Perceived Physical Health and Psychological Distress of International Refugees: The Case of Early Wave Somali Refugees to The United States

The purpose of this paper is to examine the relationship between percieved physical health and psychological distress among early wave refugees from the conflict, political instability, and social disorganization of Somalia to residential resettlement in United States. Columbus, Ohio was selected as the site of the study since-along with Minneapolis, Minnesota-it was a main point of early wave Somali settlement. A random sample of 100 Somali refugees was selected for study. The participants received their health care at the main Columbus, Ohio neighborhood safety net health center that serves the city’s Somali population. The Somali participants were interviewed with a structured questionnaire in the Somali language by a trained Somali medical interpreter. The data show a strong negative correlation between self-rated health as measured by a three item scale and psychological distress as measured by the culturally appropriate 35 item version of the Somali Psychological Distress Scale (SPDS). The SPDS was developed specifically for Somalis in conjunction with the Ohio Department of Mental Health. In addition, net of other factors, age and social support are also correlated with psychological distress among both men and women.


Introduction
The purpose of this paper is to examine the perceived physical and psychological distress of early wave refugees from the conflict, political instability, and social disorganization of Somalia to residential resettlement in United States. The central focus of the paper is on the relationship between perceived physical health and psychological distress, we also include a number of variables that may serve to moderate that relationship. By focusing on early wave refugees, we are able to determine their social and physical conditions while the effects of post migration experiences are still relatively minimal.

Background
Somalia is a globalized nation. More than 1 million Somalis currently live outside the country [1]. Refugees from Somalia form one of the newest arriving groups in American society [2]. Since the early 1990s the civil war in Somalia has forced hundreds of thousands of adults and children to flee to other countries leaving behind property, family members, and friends [2][3][4]. Most have witnessed atrocities and have been exposed to brutal experiences and extreme incivilities. After fleeing Somalia many refugees have spent years in relocation camps in Kenya and other countries. After having being granted refugee status, many have moved to several countries including England, Italy, Australia, Canada, and the United States. In the U.S. a few cities have received heavy concentrations of Somali refugees including Minneapolis (60,000), Columbus (50,000) and Seattle (30,000). Making their home in Columbus, the site of this study, are approximately 50,000 Somali refugees and another 15,000 Bantu Somalis, who are culturally and linguistically different from the general Somali population [5]. Some Somalis have come to Columbus directly from relocation camps. Others who were originally settled in other U.S. cities have moved to Columbus because of good economic and housing prospects and family reunification.
The relocated refugees face major challenges of adaptation.
In their new home communities they must find jobs, housing, and the human services necessary to sustain themselves. Health care is one of the critical institutional areas to which a mutual adaptation must proceed between refugees and community residents [4]. Refugees are required to have medical examinations in relocation centers before resettlement, and then again upon arrival. Treatment protocols for the physical and mental problems they present are initiated and, ideally, regularly monitored [5].
Consequently, the refugees come into contact with the health care system early in their tenure in this country. Since the Somalis are culturally, experientially, linguistically, and behaviorally different from the general American population and from earlier groups of immigrants to the U.S., they constitute a significant challenge to the capacity, capability, and performance of the health care system to meet their needs [6]. Issues of communication between health care providers and patients can be barriers when the providers are attempting to understand, diagnose, and treat the newcomer [7][8][9].
It has been well established clinically that refugees present a wide variety of physical and mental issues and problems [1,[10][11][12].
However, we have little information on how physical and mental illness are generally comorbid in refugee populations [13]. This is particularly true for the Somali refugees. In this paper we seek to

Conceptual Framework
Perceived Health: Our approach to the physical and psychological distress of Somali refugees is informed by several general observations from past research of both ours and others.
The first observation is that the accumulated experiences of Somali For example, people with schizophrenia often suffer the long-term effects of antipsychotic medication and have high rates of substantive abuse. Also, the rate of depression is twice as high among the physically ill as it is among the healthy. Indeed, there is evidence that PTSD victims have higher cardiovascular risk because of a low grade systemic proinflammatory state that is related to PTSD [14]. In addition, psychologically distressed individuals tend to develop poor health behaviors-they eat less well, take less exercise than the general population, and avoid contact with health care professionals. It is likely that Somalis would experience these stressors as well. Finally, refugees have a "triple place" exposure to stressors that can produce physical illness and injury and psychological disorders. The first is in Somalia itself where the warring and social disorder continues. The second place is the refugee camps [13][14][15]. In the camps interethnic conflict, assaults, and disease epidemics repeat many of the conditions that lead to and accompanied the initial flight from Somalia [16,17]. Somali refugees, the poorer the perceived health, the higher the psychological distress.

