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Abstract

The Refugee Access Service (RAS) is a triage, assessment and referral service established in Melbourne, Australia to ensure timely and appropriate mental health support for young refugees. This qualitative study sought to explore the experiences of young people aged 12–25 years, and their families, newly arrived from Iraq and Syria, who had contact with the RAS, for the purposes of further programme development. Semi-structured interviews were conducted with participants, either individually or in family groups. Thematic analysis was used to identify themes. Four key themes were identified. These were that mental health help-seeking of newly arrived young people and families is influenced by cultural norms; that trauma, grief and loss influence mental health service needs; that settlement challenges influence mental health service needs; and that the cultural responsiveness of mental health care is important to young people and families. Results highlight ways in which this service, and similar models, can improve to better meet the needs of young refugees and their families. Services should be developed in partnership with the wider operating environment. This will improve providers’ understanding of communities they serve. It will also promote pathways between, and collaboration with, different types of services.

Keywords

adolescent caregivers mental health needs assessment refugees young adult

Introduction

The negative mental health impacts of refugee experiences are well documented (Porter & Haslam, 2005; Steel et al., 2009). Children exposed to violence are particularly vulnerable to poor mental health outcomes, including worsening of existing mental disorders; adverse outcomes of trauma and loss; and adjustment problems (Hassan et al., 2016). Exposure to trauma can continue to significantly impact the mental health of resettled children and young people directly (Barghadouch et al., 2016; Ziaian et al., 2012) or indirectly, via caregivers (Bryant et al., 2021; Javanbakht et al., 2018). The prevalence of emotional distress is high in refugees from Iraq and Syria, where exposure to multiple traumatic events is common (Hassan et al., 2016; Willard et al., 2013). Yet despite high prevalence of distress and vulnerability, mental health service utilization by young people with a refugee background has consistently been found to be lower than their age peers (Barghadouch et al., 2016; Colucci et al., 2014; Ziaian et al., 2012). There are few longitudinal studies examining the impact of psychiatric symptoms on newly arrived young people as they grow into adulthood (Frounfelker et al., 2020). However, given the apparent relationship between delayed treatment and poorer symptomatic and functional outcomes (Ghio et al., 2014; Harris et al., 2005), the treatment gap between refugee and locally born young people is a health equity issue deserving of consideration.

In 2015, the Australian government announced a one-off increase of 12,000 humanitarian refugee resettlement programme places for those displaced by conflicts in Iraq and Syria. In addition, the Victorian government committed to providing an additional 4,000 places to people who were fleeing Iraq and Syria (Department of Health and Human Services [DHHS], 2016). It was anticipated that 50% of these refugees would be children, and likely to settle in established Iraqi and Syrian communities in the northern and western metropolitan suburbs of Melbourne (DHHS, 2016).

The Better Access to Mental Health Care for Syrian and Iraqi Refugees initiative aimed to address the anticipated support needs of these newly arrived families (DHHS, 2016). The initiative consisted of programme components contracted across different organizations including a clinical mental health triage and assessment service for young people (hereafter referred to as “young people”), known as the Refugee Access Service (RAS).

Established in 2017, RAS is based in Orygen, a publicly funded specialist youth mental health service. RAS was designed to work in close partnership with universal and specialist services working with newly arrived refugees. RAS operates as an entry point to the wider mental health system, incorporating the continuum of primary and specialist mental health services, and specialist trauma counselling services. Mental health professionals were recruited to provide outreach triage and assessment services to refugee young people aged 0–25 years. Young people referred to the RAS are generally seen in-person, at the family home, school or service setting familiar to them, and engaged over several sessions to identify the best plan to meet their needs. Family work, secondary consultation and/or support is offered to the child or young person's existing informal and formal supports. Where appropriate, referrals are made for further mental health care.

As with any new service, evaluation activities were necessary to ensure RAS’s implementation met service aims. Substantive impact evaluation was not practical, but implementation evaluation was both possible and desirable. Consequently, the aim of this study was to explore the implementation of RAS from the perspectives of the young Iraqi and Syrian refugees and their families who used the service.

Methods

A qualitative approach was deemed most likely to elicit rich information about the experiences of service users, and thus enable identification of specific service improvements. This study has been reported in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines (Tong et al., 2007).

Research team

All members of the research team were mental health clinicians based at the Psychosocial Research Centre, the University of Melbourne. Discipline backgrounds of the team included psychiatry, social work and occupational therapy, and together represented decades of work and research in mental health. Expert consultation (steering group and community reference groups), recruitment, data collection and analysis of the data, and report writing were conducted by AK and LM. AK and LM are mental health clinicians with experience working in specialist mental health services for young people and families, including working with those with trauma and refugee experiences. CH and CM were supervisors to the project. KM developed the evaluation protocol.

