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The persistence of predictors of wellbeing among refugee youth eight years after resettlement in Melbourne, Australia
Social Science & Medicine 142 (2015) 163e168
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Short communication
The persistence of predictors of wellbeing among refugee youth eight years after resettlement in Melbourne, Australia Ignacio Correa-Velez a, *, Sandra M. Gifford b, Celia McMichael c a
School of Public Health and Social Work, Faculty of Health, and Institute of Health and Biomedical Innovation, Queensland University of Technology, Kelvin Grove, Queensland 4059, Australia b The Swinburne Institute for Social Research, Swinburne University of Technology, PO Box 218 Hawthorn, Victoria 3122, Australia c School of Social Sciences, La Trobe University, Bundoora, Victoria 3086, Australia
a r t i c l e i n f o
a b s t r a c t
Article history: Received 8 April 2015 Received in revised form 9 August 2015 Accepted 11 August 2015 Available online 14 August 2015
This short report assesses the predictors of subjective health and happiness among a cohort of refugee youth over their first eight years in Australia. Five waves of data collection were conducted between 2004 (n ¼ 120) and 2012e13 (n ¼ 51) using mixed methods. Previous schooling, self-esteem, moving house in the previous year, a supportive social environment, stronger ethnic identity and perceived discrimination were significant predictors of wellbeing after adjusting for demographic and pre-migration factors. When compared with a previous analysis of this cohort over their first three years of settlement, experiences of social exclusion still have a significant impact on wellbeing eight years after arriving in Australia. This study contributes to mounting evidence in support of policies that discourage discrimination and promote social inclusion and cultural diversity and which underpin the wellbeing of resettled refugee youth. © 2015 Elsevier Ltd. All rights reserved.
Keywords: Australia Refugee youth Wellbeing Settlement Discrimination Social exclusion Longitudinal
1. Introduction In 2010, the predictors of wellbeing among a cohort of refugee youth (aged 11e19) over their first three years of settlement in Melbourne, Australia were reported (Correa-Velez et al., 2010). The authors concluded that predictors of wellbeing were “those that can be understood to promote a sense of belonging, becoming at home, being able to flourish and become part of the new host society” (Correa-Velez et al., 2010) (p.1406). The report stated, “settlement specific policies and programs can ultimately only be effective if embedded within a broader socially inclusive society ( … ) And this requires broader social reform relating to tackling issues of racism, discrimination, bullying, and increased flexibility in the ways these youth can access the social goods to which they are entitled” (p.1407). Two additional waves of data collection were conducted in 2007e08 (wave four) and 2012e13 (wave five). Further analysis of
the predictors of wellbeing is of value given the scarcity of research examining the longer term settlement experiences of refugees (RCOA, 2010; Smyth et al., 2010). International evidence on predictors of migrant health, including refugees, shows a strong and consistent association between social exclusion and poor mental health, subjective health and wellbeing (Beiser et al., 2015; Lecerof et al., 2015; Montgomery and Foldspang, 2008). Conversely, indicators of social inclusion and social participation are consistently associated with positive health and wellbeing (Edge et al., 2014; Lecerof et al., 2015; Sleijpen et al., 2015). This short report asks whether the factors that predict wellbeing in the short term persist over time as these adolescents transition to young adults. It contributes to the evidence that social exclusion, including discrimination, has an adverse impact on the wellbeing of refugee youth not only in the early settlement period but over time. 2. Methods 2.1. Sampling
* Corresponding author. E-mail addresses: [email protected] (I. Correa-Velez), sgifford@ swin.edu.au (S.M. Gifford), [email protected] (C. McMichael). http://dx.doi.org/10.1016/j.socscimed.2015.08.017 0277-9536/© 2015 Elsevier Ltd. All rights reserved.
Immigrant youth typically spend 6e12 months at an English Language School (ELS) during their first year in Australia before
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entering mainstream schools. Participants were recruited through three ELSs that had high numbers of refugee students. 120 young people (55 female, 65 male) were recruited. Ethical clearance was obtained from La Trobe University and from partner organizations. 2.2. Data collection Four annual waves of data collection were conducted between 2004 and 2008. The first three involved completion of a ‘Settlement Journal’ using standardised quantitative measurements of psychosocial health and settlement outcomes, and qualitative methods such as drawings, photos and open-ended questions (Gifford et al., 2007). Data collection was initially conducted in ELSs and facilitated by research assistants, bicultural aides and interpreters. Later waves were conducted by research assistants at participants' homes, schools or public libraries, and without need of interpreters. A fifth wave of data collection occurred in 2012e13, and included in-depth interviews and a short questionnaire which gathered data on settlement and wellbeing. 2.3. Measures Similar to the previous analysis (Correa-Velez et al., 2010), a theoretical model of associations between the demographic/psychosocial factors and outcome measures was developed (Fig. 1). Table 1 shows the wellbeing and psychosocial measures used. Single items assessing subjective health status and happiness were used as outcome measures.
