Addressing Social Determinants to Reduce Refugee Mental Health Disparities

The goal of this study is to test an ecological/empowerment approach to reducing mental health disparities among socioeconomically disadvantaged Central African and Iraqi refugee adults by examining the effectiveness of a community-based advocacy, learning, and social support intervention (Refugee Well-being Project, RWP) that addresses social determinants of mental health and incorporates an evidence-based trauma treatment (Narrative Exposure Therapy, NET) for refugees with PTSD. The waitlist randomized controlled trial with 180 African and Iraqi refugee adults is innovative and significant because it will rigorously test the effectiveness of addressing social determinants of mental health (poverty, social and physical environments, access to services, marginalization) to reduce mental health disparities, as well as examine the impact of a community-based, mutual learning intervention on improving engagement and retention in evidence-based trauma-focused treatment for those who need it. The RWP intervention emphasizes a sustainable and replicable partnership model between refugee resettlement agencies and universities/colleges that involves refugee adults and undergraduate advocates working together to:

  1. Increase refugees' abilities to navigate their new communities
  2. Improve refugees' access to community resources
  3. Enhance meaningful social roles by valuing refugees' culture, experiences, and knowledge
  4. Reduce refugees' social isolation
  5. Increase communities' responsiveness to refugees.

The RWP intervention is administered by university undergraduate students enrolled in a service learning course, and has two elements:

  1. Learning Circles, which involve cultural exchange and one-on-one learning opportunities
  2. Advocacy, which involves collaborative efforts to mobilize community resources related to health, housing, employment, education, and legal issues.

Pilot testing of RWP demonstrated feasibility, appropriateness, acceptability, and preliminary evidence that the intervention decreased Hmong, Central African, and Iraqi participants' psychological distress and increased protective factors. A mixed methods strategy with data collected from each participant at four time points over a period of 14 months will be used to test the effectiveness of the 6- month intervention to reduce psychological distress (PTSD, depression, and culturally-specific distress), increase protective factors (access to resources, English proficiency, environmental mastery, mental health service use, and social support), and engage and retain refugee adults with PTSD in an evidence-based trauma treatment (NET). Mechanisms of intervention effectiveness will be explored by testing mediating relationships between protective factors and psychological distress. Qualitative components of interviews with refugee participants and paired qualitative interviews with refugees and undergraduates will explore participants' experiences in the intervention, inform interpretation of quantitative data, and investigate unexpected impacts.

Research Plan:

The objective of this study is to test the effectiveness of a community-based advocacy, learning, and social support intervention (RWP) that addresses social determinants of health and builds trust and connections with other mental health services to:

  1. Reduce mental health disparities (PTSD, depression, and other psychological distress) among low-income African and Iraqi refugee adults in the United States
  2. Engage and retain refugees in trauma-focused treatment, if needed. Using a universal preventive intervention framework, participants will be randomly assigned to receive either the RWP or brief psychoeducation on managing stress and trauma. Through an innovative, personalized design, participants in both groups who have clinically significant PTSD symptoms will also be offered the 6-session evidence-based Narrative Exposure Therapy (NET).1 By comparing engagement and retention in NET, as well as increases in protective factors (access to resources, English proficiency, environmental mastery, mental health service use, and social support), and reductions in mental health problems (PTSD, depression, and other symptoms of psychological distress) between the RWP and waitlist control groups, the role of strengths-based, empowerment interventions that address social determinants of health in reducing mental health disparities will be illuminated. We propose specific aims:

Aim 1. Test the effectiveness of RWP to reduce mental health problems and increase protective factors.

1.1 Adults who receive the RWP intervention will show lower psychological distress (PTSD, depression, and culturally-specific distress) as compared to adults in the psychoeducation control group.

1.2 Adult participants' protective factors (access to resources, English proficiency, environmental mastery, mental health service use, social support) will increase significantly over time as compared to adults in the psychoeducation control group.

Aim 2. Test the effectiveness of RWP to engage and retain refugee adults with clinically significant PTSD symptoms in an evidence-based trauma treatment (NET) and to improve NET outcomes

2.1 Participants with initial clinical levels of PTSD symptoms in the RWP group will have higher rates of engagement (agreement to participate in NET) and retention (dosage and completion rates for NET), as compared to refugees with initial clinical levels of PTSD symptoms in the psychoeducation control group.

2.2 Participants with initial clinical levels of PTSD symptoms, who are provided with RWP and NET, will show reduced levels

Aim 3. Assess of psychological distress, as compared to refugees with initial clinical levels of PTSD symptoms in the control group who are provided with psychoeducation and NET. mechanisms of intervention effectiveness

3.1 For all RWP participants, lower levels of psychological distress will be mediated by increased access to resources, English proficiency, environmental mastery, mental health service use, and social support. through examination of mediating pathways.

3.2 For adults who have initial clinical levels of PTSD symptoms, the effects of RWP with NET on distress will be mediated partially through the impact of improved social determinants of health and partially through the direct effect of NET in reducing PTSD symptoms, depression symptoms and other psychological distress.

This mixed methods study will employ a longitudinal randomized waitlist control group design with 4 data collection points over 14 months. Ninety Africans and 90 Iraqis will be randomly assigned to the RWP or a psychoeducation waitlist control group (WCG) in 3 waves in Years 1-3; the RWP will be offered to the WCG in Year 4 (all interested WCG participants will be accommodated), once data collection is completed. Quantitative interviews will be conducted pre-, mid-, and post-intervention, and 8 months after the end of the intervention, with equivalent time points for WCG. Qualitative data will be collected at the pre- and post- time points.

IN THE NEWS: 

Unique Course Turns Students into Advocates for Albuquerque Refugee Families -  UNM Newsroom, December 2015

REPORTS:

Progress report due in January 2015, Final report due in 2018. For more information, see the Refugee Well-being Project website.