No members of the research team were from Iraq or Syria. Several steps were taken to attend to known limitations in cross-cultural research (Hennink, 2008). AK and LM engaged in formal training regarding the safe and effective use of interpreters, and culturally responsive mental health care. With KM, both attended a community reference group meeting with Iraqi and Syrian communities—including Chaldean, Assyrian, Kurdish and Arab; Muslim (both Sunni and Shi’a) and Christian community members—to seek their advice regarding the approach to interview, and cultural safety. This occurred prior to interviews commencing. Interviewers accessed further consultation from two bicultural workers, themselves refugees from Iraq with experience in working with both Iraqi and Syrian refugees.

Community engagement

The evaluation design was shaped by a steering group consisting of membership from specialist mental health services, specialist trauma counselling services, and primary care providers. In addition, two community reference groups—one comprised of members of the Iraqi and Syrian communities and one comprised of young people aged 16–25 years with multiple country-of-origin refugee backgrounds—were each involved in development of the interview guide and recruitment strategy.

The Iraqi and Syrian communities reference group recommended interviewers meet with families in their homes, where possible, to increase participants’ sense of comfort with the process. The youth reference group recommended provisions for young people aged over 18 to be interviewed independently of their family, irrespective of family norms. Both groups advocated that, irrespective of literacy, all plain language statements and consent information should be translated into community languages to demonstrate the research team's commitment to cultural responsiveness. Members of the reference groups also made recommendations regarding wording of items in the interview schedule and demographic questionnaire, and some preferred translations for key terms were identified.

Sampling and recruitment

Sampling was purposive, employing a sampling frame that aimed to ensure representation of young people from the major ethnic groups of the Iraqi and Syrian refugee communities. A register of people who had used the RAS between November 2017 and March 2019 was consulted, and all who were registered as having been born in either Iraq or Syria were considered eligible for inclusion. Young people or caregivers were excluded if the RAS team identified that their psychosocial circumstances would significantly interfere with, or make burdensome, their participation in an interview.

Initial contact with eligible participants was then made by telephone, by RAS staff, to seek initial consent to be contacted by project team members. AK and LM then contacted potential participants by phone, using interpreters as advised by RAS staff. One young person was unable to be contacted. Three young people and two families declined to participate in the project when contacted by researchers. Reasons for not wishing to participate—when provided—included acute distress of the young person. In these instances, with permission from young people or their families, researchers notified RAS staff for their follow-up engagement.

Consent

Written, informed consent was obtained prior to commencement of the research interview. Following a discussion regarding the purpose of the research, young people and/or their caregivers were given the opportunity to decline further contact or arrangements were made for a face-to-face meeting. Caregivers of service users under the age of 18 provided consent for their young person's participation, following which the child's own consent was also sought. Young people over the age of 18 years were contacted directly for consent. Translated consent forms were provided in participants’ language of choice (Arabic, Aramaic, Assyrian or English) and consent was sought via an interpreter. One participant withdrew after this discussion because of concerns about their responses being recorded (in either audio or written form). No participants withdrew consent.

Data collection

Qualitative data was sought using in-depth interviews with participants using a semi-structured interview schedule (Supplement 1, available online). Interviews occurred between April and July 2019. Participants’ preferences for time and location of interview, and for the language, ethnicity and gender of interpreter were accommodated. Young people were given the option to be interviewed alone or with family members, for all or part of the interview. Interviews ranged between 45 and 75 minutes in duration. No repeat interviews were conducted. A $50AUD gift voucher was provided for each participant in acknowledgement of their time and effort, with a maximum of two vouchers where multiple family members were interviewed together. Interviews were audio-recorded and transcribed by a professional transcription service. Transcripts were not returned to participants.

Data analysis

Thematic analysis was conducted by AK and LM using the method described by Braun and Clarke (2006). Interview transcripts were checked for accuracy and inductively coded by the applicable interviewer, using NVivo 12 (AK) and Microsoft Excel (LM) software. Two interviews were coded by a second interviewer to give a sense of their content with reference to other interviews analysed. Throughout the data analysis, AK and LM met to discuss consistent and divergent codes across interviews and potential themes identified. Between interviews 10 and 13, no new themes were identified. Field notes, recorded during the process of data collection, helped shape the identification of overarching themes across interviews (Phillippi & Lauderdale, 2018). Preliminary anonymized data analysis was shared with bicultural workers and with the project steering group for refinement. Both groups endorsed the broad themes identified by researchers. Each group shared additional information that informed further refinement and interpretation of data.

Ethical considerations

The project received ethical approval from the Melbourne Health Human Research Ethics Committee (approval no. 2018.233).

Findings

Thirteen interviews were conducted, involving 21 participants. Five interviews occurred with the young person alone, and six occurred with young people accompanied by one or more family members. Two further interviews were conducted with parents alone. Most interviews involved an interpreter (n = 10).

Overall, the interviews represented the experiences of young people aged between 15 and 24 years at the time of interview, and their families. Seven young people were female, and six were male. Eight young people had arrived in Australia who were originally from Iraq and five from Syria. All but one young person had arrived in Australia in the previous five years at time of interview. Chaldean, Assyrian and Arab ethnicities were represented in participants from both countries of origin. The ethnicity of participants was one lens considered during analysis. Quote attributions include interview number (denoted by #), role if a quote from a parent, gender (F or M of young person) and age group (<18 years or ≥18 years) of the young person, and country-of-origin to reduce the risk of identifying participants from small ethnic communities.

