The long-term financial and psychological resettlement outcomes of pre-migration trauma and post-settlement difficulties in resettled refugees

https://doi.org/10.1016/j.socscimed.2020.113246Get rights and content

Highlights

  • Resettled refugees can experience prolonged financial and psychological problems.

  • Financial hardships and psychological distress are mutually reinforcing over time.

  • Difficulties adjusting to a new country can precede low fiscal and mental health.

  • Compared to post-settlement difficulties, trauma had no long-term effects.

Abstract

Rationale

Humanitarian crises and ongoing conflicts around the world have created large populations of refugees who require permanent resettlement. The often-difficult pathway to resettlement for refugees places them at elevated risks for ongoing psychological and financial problems, creating an imperative to investigate the longterm outcomes for refugees as they resettle.

Objective

The current study explores how adversities before and after resettlement impact the psychological distress and experiences of financial hardship over the course of four years postsettlement for a large group of resettled refugees in Australia.

Method

Data from the first four waves of the Building New Life in Australia (BNLA) study (N = 1509) were used. Recently resettled refugees completed measures of pre-migration trauma and post-settlement difficulties at the initial data collection wave as well as measures of psychological distress and financial hardship across all four waves.

Results

Through a random intercept cross-lagged panel model, a time-sensitive bi-directional relationship between psychological distress and financial hardship was found. Additionally, early post-settlement difficulties were indirectly related to both psychological distress and financial hardship over time. In contrast, pre-migration trauma did not significantly predict later outcomes.

Conclusions

These results illustrate that trauma focused interventions may be insufficient on their own for assisting resettled refugees in this context. As such, our findings highlight the crucial importance of early identification and responsiveness to the variety of initial difficulties, such as language and housing problems, that may be experienced by resettled refugees to mitigate against subsequent psychological and financial difficulties in the long-term.

Introduction

The previous decade has seen a dramatic increase in the number of people forcibly displaced from their place of birth or residence as a result of war, persecution, natural disasters, famine, and violence. Recent estimates place the number of people of concern (including refugees, asylum seekers, and internally displaced peoples) at over 70 million – a considerable increase compared to the estimate of 43 million people of concern in 2009 (United Nations High Commissioner for Refugees [UNHCR], 2018). The increase in displaced persons can be largely attributed to ongoing conflicts and human rights abuses in the Middle East, South Sudan, Myanmar, and Somalia, as well as recent domestic unrest in countries like Venezuela (UNHCR, 2018). Displaced persons who cannot safely return home often make claims of asylum to the United Nations. Asylum seekers’ claims are then assessed to determine if they meet the protected status of refugees under the UNHCR convention. Those who meet the criteria can then be permanently resettled into a diverse array of host nations as refugees (UNHCR, 2018).

For all resettled refugees, the potentially difficult and unplanned pathways to resettlement in a novel intercultural context can manifest in challenges adjusting psychologically and acquiring resources in new cultural settings (Ward and Geeraert, 2016). These challenges can persist over time and may lead to long-term inequities in well-being and social functioning even well after being resettled in a host nation (Hynie, 2018). In the current study, we identify ongoing mental health concerns, measured by psychological distress, and experiences of financial hardship as key barriers to successful resettlement. Previous longitudinal investigations of refugees resettled in developed countries, reviewed below, indicate that poor psychological and indicators of financial well-being are mutually reinforcing, whereby a deterioration in either domain leads to worsened outcomes in both financial and psychological well-being in the future (e.g., Beiser; Hou, 2001).

We expand upon previous investigations of the reciprocal relationship between psychological distress and financial hardships in recently resettled refugees by also considering the cumulative impacts of early risk factors before and after resettlement. More specifically, we examine the effects of pre-settlement trauma and post-settlement difficulties on psychological distress and financial hardship. Self-report data from a nationally representative sample of recently resettled refugees in Australia were utilized to explore initial risk factors and the subsequent co-development of psychological distress and financial hardship over the first four years following permanent resettlement.

