A cross-sectional survey of the mental health needs of refugees and asylum seekers attending a refugee health clinic: a study protocol for using research to inform local service delivery

A cross-sectional survey of the mental health needs of refugees and asylum seekers attending a refugee health clinic: a study protocol for using research to inform local service delivery
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  STUDY PROTOCOL Open Access A cross-sectional survey of the mental healthneeds of refugees and asylum seekers attendinga refugee health clinic: a study protocol for usingresearch to inform local service delivery Frances Shawyer 1* , Joanne C Enticott 1,2 , Anne R Doherty 3 , Andrew A Block  4,5 , I-Hao Cheng 2 , Sayed Wahidi 2 and Graham N Meadows 1,3,6 Abstract Background:  Refugees and asylum seekers have high rates of risk factors for mental disorders. In recent years,Australia has experienced a rapid increase in asylum seeker arrivals, creating new challenges for services in areaswith high settlement numbers. This paper describes the design, including analytic framework, of a project set in arefugee health service in the state of Victoria, Australia, as part of their response to meeting the mental healthneeds of their burgeoning local population of refugees and asylum seekers. In order to assist service planning, theprimary aim of this study is to determine: 1) an overall estimate of the prevalence of psychiatric disorders; 2) thespecific prevalence of post-traumatic stress disorder 3) the perceived need and unmet need for mental healthtreatment. The secondary aim of the study is to establish matched risk ratios based on an Australian-born matchedcomparison group from the 2007 National Survey of Mental Health and Well-Being. Methods/Design:  A cross-sectional survey is used to estimate the prevalence of psychiatric disorders in refugeesand asylum seekers attending a local refugee health service. Measures include the Kessler Psychological DistressScale-10, the Post-Traumatic Stress Disorder-8, the General-practice User ’ s Perceived-need Inventory together withservice utilisation questions from the National Survey of Mental Health and Well-Being. Data collected from refugeesand asylum seekers ( n = 130) is matched to existing data from Australian-born residents drawn from the 2007National Survey of Mental Health and Well-Being ( n = 520) to produce estimates of the risk ratio. Discussion:  The paper describes a prototype for what is possible within regular services seeking to plan for anddeliver high quality mental health care to refugees and asylum seekers. A novel project output will be thedevelopment and dissemination of an epidemiological methodology to reliably compare mental health status in arelatively small target sample with a matched comparator group. Keywords:  Refugee, Asylum seeker, Trauma, Epidemiology, Surveys, Screening, Mental disorders, Affective disorders,Anxiety disorders, Posttraumatic stress disorder Background Displaced persons internationally The United Nations High Commissioner for Refugees(UNHCR) defines a refugee as a person who is outsideof their country of nationality due to a well-founded fearof persecution for reasons of race, religion, nationality,particular social group membership or political opinionand is unable or unwilling to avail themselves of theprotection of their country or return to it [1]. An asylumseeker is someone who is seeking protection outsidetheir country and who may or may not be a refugee [2].According to the UNHCR ’ s most recent report for 2013[3], 51.2 million people were forcibly displaced world-wide by the end of 2013, of which 16.7 million were ref-ugees and 1.2 million were asylum-seekers. Afghanistan * Correspondence: frances.shawyer@monash.edu 1 Department of Psychiatry, Monash University, Clayton, VIC 3800, AustraliaFull list of author information is available at the end of the article © 2014 Shawyer et al.; licensee BioMed Central. This is an Open Access article distributed under the terms of the CreativeCommons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the srcinal work is properly credited. The Creative Commons Public DomainDedication waiver (http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article,unless otherwise stated. Shawyer  et al. BMC Psychiatry   (2014) 14:1 DOI 10.1186/s12888-014-0356-y  was the leading country of srcin of refugees (2.56 million)with the Syrian Arab Republic second (2.47 million) andSomalia third (1.12 million). Migrants and refugees in Australia Australia has a very high population of immigrants,comprising 27% of the estimated resident population(ERP) (6 million) [4]. Refugees, however, comprise just0.8% of all immigrants [5]. While refugees make for only a small proportion of the ERP, Australia has experienceda significant increase in asylum-seeker arrivals over thepast few years creating new challenges in areas with highsettlement numbers. Arrivals by air have been risingsteadily since 2004 – 5, primarily the result of increasedlodgments by