For all families participating, their encounters with the RAS were their first encounters with mental health services. Young people and their families described a range of reasons that they had contact with the RAS: changes in sleep and appetite; tiredness; difficulty concentrating; racing thoughts; and reduced interest and pleasure in activities. Several young participants reported they had had thoughts of ending their lives. Others described difficulties with managing emotions such as anger, or feeling overwhelmed.

Researchers identified four key themes relating to the research aims: help-seeking is influenced by cultural norms; mental health needs are shaped by trauma, grief and loss; settlement experiences shape mental health needs; and the cultural responsiveness of mental health care. Description of these themes forms the rest of this article.

Help-seeking is influenced by cultural norms

Young people and families described how their initial involvement with the RAS was shaped by prior expectations or beliefs about mental health care. Among other factors, intentions to seek help were shaped by cultural and religious beliefs related to distress and pathways to healing, family reputation and honour, and experiences of resource availability in countries of birth.

Some participants described their perceptions of Iraqi and Syrian cultural attitudes to help-seeking from professionals.

Because in my country—actually, the people who go to the psychologist or the psychiatrist, they had to be in very, very, very hard situations. So, you will be—if you go and the people don’t feel that you are a mental health person—they will say you are a crazy person or something … Our culture is very different, and our people cannot accept something new very easily. It's very sad for the person who is going to that psychologist, and how the culture or the public is treating him. (#8, F, ≥18 years, Iraq)

Young people refuted singular ideas about culture or cultural norms, and instead described navigating layered socio-political contexts, while living within communities with diverse ethnicities, languages and religions. They noted, however, that the cultural beliefs and practices of other family members continued to be pertinent to their lives and well-being.

I’m Christian Chaldean, she's Muslim … when I told her [mother] the truth that I had a Muslim girlfriend she said, you better forget that. (#1, M, <18 years, Iraq)

For young people, family honour and prohibitions might explicitly influence help-seeking intentions, or capacity to engage with the help available.

We have that negative perspective of psychiatric in general. We were very covert about this, yes, this thing has been, let's say, kept secret within the family members so that it won’t get out, it won’t get bigger. (#3, Mother, M, <18 years, Syria)

I felt sometimes I was embarrassing my parents. [I] feel very sad because some people are saying something to me, “Oh, why are you going to the psychologist? You don’t have anything to go to the psychologist. It was very hard actually. (#8, F, ≥18 years, Iraq)

Trauma, grief and loss influence mental health service needs

Political and interpersonal violence, displacement and deprivation prior to, and during, their journey to Australia permeated participants’ interviews.

When my mum had me, Iraq was under siege, when Saddam was in power. We didn’t have enough food; I wasn’t provided with any toys or activities to do. (#4, M, ≥18 years, Iraq)

My old town. My dead town (#1, M, <18 years, Syria)

Some participants explicitly linked their experiences of forced migration with experiences of current distress:

I get very nervous quickly. When we got kicked out from Iraq because of Daesh I had a mental disturbance, mental state. At Jordan it got worse. (#4, M, >18 years, Iraq)

For some participants, these experiences impeded engagement with mental health care:

Even like my wife, she's not feeling well, as well. Now that she—any appointment that [my children] have, she just runs away. She doesn’t like [seeing visitors]. Even today she just went away to not be involved. (#7, Father, M, ≥18 years, Syria)

Overall, participants highlighted the importance of trusting, consistent and collaborative relationships with service providers if they were to have positive experiences of service engagement. The significant and complex nature of the kinds of traumatic events young people and their families had experienced led some participants to reflect that there is a need for practitioners to be skilled in working with people affected by trauma.

If you’re from Iraq or Syria, both countries have experienced war and, to be honest, I’ve experienced both wars. I think that really made me needy to get a very comfortable life. Not trusting anyone. I think people who come from these places just need somebody who's really brilliant to help them in any way possible (#12, F, ≥18 years, Iraq)

Young people described the difficulty of repeatedly speaking about difficult experiences and with different people while trying to access mental health care:

It's hard once you talk to somebody about yourself for a while and then they have to change to someone else and then start all over again telling the same thing. It is difficult. (#13, F, <18 years, Syria)

Some participants described some (common) service constraints that they did not like such as frequency of appointments, length of appointments and short duration of service involvement.