Australia has a modest annual intake of permanently resettled refugees, with its annual commitment having grown from 13,507 to 18,762 in the last decade (Department of Home Affairs, 2019). The median time to finalize an application is 248 days (Department of Immigration and Border Security, 2014). Most resettled refugees are referred for resettlement by the UNHCR, but a smaller number of asylum seekers apply directly to Australia once onshore. Under the Australian humanitarian migration system, onshore protection visas are labelled and processed differently than offshore refugee referrals. Nevertheless, asylum seekers assessed to meet Australia's international and domestically legislated protection obligations can be granted a protection visa and be permanently resettled in Australia (Department of Home Affairs, 2019). Due to the distinct resettlement processes and visas, the groups of individuals seeking protection are domestically considered to be distinct. In the current study, we singularly refer to both groups as resettled refugees due to their common experiences of forced migration and permanent resettlement. Indeed, it is their experiences before and after resettlement that are examined in the current study to explore the development of psychological distress and financial hardship in resettled refugee populations.

Given the potential urgency, unpreparedness, and traumatic nature of emigration for refugees, there is considerable evidence that they have proportionately higher rates of post-traumatic stress disorder, depression, anxiety, and experience more psychological distress than other groups in the social contexts where they are resettled (Bogic et al., 2015; Bronstein and Montgomery, 2011; Fazel et al., 2005; Jankovic-Rankovic et al., 2020). For example, a comprehensive, multi-country review on the mental health disorders of migrants found the prevalence of depression and anxiety among refugees was twice that of labor migrants (Lindert et al., 2009). In the Australian context, refugees have been found to be 3.16 times more likely to report clinically high levels of distress compared to Australian-born residents (Shawyer et al., 2017).

Moreover, resettled refugees tend to experience a high degree of financial hardship during the resettlement process. Financial hardships are a form of economic strain that encompasses factors such as employment, income, number of dependents, and access to resources (Kahn and Pearlin, 2006). Resettled refugees are disproportionately at risk of experiencing financial hardships because they arrive into the host nation with very few resources and they can face inequalities in accessing fiscal opportunities (Hynie, 2018). These difficulties include finding employment (Bakker et al., 2017), being underemployed (Austin and Este, 2001), providing financial assistance to dependents overseas (Wilmsen, 2013), and trouble with accessing financial assistance (Silove et al., 1999). In many cases, resettled refugees can continue to experience these constraints after resettlement. A longitudinal study conducted in the Netherlands exemplifies these ongoing constraints, as only a quarter of refugees worked more than 8 hours a week two years post-settlement, considerably lower than the 90% of labor migrants and 80% of natives who met the same criteria (Bakker et al., 2017).

Restrictions on economic opportunities often cooccur with poor mental health outcomes among resettled refugees. Previous cross-sectional research on resettled refugees in America found unemployment to be one of the strongest risk factors for anxiety and depression in this population (Kim, 2016). Lack of financial security may negatively influence mental health as a result of restricted access to basic resources as well as through the experience of loss of social status and prestige (Ritsner et al., 2001). Additionally, psychological distress can increase financial hardship by impeding efforts to find future employment (Beiser and Hou, 2001), decreasing self-perceived control over one's life (Creed and Bartrum, 2008), and contributing to greater household expenditure (Price et al., 2002).

Cooccurring problems with psychological and financial well-being are further exemplified by longitudinal research. Psychological distress and financial hardships during early resettlement can influence later outcomes for refugees through dynamic processes, whereby early risk in these areas is mutually reinforcing throughout resettlement (Beiser and Hou, 2001; Beiser et al., 1993; Wickrama et al., 2002). Specifically, Beiser and colleagues used employment status as a key financial indicator for resettled refugees in Canada (e.g., Beiser; Hou, 2001; Beiser et al., 1993). This research found lower levels of distress in the initial period of resettlement predicted later employment and being employed in the early stages of resettlement predicted lower distress in the future. These studies highlight that the resettlement of refugees is not a static process with inevitable poor psychological and financial outcomes for all. Rather, there are dynamic processes where an initial deterioration in either domain could lead to maladaptive outcomes in both domains over time (McMichael et al., 2014). Accordingly, we hypothesize (hyp. 1) a bi-directional relationship between psychological distress and financial hardship to emerge overtime for the resettled refugees in the current study. In addition to investigating the reciprocity of psychological distress and financial hardship, we also endeavor to explore prominent risk factors during the resettlement process that could lead to an initial deterioration in these areas.