international students seeking protection[2]; arrivals by sea have risen more dramatically.In Australia, protection for refugees is offered throughthe Humanitarian program. The program includes anonshore component for people applying for protectionor asylum after arrival in Australia and an offshore re-settlement component for people in need of assistanceoverseas. In 2012 – 13 the number of places available wasset at 20,000 (9.5% of total immigration) including12,000 for offshore refugees and 8000 for onshore pro-tection and the Special Humanitarian Program (SHP),this latter being for people experiencing substantial dis-crimination in their home country who are proposed by an immediate family member already granted protectionin Australia [6]. Permanent Protection visas are forpeople who are already in Australia who apply for protec-tion (or asylum) and who are found to meet Australia ’ sprotection obligations under the Refugees Convention orthe complementary protection criteria [7]. In 2012 – 13,20,019 visas were granted including 60% Refugee visas,2.5% SHP visas and 37.5% Protection and other onshore visas [6]. The top two countries of birth of recipientsof visas granted offshore were Iraq (4064: 32.5%) andAfghanistan (2431: 19.4%): nearly half of visas grantedwere to people born in either of these two countries[6]. Onshore asylum applications have also risen substan-tially. In 2012 – 2013, 25,091 asylum seekers arrived by sea[8], an increase of over 300% on the previous year wherethere were 7983 boat arrivals [9]. As the demand foronshore places has increased over the past 5 years, therehas been a reciprocal decrease in the number of SHP visasbeing granted ([6], p. 23).This paper describes the design of a project conductedwithin a local Refugee Health Service in the state of Victoria as part of their response to meeting the mentalhealth needs of their burgeoning local population of refugees and asylum seekers. This Refugee Health Servicewas established in 2007 and includes a hospital-basedclinic and a community-based clinic. This service had aninitial focus on addressing physical health needs includingpaediatrics, infectious diseases and complex care. How-ever, in the context of other overstretched and inadequatelocal services [10], the Refugee Health Service has beenexpanding in order to also address the mental healthneeds of their clients. In order to target these finiteservices appropriately, it was important to ascertain thenature of their needs.It is well understood that the majority of refugeesarriving in Australia will have experienced traumaticevents such as human rights abuses, persecution, vio-lence, loss of identity and culture, and loss of family members [11]. Such experiences have a direct dose – re-sponse relationship to psychological symptoms both atindividual and family levels [12]. Post migration livingdifficulties contribute further to mental health symptom-atology [13]. Not surprisingly, the rate of long-term med-ical and psychological conditions is higher compared toother migrants while access to family and community sup-port is lower [14].From a local perspective, it seemed very evident toclinicians working in the clinics and in the community that refugees in this region often encounter serious men-tal health problems. However, only patchy informationwas available about the nature of these problems andlittle was known about the mental health needs of localrefugees from the perspective of the refugee clientsthemselves [10]. In order to address these critical gaps inknowledge, an independent university-based researchunit was commissioned to conduct a survey of the men-tal health needs of clients attending the Refugee HealthService. Aims of study The primary aim of this study is to survey clients attend-ing the community-based clinic within the Refugee HealthService in order to determine: 1. An overall estimate of the prevalence of psychiatricdisorders.2. The specific prevalence of post-traumatic stressdisorder (PTSD).3. The perceived need and unmet need for mentalhealth treatment. The secondary aim of the study is to compare theprevalence findings with an Australian-born matchedcomparison group from the 2007 National Survey of Mental Health and Well-Being (NSMHWB) in order toestablish matched risk ratios. The NSMHWB, funded by the Australian Federal Government, provides informa-tion on the prevalence of selected lifetime and 12-monthmental disorders based on a sample of around 8,800Australians aged between 16 and 85 years. We hypo-thesised that refugees and asylum-seekers attending the Shawyer  et al. BMC Psychiatry   (2014) 14:1 Page 2 of 11  clinic would show evidence of greater psychiatric morbid-ity relative to Australian-born residents. From a transla-tional research perspective an aim of the study also is topilot a suite of measures for screening use in this serviceand in the future, elsewhere. Hence the description of thestudy methods both describes the study as implementedin this setting and provides a practical description of how this set of methods