So, like, if they could make more appointments. The person that is getting the help, [it's only] every two weeks and it was, like, every month. Kind of. It's a bit long time for him to control himself and not get backwards in that two weeks. So, it's a bit annoying for him to wait so he's having anger he can’t control it and he has to wait. (#1, M, <18 years, Iraq)

Where relationships were longer-term with RAS, the sense of continuity and collaboration allowed for the building of a relationship that was experienced as reliable and helpful:

You feel like there's someone there for you, standing by you to help. Yes, and we felt since then, we are better, every day getting better and better. (#2, Father, M, ≥18 years, Syria)

Settlement challenges shape mental health service needs

Families described that, at the time of referral to RAS, they were dealing with a range of stressors including financial hardship, inappropriate housing, unemployment, physical ill health, disability, and family violence. As well as influencing resources available to engage with mental health care, young people and their families reflected on how resettlement challenges influenced individual and family distress. Some participants reported social isolation uncharacteristic of their age peers.

… he doesn’t have any friends here or like a girlfriend that he can go out with or speak to someone. That's why he doesn’t know where to go (#7, Father, M, ≥18 years, Syria)

I go home, I [eat], I finish my study, and then that's it (#8, F, ≥18 years, Iraq)

Families had typically made efforts to respond to distress.

What we tried is, tried to go out, go to parks, tried to do things to get his mind off what happened and what he's seen, what they’ve seen. (#2, Mother, M, ≥18 years, Syria)

I used to try to take her out just to change the atmosphere, do things with her, talk to her, just to make her feel better. (#13, Father, F, <18 years, Syria)

Individuals and families appeared to have normative expectations of themselves and settlement. Being unable to meet these expectations shaped some individual's sense of competence.

One day I was like just crying … at the school because I didn’t understand anything from the class. I was seeing my friends are understanding, they can answer, but I can’t. I was feeling the problem is with me. So, I went home, I said to my father that's it, I don’t want to complete it (#9, F, ≥18 years, Iraq)

Families and young people often looked to the formal service system for support. When RAS worked in concert with settlement services and educational settings to address settlement challenges and psychosocial stressors, this was experienced as helpful:

I felt that there was some sort of chain support, like each is putting something or chipping in to and if like that chain support is for a purpose to complete the help he needs. (#2, Mother, M, <18 years, Syria)

When mental health care included similar practical strategies, this could be experienced as helpful, particularly when young people were provided with support to persist.

So, they were recommending that I just do some exercise, and maybe just walk, listen to music, do something that I love and like. I found it difficult to just going with it—at the first time it wasn’t very useful. But it's—as I’m going, it's become useful. (#1, F, ≥18 years, Iraq)

For young people and their families, efforts to reduce distress could be constrained by settlement demands. For example, one family did not have the disposable income for music lessons, despite strongly believing this would help to bring their child pleasure and alleviate her distress. Young people and families alike felt that, if practical challenges of settlement could not be addressed, mental health was unlikely to improve.

My situation will only be better if I can find a job. If I can work, I’ll feel much more mentally calm and happier. (#4, M, ≥18 years, Iraq)

If they had more help options, like helping her to find a job or, like, at school with her subjects. Those things might help as well. (#6, Mother, F, <18 years, Iraq).

Cultural responsiveness in mental health care

Through their experiences of accessing mental health services in Australia, participants described awareness of their own cultural norms, and also the cultural norms of the health professionals with whom they had contact. One participant described an experience of coming into contact with ideals of individualism in healthcare decision-making that conflicted with her family's collectivist decision-making:

If I don’t let my father know, I feel like I’m doing something wrong. So as maybe a way that we grow up with, it is very important to get the approval of our families… But here in Australia, no, maybe if he is 18 … he can just … make his decisions alone. But I don’t feel that I would, even if I am 40. (#8, F, ≥18 years, Iraq)

Participants highlighted the importance of practitioners taking time to understand and navigate cultural differences:

Maybe just the understanding … that our culture is very different, and [our people] cannot accept something [new] very easily. Just time to deal with that. (#8, F, ≥18 years, Iraq)

The provision of outreach was seen as a valuable service component.

I find it really helpful that they actually come to the school because, to be honest, when I went to [clinic-based youth mental health service] it felt really strange … It's like you’re coming to get assessed mentally. I didn’t like that so, as I said, when they come to, actually, a safe place, which is here, it's really comfortable. (#12, F, ≥18 years, Iraq)

Families were open to negotiating new ways of communicating with one another, and with health professionals.

She used to tell [RAS worker] some things that she wasn’t telling [me]. That way [I] could take care of her. At one point she was thinking suicide but she didn’t tell [me]. But [RAS worker] told [me] and that was helpful for [me] to help [her]. (#6, Mother, F, <18 years, Iraq)

… in those sessions [the RAS worker] sat with us and she sat with him, by themselves, then she sat with us as a whole family, and I was very surprised that he talked that much. (#3, Mother, M, <18 years, Syria).

Discussion

Participants in this service evaluation described experiences of accessing a service designed to improve access to mental health care for newly arrived refugees. A growing body of research explores the impact of therapeutic interventions on newly arrived refugee young people in high-income settings (Uphoff et al., 2022), but we have been unable to identify programmes that examine the experiences of referral and engagement. These are equally vital to consider in making sense of any mental health treatment gap. Participants’ descriptions of their experience of service provide valuable contributions to further service development.