The inherent difficulties in the resettlement process for resettled refugees places them at unique risk for ongoing problems. Unlike voluntary immigrants who choose to resettle in a new country and can plan for the move practically and psychologically, resettled refugees often relocate at short notice to uncertain or suboptimal destinations after experiencing or witnessing traumatic events (Li et al., 2016). Consequentially, they may leave their assets, support networks, and livelihoods behind (Becker and Ferrara, 2019). These experiences can result in stress, poor living conditions, and physical and mental health difficulties before leaving their country of origin and during the post-migration period (Donà and Young, 2016). As such, the current study will build upon the existing evidence for a bi-directional relationship between psychological distress and indicators of financial hardship (e.g., Wickrama et al., 2002) by considering if, and how, pre-settlement trauma and post-settlement difficulties impede positive psychological and financial outcomes for resettled refugees.

Trauma is defined as experiencing or witnessing events that evoke intense feelings of fear or horror which tend to be both uncontrollable and overwhelming (Herman, 2015). For refugees, experiences of trauma may broadly include events in which an individual fears for their own or others’ lives and safety, and can occur before relocation as well as during the migration process (Herman, 2015). Common sources of trauma include experiencing or being a witness to war, violence, assault, torture, forced labor, family separation, natural or manmade disasters, imprisonment, or political or religious persecution (Li, 2016; Nicholson, 1997). Trauma in the pre-settlement period is an important factor in refugee mental health. Previous work in this area has found that it is a common and reliable predictor of elevated psychological distress even after permanent resettlement (e.g., Li and Anderson, 2016; Torres and Wallace, 2013). In one long-term assessment of resettled refugees in Australia, the impact of pre-settlement trauma on mental health dissipated over time but remained an important predictor 10 years post-settlement (Steel et al., 2002).

Much less research has examined the impact of trauma on post-settlement financial hardships in resettled refugees. However, a limited number of studies have found that traumatic experiences can detract from a resettled refugees’ focus on long-term financial advancement (Hauff and Vaglum, 1993; Uba and Chung, 1991). These cross-sectional findings provide evidence to suggest that traumatic experiences may contribute to both ongoing financial hardships, but more systematic investigations are required. Considering this cumulative body of evidence, we hypothesize (hyp. 2) that pre-settlement trauma will be related to continuing psychological distress and financial hardships in the post-settlement period.

Alongside traumatic events, stressors that are a result of the experience of transition within the early resettlement process have also been shown to impede the successful settlement of refugees across psychological and financial domains (e.g., Blackburn and Barker, 2011; Chen et al., 2017; Carswell, Montgomery, 2008; Schweitzer et al., 2011). There are a range of post-settlement difficulties that can encumber refugees during the resettlement process. For example, the psychological well-being of refugees is adversely impacted by social exclusion, experiences of discrimination in the host country (Correa-Velez et al., 2013), concerns regarding family who have been left behind, cultural differences (Nickerson et al., 2010), temporary housing arrangements (Warfa et al., 2006), and lack of language proficiency (Tip et al., 2019).

Similarly, these early difficulties can impede the successful economic integration of resettled refugees through limiting employment and available income. Research suggests that much like psychological distress, financial hardship is impacted by a range of post-settlement difficulties, including language proficiency (Beiser and Hou, 2001), poor access to services (Correa-Velez et al., 2013; Pursch et al., 2020), and disbursements to family overseas (Wilmsen, 2013). Indeed, it is apparent that whilst financial hardships can inhibit successful adjustment, the likelihood of experiencing that hardship is dependent upon a range of other difficulties possibly experienced in the very early post-settlement period. Therefore, we expect (hyp. 3) that initial post-settlement difficulties will contribute to greater psychological distress and financial hardship during the first four years post-settlement for resettled refugees in the current study.

Extensive literature reviews have concluded that both exposure to traumatic events and post-settlement difficulties can uniquely contribute to negative outcomes for resettled refugees (Fazel et al., 2012; Li et al., 2016; Porter and Haslam, 2005). However, a growing literature conducted among refugees resettled in developed countries suggests that post-settlement difficulties (such as those outlined above) may be more strongly related to negative psychological outcomes than traumatic experiences in the pre-migration period (Chen et al., 2017). However, these investigations have been criticized for relying on cross-sectional findings that cannot determine which risk factors prospectively impact the long-term psychological well-being of resettled refugees (Fazel et al., 2012). Regardless of these limitations, the maladaptive outcomes associated with both pre-settlement trauma and post-settlement difficulties have led to calls for researchers and practitioners to consider the cumulative effect of both types of stressors across the adjustment process (Porter and Haslam, 2005; Watters, 2001). To date, however, most of the research has focused on the impacts of trauma and post-settlement difficulties on the mental health of refugees (e.g., Ellis et al., 2008; Schweitzer et al., 2011), ignoring other indicators of successful adaptation, like financial hardships. To address these limitations, the current study will longitudinally model the impact of pre-settlement trauma and post-settlement difficulties on the subsequent co-development of both psychological distress and financial hardship.