Modifying variables:
In order to further refine our understanding of the primary hypothesis, we propose four secondary hypotheses to examine the influence of gender, age, social isolation, and length of residency.

Gender: Another observation from past research is that gender
is an important factor in psychological distress. There is evidence that some of the difference between men and women is biologically based so that women may be more likely to develop depression [18].
Also, there is evidence that sociological factors and conditions lead to a higher likelihood among women than among men of developing psychological distress. This is particularly true in westernized societies [19]. There is little systematic evidence on differences in depression among men and women in lesser developed societies.
Relevant to the Somali situation is the general finding that differential exposure to stress contributes to differences between men and women in psychological distress [20]. Somali men and women differ in the content of their accumulated life experiences.
For example, the physical results of female circumcision are lifelong health complications especially during childbearing [21][22][23]. Rape is also mainly a female experience. Indeed, many Somali women have experienced seeing their husbands killed, then being raped by the murderers [24]. Also, females have the primary responsibilities in tending and caring for children in the refugee camps and in transit to the resettlement destination.
Additional stressors for women include becoming head of the household upon the death of the male family members; being homeless; and losing family members and friends who would normally provide social support [25]. In addition, some have argued that the mental health of women in general (not just Somalis) is not as good as men's because women perceive more personal and group discrimination than do men. Taking these experiential gender differences into account, our second hypothesis is: H2: Net of other factors, among Somali refugees, women report a higher level of psychological distress than do men.
Age: While the relationship between advanced age and psychological distress among relocated Somali refugees has been addressed little in research to date, findings reported in the broader literature of psychology and gerontology can be informative. In short, the relationship of age to psychological distress is complex.
For example, a parabolic or U-shaped relationship between age and psychological distress has been reported such that distress is high among those adults under 55 years of age, then falls until the mid-70's, but then rises again for those over 75 years of age [26,27].
The rise in psychological distress the later years in the general population has been attributed to increasingly limited resources, declining health, loss of friends and support system through death, and loss of control over significant aspects of one's life [28][29][30][31].
Among Somali refugees we would expect the social isolation accompanying the "relocation syndrome" to have more impact on older people. As compared to the younger and employed Somalis and others active in the larger community through business, politics, and civic involvement, the elders tend to find the process of adaptation to a strange culture and land may contribute to a sense of social isolation. Indeed, it has been argued that a sense of social isolation and loneliness is the single most important predictor of psychological distress for old people Paul et al. [29].
Beyond isolation, per se, a phenomenon has been identified when

Recency of Immigration
The fifth observation is that some investigators have found that recency of immigration is correlated with a number of variables including PTSD, anxiety, and depression [33], while other researchers have argued that a curvilinear relationship exists between length of time since arrival and psychological distress [34]. The argument is that an initial euphoria characterizes the first year. This is followed by disenchantment and demoralization

Participants
The 100 participants in this study were selected randomly from Somalis living in Columbus, Ohio aged 18 years and over who receive their health care at the safety-net healthcare clinic located near the major residential concentration of the Somali population in the city [35].

Data Collection
The data were collected through a face-to-face interview Recency of residency is measured by two questions: 1) How many years have you lived in the United States?
2) How many years have you lived in Columbus?

Analysis
We first present the summary profile for the participants. We then perform three multiple regressions of psychological distress on the independent variables. Then we repeat the multiple regression for the men and the women in the study. Finally, we test the significance of difference of the correlations between psychological distress and perceived physical health between men and women. Table 1 shows the characteristics of the sample. In general:

Summary Discussion
The data show that for first wave Somali refugees to Columbus, Ohio that health and psychological distress are related for both men and women. That is, they tend to move together; psychological distress increases as health declines, and as health increases psychological distress declines. For refugees, the health care system must be prepared to deal with both physical health challenges and psychological distress simultaneously. This is especially difficult