Help-seeking is influenced by cultural norms

Participants in this study highlighted the influence of cultural differences on their mental health help-seeking. The availability of specific mental health professions in their country of birth, beliefs about family honour and anxieties about “burdening” other family members all shaped young people's help-seeking intentions. Differences in patterns of help-seeking from Australian-born peers have been found in research with other culturally and linguistically diverse communities (Rickwood et al., 2005). Valibhoy et al. (2017) found stigma associated with mental health service use, high thresholds for help-seeking, and preference for self-reliance or other forms of assistance prevented young people from refugee backgrounds from seeking help. A recent study of Afghani refugees in Australia found help-seeking for mental health difficulties was positively associated with self-recognition of signs of mental ill health and functional impairment (Slewa-Younan et al., 2017): this suggests the value of targeted population-based education programmes. A community mental health literacy project for Iraqi and Syrian communities was funded concurrently to RAS, serving the same geographic area. Iterative relationships between the two programmes have enabled the continuing evolution of a more culturally resonant model of service delivery for RAS, with less emphasis on the specific professionals involved (“psychiatrist”, “psychologist”) and more emphasis on recognition of, and responses to distress.

Participants’ descriptions of accessing mental health support suggest some common phenomena related to cultural constructs and norms. Most prominent among these were: shame associated with professional help-seeking; and deference to those in positions of authority, such as parents and health professionals. Some participants explicitly referred to conflict between their own values and norms, and individualistic approaches to mental health care practiced in Australia. As “persons of authority” (Hassan et al., 2016), healthcare providers should be particularly conscious of power and its salience in relation to young people's culture and trauma histories. These findings underline the importance of mental health professionals having some knowledge of dominant cultural and religious understandings of mental health, well-being, and appropriate responses in countries of origin. Mental health professionals must find ways to sensitively navigate intergenerational taboos and prohibitions.

Although young people and caregivers often shifted in their feelings of shame associated with experiencing mental health challenges following contact with the RAS, it was evident that they still feared disclosure to extended family or other members of their ethnic communities. Translated and Easy English information about privacy and confidentiality may be an important programme component.

Trauma, grief and loss influence mental health service needs

Participants in this research highlighted a relationship between their current distress, and their experience of traumas prior to and during migration. This reflects findings from epidemiological studies of refugee mental health (Steel et al., 2009). Refugees’ experiences of engaging in mental health assessment will be shaped by their experiences of trauma. Pathways to support that required young people to repeatedly “tell their story” felt unsafe. Early and transparent communication about the service model with children, young people and families, and collaborative decision-making with respect to frequency, duration and content of engagement, may further improve the acceptability of the existing RAS model. Further, new service models should adopt principles of trauma-informed care described in the general literature, such as collaboration and mutuality; trustworthiness and transparency; empowerment, choice and control (Sweeney et al., 2018).

In addition to trauma, when sharing their stories, participants also often described grief and loss, which are increasingly represented in Australian and international literature (Bryant et al., 2021; Killikelly et al., 2018). Recognizing and responding to grief is an important skill for mental health professionals working with refugees. For practitioners working with newly arrived refugees, access to evidence-based approaches to identifying and responding to grief may be as pertinent.

Settlement challenges shape mental health service needs

Families interviewed here described how unemployment and financial constraints impacted family well-being, and limited their access to resources that they felt would improve their child’s well-being. Families and young people alike noted that perceived educational and vocational underachievement, and social isolation, could perpetuate young people's distress. As described throughout the Australian literature (Lau et al., 2018; O’Donnell et al., 2020), settlement experiences profoundly shape mental health and well-being.

Mobilizing supports that enabled families to support young people to use pre-existing coping resources, or to develop new coping resources, was perceived as vital by participants in this research. Multiple services working together led to some families feeling that they had a safety net supporting them. Australian and international research with refugees highlights the benefits of cross-agency collaboration and coordination to support timely access to mental health care, as well as comprehensive psychosocial supports that are likely to lead to better mental health outcomes (Fazel, 2018; Sweeney et al., 2018; Valibhoy et al., 2017). Our findings echo this, and support the RAS approach to working in close cooperation with other service providers, to meet family's settlement needs.

Cultural responsiveness in mental health care

Young people and families in this study spoke in nuanced ways about cultural identities, including such aspects as ethnic and faith membership, country of birth and family identities. The construct of acculturation was not specifically identified by interviewers, but young people described their cultures in ways that acknowledged dynamism and hybridity. These findings underline the importance of mental health professionals embracing cultural curiosity (Dyche & Zayas, 1995) and cultural humility (Tervalon & Murray-Garcia, 1998). Standardized guides such as the DSM-5 Cultural Formulation Interview may support conversations about culture between providers and service users, however, these should be used with clinician discretion, as they have the potential to interfere with rapport (Lindberg et al., 2018). In addition to formal tools, formal and informal opportunities to reflect with workers from refugee or relevant cultural backgrounds should be considered, for the purposes of promoting culturally responsive practice (Kirmayer et al., 2003).