The hypotheses, introduced above, were tested using a nationally representative sample of recently resettled refugees in Australia. Effectively, it is suggested that a bi-directional relationship between psychological distress and financial hardship over time will emerge. We anticipate that pre-migration trauma and post-settlement difficulties may underpin many of the long-term inequities in resettled refugee populations, as any proximal effect on psychological distress or financial hardship could lead to maladaptive outcomes in both domains over time. The assertations made concerning resettlement processes fundamentally refer to changes within a person, whereby we assert that early factors alter an individual's subsequent outcomes. Therefore, modelling techniques capable of identifying within-person changes across time were employed to test these hypotheses.

Section snippets

Participants and procedure

The current study utilized data from the primary respondents sampled in the Building New Life in Australia study (BNLA), a longitudinal study that collected data at yearly intervals on a large, nationally representative sample of refugees in Australia. This study is the largest longitudinal survey of refugees in Australia and one of the most comprehensive studies of its type internationally (Edwards et al., 2018). The BNLA study is conducted to increase our understanding of the experiences of

Materials

Psychological Distress. The 6-item Kessler Psychological Distress scale was administered to the participants. Participants were asked how often they had felt different symptoms of distress during the previous 4 weeks on a 5-point scale (1 = None of the time to 5 = All of the time). The summary score of the items measure a non-diagnostic form of general psychological distress. The scale has been widely validated in cross-cultural contexts (e.g., Kessler et al., 2010; Mitchell and Beals, 2011;

Results

Model fit was evaluated using standard indices and cut-offs (Hu and Bentler, 1999). The full model (Fig. 1) yielded a good model fit, χ2(17) = 110.59, p < .001; RMSEA = 0.06; SRMR = 0.04; CFI = 0.96; TLI = 0.89. Initially, a model comparison was conducted to compare the RI-CLPM to a standard CLPM. The standard CLPM infers the absence of inter-individual differences in the manifestation of financial hardship and psychological distress over time. This model yielded poorer fit, χ2(20) = 233.08, p

Discussion

Novel to the field, the current study utilized a nationally representative sample of recently resettled refugees to explore the impact of pre-settlement trauma and post-settlement adjustment difficulties on the longitudinal co-development of financial hardship and psychological distress. The results clearly illustrate that resettled refugees who experience initial difficulties have worse long-term outcomes, and that experiences in the early post-settlement period exacerbate the course of poor

Conclusions

Collectively, the results indicate that resettled refugees with post-settlement difficulties are predisposed to continue or develop both financial and psychological problems over time. Given the high incidence of economic and mental health problems in this sample, and the negative implications this has over time, our findings highlight the crucial importance of early identification and responsiveness to the variety of problems that may be experienced by resettled refugees. We argue that

Credit Author Statement

Alexander W O'Donnell: Conceptualization, Formal analysis, Writing - original draft, Writing - review & editing. Jaimee Stuart: Conceptualization, Formal analysis, Writing - review & editing. Karlee J. O'Donnell: Conceptualization, Writing - original draft, Writing - review & editing.

Acknowledgment

The authors would like to acknowledge the Australian Institute of Family Studies (AIFS), the Department of Social Services (DSS), the National Centre for Longitudinal Data (NCLD), the BLNA advisory group, and all other parties involved in the creation, administration, and maintenance of the Building New Life in Australia (BLNA) study. The authors would also like to thank and acknowledge the humanitarian migrants who shared their experiences by completing this survey.

References (73)

  • B. Pursch et al.

    Health for all? A qualitative study of NGO support to migrants affected by structural violence in northern France

    Soc. Sci. Med.

    (2020)
  • M. Ritsner et al.

    Gender differences in psychosocial risk factors for psychological distress among immigrants

    Compr. Psychiatr.

    (2001)
  • D. Silove et al.

    Problems Tamil asylum seekers encounter in accessing health and welfare services in Australia

    Soc. Sci. Med.

    (1999)
  • Z. Steel et al.

    Long-term effect of psychological trauma on the mental health of Vietnamese refugees resettled in Australia: a population-based study

    Lancet

    (2002)
  • C. Ward et al.

    Advancing acculturation theory and research: the acculturation process in its ecological context

    Curr. Opin. Psychol.

