5
55.746.6
Lost a child - Yes - No
19.316.6
30.526.6
55.249.0
Natural disaster - Yes - No
16.017.4
26.527.4
48.650.6
Fire/explosion - Yes - No
19.216.5
30.126.4
57.248.2
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Anxiety Depression PTSD
Sexual assault - Yes - No
20.616.8
33.826.8
59.149.5
Combat/exposure to war - Yes - No
16.317.8
25.429.3
46.354.3
Captivity/hostage - Yes - No
18.516.8
30.826.6
57.848.8
Life-threatening illness - Yes - No
19.216.1
30.925.5
56.647.1
Torture - Yes - No
20.916.4
34.526.0
67.447.3
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Food security and anxiety, depression
AnxietyOR
DepressionOR
Food insecurity 5.4 7.2
Female ns 1.9
Divorced 3.5 1.8
Forced to leave ns 2.1
No social support ns 1.5
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Post-migration adaptation
• Recent arrival in SA - depression(OR 3.1)
- PTSD (OR 4.7)• Older age on arrival - depression (OR 5.6)
- anxiety (OR 5.3)• Family separation
since arrival - depression (OR 2.4)
- PTSD (OR 2.3)• Discrimination in SA - depression(OR 2.5)
- anxiety (OR 1.9)
- PTSD (OR 2.4)• Divorced - PTSD (OR 3.1)• Low income - PTSD (OR 2.2)
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Conclusions
• African refugees in SA are a vulnerable group• High levels of trauma exposure pre-migration• In SA they encounter major problems of poverty and
food insecurity, hostility, discrimination/xenophobia, and violence
• Half have anxiety & depression, and a quarter PTSD
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Major risk factors for mental health problems:
Pre-migration factors:
- previous traumatic experiences
- being forced to leave
Post-migration factors:
- food insecurity
- low income
- discrimination in host country
- lack of social support
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Take home messages
1. Trauma leads not only to PTSD, but also to other mental disorders
1. While pre-migration exposure to trauma is an important cause, post-migratory challenges and difficulties are also potent drivers of mental health problems in this vulnerable population
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Acknowledgements
Andrew Tomita
Charlotte Labys
Varsha Maharaj
Lindokuhle Thela
Mpho Mhlongo
Dennis Hurley Centre
South African Medical Research Council
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