(Gibbons et al., 2010) and is well suited to address our research question which is to provide an overall picture of the predictors of wellbeing among this cohort over their first eight years in Australia, rather than individual causal pathways or reciprocal relationships between variables included in the model which can be assessed using other statistical approaches (Robins et al., 2000). The two outcome variables were continuous and were modelled assuming a Normal distribution. SPSS (IBM v21) was used to run the statistical analyses. The analyses involved three stages. In stage one, all demographic and predictor factors shown in Fig. 1 were entered into a GEE model for each outcome variable. In stage two, a backwards elimination procedure was applied to the predictor factors leaving in the model only those with a p-value 0.05. Demographic and pre-migration factors were fixed into the model to control for the potential confounding effects of gender (females vs. males), region of birth (Africa vs. Other), age (in years), years of schooling before coming to Australia, time (months since arriving in Australia), and English language proficiency (good vs. poor). In stage three, interaction effects for gender were entered into the models. The R2 statistic was used to estimate overall model fit. Participants' retention into the study decreased from 109/120 (91%) in wave two to 100/120 (83%) in wave three, 80/120 (67%) in wave four, and 51/120 (43%) in wave five. When considering the number of participants at each wave, missing responses on individual wellbeing and psychosocial measures ranged from zero to 7.2% over the five waves of data collection. 3. Results
2.4. Statistical analysis
3.1. Participants' characteristics
Chi-square tests for categorical variables and non-parametric ManneWhitney test for continuous variables were used to estimate differences in demographic and pre-migration factors between males and females at first wave. Generalised Estimating Equations (GEE) (Diggle et al., 2002) were used to model the predictors of wellbeing outcomes over the first eight years of resettlement. GEE is a well-recognised method for longitudinal analysis
Participants' characteristics at each wave are shown in Table 2. When comparing wave one data between respondents to wave five (n ¼ 51) and those lost to follow-up (n ¼ 69), there were no statistically significant differences in terms of gender (p ¼ 0.547), region of birth (p ¼ 0.146), age (p ¼ 0.705), previous schooling (p ¼ 0.550), time in Australia (p ¼ 0.052), and English language proficiency (p ¼ 0.552). Similarly, no statistically significant
Fig. 1. Theoretical model of associations between demographic/psychosocial factors and wellbeing outcomes.
I. Correa-Velez et al. / Social Science & Medicine 142 (2015) 163e168 Table 1 Measures used to predict participants' subjective health and wellbeing over their first eight years of settlement in Australia. Item/scale
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differences in demographic and pre-migration factors were found between males and females at wave one.
Cronbach's alpha
Wellbeing outcomes Subjective health ‘How satisfied are you with your health?’ status (1 ¼ very dissatisfied to 5 ¼ very satisfied) (WHO, 1996) Happiness ‘How happy are you now?’ (1 ¼ not at all happy to 4 ¼ very happy) Psychosocial factors Individual Self-esteem 10-item Rosenberg Self-Esteem Scale (Rosenberg, 1989) Family/Neighbourhood Moved house past ‘How many times have you moved home year in the last year?’ (0 ¼ none; 1 ¼ one or more) Ethnic community Ethnic identity 5-item Affirmation and Belonging subscale e Multigroup Ethnic Identity Measure (Phinney, 1992) Status in ethnic Social status of family in ethnic community e community Adapted from MacArthur Scale of Subjective Social Status (Goodman et al., 2001) (1 ¼ lowest status to 10 ¼ highest status) Broader community Supportive 4-item Supportive Environment subscale e environment Baruth Protective Factors Inventory (Baruth and Caroll, 2002) Status in broader Social status of family in broader Australian community community e Adapted from MacArthur Scale of Subjective Social Status (Goodman et al., 2001) (1 ¼ lowest status to 10 ¼ highest status) ‘The Australian community cares about me’ A caring (1 ¼ not at all to 4 ¼ very much) Australian community Perceived Item from the Experiences of Discrimination discrimination scale (Krieger et al., 2005), ‘Ever experienced discrimination because of your ethnicity, religion or colour?’ (0 ¼ No; 1 ¼ Yes)
3.2. Predictors of wellbeing N/A
N/A
0.75
N/A
0.81
N/A
0.80
N/A
N/A
N/A
At wave one, no statistically significant differences for any of the wellbeing outcomes or psychosocial factors shown in Fig. 1 were found between males and females. Table 3 shows the final GEE models for subjective health status and happiness. Gender interaction effects were not statistically significant. After adjusting for demographic and pre-migration factors, previous schooling, self-esteem, moving house in the previous year, and a supportive social environment were significant predictors of subjective health status over time. For every year of schooling prior to arrival in Australia, young people's subjective health status score increased by 0.04 on average (95% CI [0.00, 0.09]; p ¼ 0.038). Participants with greater levels of self-esteem scored 0.03 higher on average in their subjective health status (95% CI [0.01, 0.05; p ¼ 0.013); those who had moved house at least once in the previous year reported a lower subjective health status (0.41 lower on average; 95% CI [0.63, 0.18]; p < 0.001). Respondents with a greater supportive social environment rated significantly higher in their subjective health status (0.05 higher on average; 95% CI [0.00, 0.10]; p ¼ 0.041). A stronger ethnic identity was positively associated with happiness after adjusting for all other remaining variables in the model (Table 3). For every unit increase in ethnic identity score, the happiness score increased by 0.05 on average (95% CI [0.01, 0.09]; p ¼ 0.021). Perceived discrimination was also a significant predictor of wellbeing; refugee migrant youth who had experienced discrimination scored significantly lower in both subjective health status (0.32 lower on average; 95% CI [0.59, 0.05]; p ¼ 0.022) and levels of happiness (0.37 lower on average; 95% CI [0.57, 0.17]; p < 0.001).