could be replicated in another study and/or introduced into routine practice. Methods/Design Research design There are two main components to the study design.Firstly, a cross-sectional survey is used to estimate theprevalence of psychiatric disorders in the Refugee HealthService (community health site). Secondly, the survey data collected from refugees is matched to existing datadrawn from the 2007 NSMHWB. This matched com-parison enables the prevalence of psychiatric disordersto be compared between refugee and Australian-bornresidents by producing estimates of the risk ratio [15].The design for this study arose following extensiveconsultation with stakeholders and experts in the fieldand with ongoing dialogue with a steering committee setup to provide oversight to the project. The project wasfunded from within the budget of local services and assuch the design was constrained by a clear funding limit.This necessitated efficient collection of information. Whilethere was early consideration of using full diagnostic inter- views this was rejected on basis of the complexity andresource demands of the translation task, concern that theassociated burden on participants could compromiseresponse rates with associated likelihood of substantialsampling bias, and on grounds of funding constraints.Thus, the approach taken was rather one of using chosenscreening instruments or other short form instrumenta-tion and only those considered essential in relation tothe research questions. Hence, we included four brief instruments plus demographics. Our free access to theNSMHWB survey data for general research purposesthrough the Australian Bureau of Statistics enables us toextend the data further at no extra cost. Setting Monash Health, where the project is based, is the largestpublic health care provider in Victoria, providing servicesto the South-Eastern suburbs of Melbourne and coveringa population of over 750,000. The region includes themost culturally diverse municipality in Victoria and itcontains disproportionally high numbers of refugees andasylum-seekers. The area receives the largest percentageof newly arrived refugees in Victoria  –  nearly a quarter of all arrivals to metropolitan areas - and around 8% of thenation ’ s refugees each year [16]. Unemployment is notably higher than average in the refugee population and medianincome lower [17]. A report examining the primary healthcare needs of refugees in this region [10] found thatas of the 1 July 2010, there were around 19149 refugees inthe region, representing around 5% (1:20) of the totalpopulation. The age of arrival showed a trend toward younger age groups with 93% under the age of 45 yearsand 44% under the age of 18. During 2012, approximately 50 asylum seekers were settling into the region each week[18]. The Afghani population was the largest and fastestgrowing group in the region making up 43% of asylumseekers for the period September-December 2012 [18].The sole site for recruitment is the Refugee HealthService. The Refugee Health Service comprises two sites:a weekly hospital-based outpatient ’ s clinic and a clinicbased in a community health centre. The latter site wasadded in 2011 as demand for services grew. Recruitmenttakes place in the community health site. Participants Participants in the project are refugees or asylumseekers, aged between 18 – 85 years, and attending theRefugee Health Service (community health site) withinMonash Health. Based on clinic attendance rates, it wasexpected that participants would be primarily fromAfghanistan and Sri Lanka with a small number fromIran. Because measures are to be translated in advance,participants are required to be fluent in at least one of the major languages from these regions, including Dari/Dari-Hazaragi, Pashto, Persian/Farsi and Tamil, or English.To maximise comparability with patients at the refugeehealth clinic, the Australian-born sample extracted fromthe NSMHWB will be selected on the basis of demo-graphics including age, gender and health service utilisa-tion. The NSMHWB dataset is confidentialised to ensureanonymity. Measures Demographic data Demographic questions are important for understandingboth the experience of mental health problems and needfor care in the population surveyed. For example, timespent in refugee camps/detention centres [19] and separ-ation from key family members [20] are both factors thatmay contribute to the development of mental healthproblems. Understanding the education, literacy, family structure, entitlements, occupation and visa category of the population surveyed may be important for consider-ing how services are best delivered. Religious affiliationmay also be an important consideration for service deliv-ery, for example services seen as incompatible with reli-gious culture may be a barrier to accessing them [21,22].The demographic data collected include: age, gender,country of birth, ethic group, religious affiliation, month/ Shawyer  et al. BMC Psychiatry   (2014) 14:1 Page 3 of 11   year of arrival in Australia, time spent in refugee campsoverseas and detention centres in Australia, visa category,marital status, number of children, number of children athome and their ages, family separation, languages spokenincluding first language, literacy, education, occupation,eligibility for a healthcare card and access to Medicare(Australia ’ s publically funded universal healthcare system). Service utilisation General health services  General health service utilisa-tion is recorded by refugee participant answers (Yes/No)to three questions from the NSMHWB assessment: 1)  In the  past 12 months  , have you seen a general  practitioner for your own physical or mental health?  