Addressing Mental Health Disparities in Resettled Refugees: The Promise of Family-Based Prevention

Background: Roughly 3.3 million refugees have resettled in the US since 1975, half of them children. Refugees have poorer mental health compared to the general population. In addition to experiencing trauma such as war-related violence, family loss, and displacement, refugee families encounter stressors after third country resettlement. Post-resettlement stressors may be compounded by anti-refugee attitudes associated with growing nationalism in many countries. Finally, both health-system and societal-level barriers contribute to poor access to and underutilization of mental health services. There are few interventions that explicitly prevent mental health problems and promote family functioning for school-aged refugee children, caregivers, and families. Existing interventions focus overwhelmingly on trauma experiences. An ecological model that also addresses daily stressors of resettlement might be more effective. Given the ever-changing dynamics of refugee resettlement, there is a need to develop flexible interventions that can be adjusted to work with multiple groups, languages, and cultures at once, rather than highly specified models that can only be used with single cultural groups.

We conducted a pilot feasibility and acceptability trial of the Family Strengthening Intervention for refugees (FSI-R) using a community-based participatory research (CBPR) approach. The FSI-R is a family home-visiting intervention, delivered by refugee community-based health workers, to promote youth mental health and improve family relationships. We hypothesized that those in the intervention would have better psychosocial outcomes and more positive family functioning post-intervention compared to care-as-usual (CAU) families. We hypothesized that FSI-R would be feasible to implement and accepted by the communities.

Methods: 40 Somali Bantu (n=102 children, 58.4% female; n=43 caregivers, 79.0% female) and 40 Bhutanese (n=53 children, 55.3% female; n=67 caregivers, 54.0% female) families with at least one child (7–17 years) were randomized to receive FSI-R or CAU. Refugee research assistants conducted psychosocial assessments at baseline and post-intervention. Multilevel modeling assessed effects of FSI-R on outcomes. Feasibility was measured from the retention rate and acceptability was measured from satisfaction surveys.

Results: The FSI-R was associated with improved individual- and family-level outcomes. Across both communities, children who received FSI-R reported reduced traumatic stress reactions and caregivers reported fewer symptoms of child depression compared to CAU families (β=-0.42; p=0.03; β=-0.34; p=0.001). Bhutanese children who received FSI-R reported reduced family arguing (β=-1.32; p=0.035) and showed fewer symptoms of depression and conduct problems by parent report (β= -9.20; p=0.038; β=-0.92; p=0.01) compared to CAU families. There were no significant differences by group on other measures of functional impairment, intergenerational congruence, or caregiver trauma symptoms. The retention rate of 82.5% indicates FSI-R was feasible and high reports of satisfaction with FSI-R (81.5%) indicates community acceptance.

Conclusion: Family-based prevention through a home-visiting intervention can be feasible and acceptable and has promise for promoting mental health and family functioning among resettled refugees.