Limitations

This service evaluation focused on the experiences of refugees from Iraq and Syria, newly arrived between 2012 and 2018, and may not reflect the experiences of other refugee communities, or those arriving at other time points. Despite our best efforts, we were unable to engage children under 14 and their families in this service evaluation. This may speak to both problems in the design of the project, as well as particular barriers to engagement that we have been unable to explore here.

We made attempts to overcome cultural and language barriers through consultation with bicultural workers, use of field notes and the engagement of professional interpreters. Nevertheless, the cultural differences between researchers and participants, and filtering of interview responses via an interpreter will have shaped the narrative and analysis.

Although religious identity is collected at client registration in our mental health service, we omitted to ask participants about their religious identity during this research. The absence of this information means that we may have missed important opportunities to consider how faith shapes people's experiences of mental health care.

Participants did not explicitly describe experiences of racism or discrimination and how this may have impacted resettlement, mental health, and service access. Other research does highlight this (Ziersch et al., 2020), and we think it likely a consequence of the research design that such experiences were not elicited here, rather than that they were not present. The use of white, female, English-speaking, Australian-born researchers, and lack of direct enquiry may be barriers that can be rectified in future research.

Use of bilingual researchers may be of assistance in future research, if provisions are made to overcome participant fears about risk of community stigma. Despite these limitations, agreement between the themes identified and those of previous research gives us confidence in the trustworthiness of our findings.

Recommendations for future programme development

Mental health services need to forge strong relationships with settlement services to facilitate earlier and more effective mental health support for young refugees.

Clear information about rights and privacy should routinely be made available in a range of community languages, and through interpreters.

Mental health assessment and treatment should consider and address the impacts of trauma and grief.

Mental health services should be aware of the practical settlement challenges faced by each family and seek to address these.

Mental health practitioners should have opportunities for reflective practice, and consultation with people from the cultures that their programmes aim to serve.

Pathways facilitating access to mental health services need to be complemented by mental health promotion initiatives to prevent the need for specialist mental health support, where possible.

Conclusion

Through qualitative interviews, young people and families who had used a specialist refugee triage and assessment service were engaged in evaluating the service implementation. Young refugees experiencing mental health problems require flexible supports that address barriers to their access to mental health care and participation in social and economic life, to reduce risk factors for mental ill health over time. Key themes in their conversations suggest the importance of strong interagency partnerships to meet families’ needs. Further, these partnerships provide mental health professionals with invaluable opportunities to develop their understanding of cultural attitudes to mental health and help-seeking, and adjust their practice accordingly. Specialist mental health teams such as RAS are a small but important piece in a wider programme of social justice and service reform to address the drivers of mental health challenges and improve the accessibility of mental health services for this population.

Supplemental Material

sj-docx-1-tps-10.1177_13634615241296970 - Supplemental material for Experiences of resettled Iraqi and Syrian refugee young people and families with a mental health triage and assessment service

Supplemental material, sj-docx-1-tps-10.1177_13634615241296970 for Experiences of resettled Iraqi and Syrian refugee young people and families with a mental health triage and assessment service by Alicia J. King, Katherine Monson, Christine Migliorini, Lenice Murray and Carol Harvey in Transcultural Psychiatry

Footnotes

Author note

Alicia J. King is also affiliated with the School of Translational Medicine, Monash University.

Acknowledgements

The authors would like to thank the members of the Iraqi and Syrian communities reference group and youth reference group, and bicultural workers of Foundation House, for their invaluable guidance in the design and conduct of the study. This research was funded by the Victorian Government Department of Health through the The Better Access to Mental Health Care for Syrian and Iraqi Refugees initiative. The Refugee Access Service is funded by the Victorian Government Department of Health. The authors have no conflicts of interest to declare.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Department of Health, State Government of Victoria.

ORCID iD

Alicia J. King

Supplemental material

Supplemental material for this article is available online.

Alicia King, BOccThy MIntlComDev PhD, is a research fellow in the School of Translational Medicine at Monash University. Dr King researches the experiences and perspectives of users of novel healthcare services and interventions. She is currently the Co-Principal Investigator of the STARTOnline and Stepping Forward studies at Melbourne Sexual Health Centre. Her published works focus on the accessibility and acceptability of healthcare services to a wide range of potential users and lived experience as a resource for healthcare design and development.

Katherine Monson, BA/BSW, MPH, MClinFamTh, is the Coordinator of Community Development at Orygen specialist programme, Royal Melbourne Hospital, Melbourne, Australia. Ms Monson works primarily in direct practice. Her direct work and research focus on mental health service innovations that improve equity of access to mental health care.

Christine Migliorini is an academic social worker with additional degrees majoring in psychology, health promotion, public health and social epidemiology. Dr Migliorini’s research over the past two decades has focused on the nexus between mental health and the social environment, as experienced by individuals, families and friends, paid and unpaid carers, and various population groups. Christine has also a particular interest in mentoring/supporting allied health clinicians in their research-related activities. Christine is well-published in many national and international peer-reviewed journals, presented in many national and international conferences and has been a valued reviewer for several international peer-reviewed journals.