    (2016)
  • N. Warfa et al.

    Post-migration geographical mobility, mental health and health service utilisation among Somali refugees in the UK: a qualitative study

    Health Place

    (2006)
  • C. Watters

    Emerging paradigms in the mental health care of refugees

    Soc. Sci. Med.

    (2001)
  • C. Austin et al.

    The working experiences of underemployed immigrant and refugee men

    Can. Soc. Work. Rev.

    (2001)
  • L. Bakker et al.

    Explaining the refugee gap: a longitudinal study on labour market participation of refugees in The Netherlands

    J. Ethnic Migrat. Stud.

    (2017)
  • M. Beiser et al.

    Unemployment, underemployment and depressive affect among Southeast Asian refugees

    Psychol. Med.

    (1993)
  • M. Bogic et al.

    Long-term mental health of war-refugees: a systematic literature review

    BMC Int. Health Hum. Right

    (2015)
  • K.A. Bollen et al.

    Direct and indirect effects: classical and bootstrap estimates of variability

    Socio. Methodol.

    (1990)
  • I. Bronstein et al.

    Psychological distress in refugee children: a systematic review

    Clin. Child Fam. Psychol. Rev.

    (2011)
  • A. Church

    Sojourner adjustment

    Psychol. Bull.

    (1982)
  • I. Correa-Velez et al.

    Working for a better life: longitudinal evidence on the predictors of employment among recently arrived refugee migrant men living in Australia

    Int. Migrat.

    (2013)
  • P.A. Creed et al.

    Personal control as a mediator and moderator between life strains and psychological well-being in the unemployed

    J. Appl. Soc. Psychol.

    (2008)
  • J. De Maio et al.

    Building a New Life in Australia: introducing the longitudinal study of humanitarian migrants

    Fam. Matters

    (2014)
  • Department of Home Affairs

    Annual Report 2018-19. Belconnen, ACT

    (2019)
  • Department of Immigration and Border Security

    Annual Report 2014-15. Belconnen, ACT

    (2014)
  • Building a New Life in Australia: the Longitudinal Study of Humanitarian Migrants, Release 4 (Waves 1-4)

    (2018)
  • G. Donà et al.

    Refugees and forced migrants

  • B. Edwards et al.

    Cohort profile: building a new life in Australia (BNLA): the longitudinal study of humanitarian migrants

    Int. J. Epidemiol.

    (2018)
  • B.H. Ellis et al.

    Mental health of Somali adolescent refugees: the role of trauma, stress, and perceived discrimination

    J. Consult. Clin. Psychol.

    (2008)
  • C.K. Enders et al.

    The relative performance of full information maximum likelihood estimation for missing data in structural equation models

    Struct. Equ. Model.: A Multidisciplinary Journal

    (2001)
  • E. Hamaker et al.

    A critique of the cross-lagged panel model

    Psychol. Methods

    (2015)
  • E. Hauff et al.

    Vietnamese boat refugees: the influence of war and flight traumatization on mental health on arrival in the country of resettlement: a community cohort study of Vietnamese refugees in Norway

    Acta Pscyhiatricia Scandinavica

    (1993)
  • Cited by (33)

    • Using a professional framework to guide research interviews with registered nurses who are former refugees: A discussion paper

      2022, Collegian
      Citation Excerpt :

      This built further rapport with Benjamin. The literature on refugee trauma post-resettlement reports that no matter the length of time, a refugee can still experience retraumatisation (O'Donnell et al., 2020). After long periods of time since their arrival (range between arriving to Australia in 1988 to 2010), it can be assumed that participants are well beyond a state of crisis but in a state of recovery as part of the settlement cycle (STARTTS 2017).

    • Explanatory models and help-seeking for symptoms of PTSD and depression among Syrian refugees

      2021, Social Science and Medicine
      Citation Excerpt :

      In combination with our results, this pattern suggests that these aspects are central in refugees' understanding of PTSD. Resettlement related stressors on a systemic level (e.g., governmental bureaucracy, not getting a job, economic challenges, uncertainty about residence permit) were seen as causing, preserving, or worsening mental health problems, as in line with previous literature (Cange et al., 2019; Miller and Rasmussen, 2017; O'Donnell, Stuart and O'Donnell, 2020; Porter and Haslam, 2005; Renner et al., 2020). Our data do not support biomedical or biopsychosocial EMs of illness.

    View all citing articles on Scopus
    View full text