2)  In the  past 12 months  , have you been admitted overnight or longer in any hospital for a physical health problem?  3)  In the  past 12 months  , have you seen any kind of   specialist health care provider such as a specialist doctor, psychiatrist, psychologist, social worker or anyone else?  Mental health services Service utilisation with regard to mental health care willalso be captured using questions from the NSMHWBassessment, for example:  In the  past 12 months  , have you been admitted overnight or longer in any hospital for problems with your   mental health ? (that is, for things like stress,anxiety, depression or dependence on alcohol or drugs). Additional questions assess what kinds of mentalhealth care participants think might be of benefit to themin the future or have/have not been of benefit to them inthe past 12 months. For example:  In the  past 12 months  , are there any kinds of help for a mental health problem that you think would havebenefitted you but that you didn ’   t receive?   If yes  , What  sort of help would have benefitted you? Who would beinvolved in that?  Patterns of service use in the previous twelve monthsfor mental health problems can be categorised into threegroups: 1) requiring hospitalisation; 2) consulting a spe-cialist health care provider such as a specialist doctor,psychiatrist, psychologist, social worker; and 3) consultinga general practitioner only. Kessler-10 The Kessler Psychological Distress Scale (K10) [23] isa simple 10-item measure of psychological distress(particularly symptoms of anxiety and depression)based on a person ’ s emotional state during the 30 daysprior to the survey interview. It is a widely used screeninginstrument in Australia, having been included in severalstate-based health surveys along with the 1997 and 2007NSMHWB. It is also a familiar clinical tool used by GPs and other clinicians in Australia, being one of theoutcome measurement tools recommended by the De-partment of Health for use in relation to mental healthtreatment funded by Medicare.The K10 has a five-level response scale for each itemranging from 1:  “ none of the time ”  to 5:  “ all of the time ” .The K10 can be used to indicate level of distress or like-lihood of having a mental disorder. High scores indicatehigh levels of psychological distress or high likelihood of having a mental disorder. Different cut-off scores havebeen used depending on whether it is being used inclinical settings or in population surveys. The clinicalcut-off score for likelihood for having distress consistentwith a anxiety or depressive disorder is ≥ 20 with therange of scores for levels of severity being mild: 20 – 24;moderate: 25 – 29; and severe: 30 – 50 [24]. The bands ap-plied in the NSMHWB for likelihood of having a mentaldisorder included low (10 – 15), moderate (16 – 21), high(22 – 29) and very high (30 – 50). In the 2007 NSMHWB,79.6% of those with a score in the very high range had a12-month mental disorder (assessed using the WorldHealth Organization Composite International DiagnosticInterview) while only 10.9% of those in the low category had a 12-month mental disorder [25].Although the Hopkins Symptom Checklist-25 (HSCL-25)[26] has been commonly used to assess anxiety and depres-sive symptoms in refugee populations, the K10 was selectedin preference to the HSCL-25 in order to enable compari-sons with the matched Australian-born sample extractedfrom the 2007 NSMHWB. For the purposes of our survey,the K10 had three other advantages compared to theHSCL-25. Firstly, unlike the HSCL-25 which was developedas a clinical tool, the K10 was developed specifically as apopulation survey instrument and has valuable psychomet-ric properties in this regard. Secondly, the time frame of 30 days for the K10 rather than the 1 week for theHSCL-25 is a more suitable time frame for establishinga significant mental disorder. A Major Depressive Episodefor example, which is likely to be a prevalent mentaldisorder in this group [27], requires that symptomsbe present for at least 2 weeks. Thirdly, and more prag-matically, the K10 is considerably shorter than the HSCL-25, an important consideration in the design of this study.The K10 has been translated into many languages andis being used in a large number of World HealthOrganization (WHO) surveys worldwide [23]. Althoughits validity has not been established specifically in refu-gee populations, it