Lenice Murray, BA/BSW (Hons) MPH, is an accredited mental health social worker who works in private practice in Melbourne, Australia. She has worked as a research assistant and evaluator on mental health services research projects with the University of Melbourne's Psychosocial Research Centre, as well as in a private consultant capacity in the community mental health sector in Australia. She has an interest in implementation, programme design, service development and intervention approaches with a focus on increasing the responsiveness and efficacy of services and professionals working with at risk populations and trauma presentations.

Carol Harvey is an honorary professor in the Department of Psychiatry, University of Melbourne. She was formerly a consultant psychiatrist in the North West Area Mental Health Service, Northern Health, in Melbourne. Carol is involved in research, policy work, and professional and service development concerning psychosocial approaches to prevention, treatment and recovery from mental illness. She is Treasurer of the Board of the Australian branch of the World Association for Psychosocial Rehabilitation and is on the bi-national committee of the RANZCP Section of Social, Cultural and Rehabilitation Psychiatry.

References

Barghadouch

Kristiansen

Jervelund

S. S.

Hjern

Montgomery

Norredam

(2016). Refugee children have fewer contacts to psychiatric healthcare services: An analysis of a subset of refugee children compared to Danish-born peers. Social Psychiatry and Psychiatric Epidemiology, 51(8), 1125–1136. https://doi.org/10.1007/s00127-016-1260-1

Braun

Clarke

(2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77–101. https://doi.org/10.1191/1478088706qp063oa

Bryant

R. A.

Edwards

Creamer

O’Donnell

Forbes

Felmingham

K. L.

Silove

Steel

McFarlane

A. C.

Van Hooff

Nickerson

Hadzi-Pavlovic

(2021). Prolonged grief in refugees, parenting behaviour and children’s mental health. Australian & New Zealand Journal of Psychiatry, 55(9), 863–873. https://doi.org/10.1177/0004867420967420

Colucci

Szwarc

Minas

Paxton

Guerra

(2014). The utilisation of mental health services by young people from a refugee background: A systematic literature review. International Journal of Culture and Mental Health, 7(1), 86–108. https://doi.org/10.1080/17542863.2012.713371

Dyche

Zayas

L. H.

(1995). The value of curiosity and naivete for the cross-cultural psychotherapist. Family Process, 34(4), 389–399. https://doi.org/10.1111/j.1545-5300.1995.00389.x

Fazel

(2018). Refugees and the post-migration environment. (Report). BMC Medicine, 16(1). https://doi.org/10.1186/s12916-018-1155-y

Frounfelker

R. L.

Miconi

Farrar

Brooks

M. A.

Rousseau

Betancourt

T. S.

(2020). Mental health of refugee children and youth: Epidemiology, interventions, and future directions. Annual Review of Public Health, 41(1), 159–176. https://doi.org/10.1146/annurev-publhealth-040119-094230

Ghio

Gotelli

Marcenaro

Amore

Natta

(2014). Duration of untreated illness and outcomes in unipolar depression: A systematic review and meta-analysis. Journal of Affective Disorders, 152, 45–51. https://doi.org/10.1016/j.jad.2013.10.002

Harris

M. G.

Henry

L. P.

Harrigan

S. M.

Purcell

Schwartz

O. S.

Farrelly

S. E.

McGorry

P. D.

(2005). The relationship between duration of untreated psychosis and outcome: An eight-year prospective study. Schizophrenia Research, 79(1), 85–93. https://doi.org/10.1016/j.schres.2005.05.024

10.

Hassan

Ventevogel

Jefee-Bahloul

Barkil-Oteo

Kirmayer

L. J.

(2016). Mental health and psychosocial wellbeing of Syrians affected by armed conflict. Epidemiology and Psychiatric Sciences, 25(2), 129–141. https://doi.org/10.1017/S2045796016000044

11.

Hennink

M. M.

(2008). Language and Communication in Cross-Cultural Qualitative Research (Vol. 34). Springer Netherlands.

12.

Javanbakht

Rosenberg

Haddad

Arfken

C. L.

(2018). Mental health in Syrian refugee children resettling in the United States: War trauma, migration, and the role of parental stress. Journal of the American Academy of Child & Adolescent Psychiatry, 57(3), 209–211.e2. https://doi.org/10.1016/j.jaac.2018.01.013

13.

Killikelly

Bauer

Maercker

(2018). The assessment of grief in refugees and post-conflict survivors: a narrative review of etic and emic research. Frontiers in Psychology, 9, https://doi.org/10.3389/fpsyg.2018.01957

14.

Kirmayer

L. J.

Groleau

Guzder

Blake

Jarvis

(2003). Cultural consultation: A model of mental health service for multicultural societies. The Canadian Journal of Psychiatry, 48(3), 145–153. https://doi.org/10.1176/foc.4.1.125

15.

Lau

Silove

Edwards

Forbes

Bryant

McFarlane

Hadzi-Pavlovic

Steel

Nickerson

Van Hooff

Felmingham

Cowlishaw

Alkemade

Kartal

O’Donnell

(2018). Adjustment of refugee children and adolescents in Australia: Outcomes from wave three of the building a new life in Australia study. BMC medicine, 16(1), 157. https://doi.org/10.1186/s12916-018-1124-5

16.

Lindberg

Johansen

Kristiansen

Lohmann

(2018). 6.10-P9 Does the Cultural Formulation Interview provide valuable cultural information in the treatment of migrant patients in mental health services in Denmark? European Journal of Public Health, 28(suppl1). https://doi.org/10.1093/eurpub/cky048.215

17.

O’Donnell

A. W.

Stuart

O’Donnell

K. J.

(2020). The long-term financial and psychological resettlement outcomes of pre-migration trauma and post-settlement difficulties in resettled refugees. Social Science & Medicine, 262, 113246. https://doi.org/10.1016/j.socscimed.2020.113246

18.

Phillippi

Lauderdale

(2018). A guide to field notes for qualitative research: Context and conversation. Qualitative Health Research, 28(3), 381–388. https://doi.org/10.1177/1049732317697102

19.

Porter

Haslam

(2005). Predisplacement and postdisplacement factors associated with mental health of refugees and internally displaced persons: A meta-analysis. JAMA: The Journal of the American Medical Association, 294(5), 602–612. https://doi.org/10.1001/jama.294.5.602

20.

Rickwood

Deane

F. P.

Wilson

C. J.

Ciarrochi

(2005). Young people’s help-seeking for mental health problems. Australian e-Journal for the Advancement of Mental Health, 4(3), 218–251. https://doi.org/10.5172/jamh.4.3.218

21.

Slewa-Younan

Yaser

Guajardo

M. G. U.

Mannan

Smith

C. A.

Mond

J. M.

(2017). The mental health and help-seeking behaviour of resettled Afghan refugees in Australia. International Journal of Mental Health Systems, 11(1), 1–8. https://doi.org/10.1186/s13033-017-0157-z

22.

Steel

Chey

Silove

Marnane

Bryant

van Ommeren

(2009). Association of torture and other potentially traumatic events with mental health outcomes among populations exposed to mass conflict and displacement: A systematic review and meta-analysis. JAMA: The Journal of the American Medical Association, 302(5), 537–549. https://doi.org/10.1001/jama.2009.1132

23.

Sweeney

Filson

Kennedy

Collinson

Gillard

(2018). A paradigm shift: Relationships in trauma-informed mental health services. BJPsych Advances, 24(5), 319–333. https://doi.org/10.1192/bja.2018.29

24.

Tervalon

Murray-Garcia

(1998). Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education. Journal of Health Care for the Poor and Underserved, 9(2), 117–125. https://doi.org/10.1353/hpu.2010.0233

25.

Tong

Sainsbury

Craig

(2007). Consolidated criteria for reporting qualitative research (COREQ): A 32-item checklist for interviews and focus groups. International Journal for Quality in Health Care, 19(6), 349–357. https://doi.org/10.1093/intqhc/mzm042

26.

Uphoff

Soltan

Cristofalo

Marshall

Purgato

Taddese

Vanderbloemen

Barbui

Uphoff

(2022). Community-based interventions for improving mental health in refugee children and adolescents in high-income countries. Cochrane Database of Systematic Reviews, 2022(5), CD013657–CD013657. https://doi.org/10.1002/14651858.CD013657.pub2

27.

Valibhoy

M. C.

Szwarc

Kaplan

(2017). Young service users from refugee backgrounds: Their perspectives on barriers to accessing Australian mental health services. International Journal of Human Rights in Healthcare, 10(1), 68–80. https://doi.org/10.1108/IJHRH-07-2016-0010

28.

Victorian State Government Department of Health and Human Services [DHHS] (2016, August). Refugee and asylum seeker settlement in Victoria: FAQ for key services and sector partners. Retrieved from https://www.health.vic.gov.au/publications/refugee-and-asylum-seeker-settlement-in-victoria-faq-for-key-services-and-sector.

29.

Willard

C. L.

Rabin

Lawless

(2013). The prevalence of torture and associated symptoms in United States Iraqi refugees. Journal of Immigrant and Minority Health, 16, 1069–1076. https://doi.org/10.1007/s10903-013-9817-5

30.

Ziaian

de Anstiss

Antoniou

Sawyer

Baghurst

(2012). Depressive symptomatology and service utilisation among refugee children and adolescents living in South Australia. Child and Adolescent Mental Health, 17(3), 146–152. https://doi.org/10.1111/j.1475-3588.2011.00620

31.

Ziersch

Due

Walsh

(2020). Discrimination: A health hazard for people from refugee and asylum-seeking backgrounds resettled in Australia. BMC Public Health, 20(1), 108. https://doi.org/10.1186/s12889-019-8068-3

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