has been validated across a number Shawyer  et al. BMC Psychiatry   (2014) 14:1 Page 4 of 11  of different cultural groups [28-32]. The K10 has alsobeen used in refugee populations in Australia [33-35]and has shown good reliability and ease of use in evenpre-literate participants in a sample of Afghan refugeesrecruited in Australia [35]. Traumatic events list and Post-Traumatic Stress Disorder-8(PTSD-8) The traumatic events list is a combined list based on the17 items in Part 1 of the srcinal Harvard Trauma Ques-tionnaire [HTQ - 26], which were derived from core war-related experiences of refugee (specifically Indochinese)populations, and the 11 items from the PTSD section of the Composite International Diagnostic Interview 2.1 [36],which were based on  Diagnostic and Statistical Manual of   Mental Disorders, 4  th  Edition  (DSM-IV) and  International Statistical Classification of Diseases and Related Health Problems 10  th  Edition  (ICD-10) definitions and criteria.Because there was overlap on 6 items, the total number of items on the traumatic events list is 22. Participants eitherread the list or have the list read to them and are asked toanswer simply yes or no as to whether they, or someoneclose to them such as a family member, have ever experi-enced or witnessed any of these events.The PTSD-8 [37] is an 8-item screening questionnairefor post-traumatic stress disorder. It was derived fromPart 4 of the HTQ [26], which is a longer measure of trauma symptoms specifically designed for use in refugeepopulations. The PTSD-8 has acceptable performancecompared to the HTQ [37]. It covers all three symptomclusters of the DSM-IV PTSD diagnosis, including fourintrusion items, two avoidance items and two hypervigi-lance items, but excludes the diagnostically non-specificdysphoria items (e.g., sleeping difficulty, difficulty concen-trating) since these overlap with depression and otheranxiety disorders. Participants are asked how much eachsymptom has bothered then a) since the trauma and, if  yes, b) in the past month. Items are answered on a fully-anchored 4-point scale ( “ not at all ” –  1;  “ a little ” –  2; “ quite a bit ” –  3;  “ extremely  ” –  4). Screening criteria forPTSD are met if there is at least one item in each symp-tom cluster with a score of  ≥ 3. General-practice Users ’    Perceived-need Inventory (GUPI) The GUPI is a very brief one-page instrument developedto assess participants ’  estimation of their needs for men-tal health care and the meeting of those needs. It hasacceptable reliability and validity [38]. Because the GUPIwas developed in the context of the Australian health-care system, an open-ended question was added to ex-plore alternative approaches to mental health care thatmay be more acceptable to people from other cultures.For example, Omeri et al. [21] noted in one Afghanrefugee sample that that people of this background weremore likely to emphasise the importance of spiritual andcommunity responses to trauma while mainstream mentalhealth services such as counselling may be viewed withdistrust. The additional question is:  Acceptability of interview  At the end of the interview, participants are asked torate how acceptable they found the interview on afully-anchored 7-point scale ranging from 1 = totally unacceptable to 7 = perfectly acceptable. Referral activation form A potentially important part of the assessment of mentalhealth need is to not only collect information about indi-cated and expressed need for care but to also track whatparticipants then do about that. Following consultationwith senior staff at the Refugee Health Service a form wasdeveloped to record participants ’  response to feedback fromthe survey regarding their mental health status: in particu-lar, whether they wished to access professional assistance.Although considered unlikely, any need for emergency careassociated with the interview is also recorded on the form. Case file review form Another locally developed form was devised to collectinformation about mental health diagnosis and treat-ment of participants from their medical records. We cancompare this information with the survey data in orderto a) obtain possible validity data for the instruments andb) assess to what extent the mental health needs of clientsare being met currently. Translation and field testing Because a large number of different interpreters are ex-pected to be utilised in the project, the measures admin-istered to participants were professionally translated intoDari, Pashto, Farsi and Tamil to support the consistency of interpreting across participants. While comprehensivecross-cultural validation of the translated instrumentswas beyond the scope of the study, the measures wereback-translated then reviewed and field tested by cul-tural advisors appointed to the project. The culturaladvisors, both refugees themselves, had good knowledgeof mental health terminology. They included an Afghani Shawyer  et al. BMC Psychiatry   (2014) 14:1 Page 5 of 11
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