Table 2 Profile of participants at each wave.a
Year Number of participants (retention rate) Gender Female Male Region of origin Africa Middle East Eastern Europe Southeast Asia Age Mean ± SD (years) Range (years) Schooling before coming to Australia Mean ± SD (years) Range (years) Time in Australia Mean ± SD (months) Range (months) English language proficiencyb Good Poor a
Wave 1
Wave 2
Wave 3
Wave 4
Wave 5
2004/05 120 (100%)
2005/06 109 (91%)
2006/07 100 (83%)
2007/08 80 (67%)
2012/13 51 (43%)
55 (46%) 65 (54%)
52 (48%) 57 (52%)
47 (47%) 53 (53%)
42 (53%) 38 (47%)
25 (49%) 26 (51%)
86 (72%) 29 (24%) 3 (2%) 2 (2%)
76 (70%) 28 (25%) 3 (3%) 2 (2%)
69 (69%) 26 (26%) 3 (3%) 2 (2%)
56 (70%) 22 (28%) 1 (1%) 1 (1%)
33 (65%) 16 (31%) 2 (4%) 0
15.2 ± 1.6 11e19
16.4 ± 1.6 12e20
17.4 ± 1.9 13e21
18.4 ± 1.9 14e23
22.8 ± 2.0 18e27
5.7 ± 3.0 0e15
5.8 ± 3.0 0e15
6.0 ± 3.0 0e15
5.8 ± 2.9 0e15
5.9 ± 3.1 0e15
5.6 ± 4.4 0e19
19.9 ± 4.8 12e33
32.9 ± 7.3 22e56
45.6 ± 10.0 27e68
96.9 ± 9.2 81e114
10 (8%) 108 (92%)
89 (82%) 19 (18%)
83 (87%) 13 (13%)
75 (94%) 5 (6%)
49 (96%) 2 (4%)
Valid responses. Single-item used by ABS (2006): ‘How well do you speak English now? (not at all; not well, well, very well). A different question, ‘How much English did you know before you came to Australia?’, was asked in Year 1, and has been used as a proxy for level of English language proficiency for the first year of data collection. Item was dichotomised into ‘good’ (well; very well) versus ‘poor’ (not at all; not well) for analytical purposes. b
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Table 3 Predictors of subjective health status and happiness among refugee migrant young people during their first 8 years of resettlement in Melbourne, Australia.a Outcome
Predictor
Mean change
95% CI
P-value
Subjective health status (R2 ¼ 0.139)
Gender (females) Region of birth (Africa) Age (years) Previous schooling (years) Time in Australia (months) English language proficiency (good) Self-esteem Moved house previous year (yes) Supportive environment (higher) Experienced discrimination (yes) Gender (females) Region of birth (Africa) Age (years) Previous schooling (years) Time in Australia (months) English language proficiency (good) Ethnic identity (stronger) Experienced discrimination (yes)
0.03 0.13 0.01 0.04 0.00 0.05 0.03 0.41 0.05 0.32 0.01 0.11 0.04 0.01 0.00 0.09 0.05 0.37
0.24, 0.18 0.10, 0.36 0.08, 0.06 0.00, 0.09 0.01, 0.01 0.18, 0.28 0.01, 0.05 0.63, 0.18 0.00, 0.10 0.59, 0.05 0.23, 0.21 0.38, 0.17 0.11, 0.03 0.03, 0.06 0.00, 0.01 0.10, 0.28 0.01, 0.09 0.57, 0.17
0.786 0.273 0.712 0.038 0.589 0.680 0.013 <0.001 0.041 0.022 0.938 0.457 0.274 0.557 0.349 0.361 0.021 <0.001
Happiness (R2 ¼ 0.091)
a
Wave 1 n ¼ 120; Wave 2 n ¼ 109; Wave 3 n ¼ 100; Wave 4 n ¼ 80; Wave 5 n ¼ 51.
4. Discussion This analysis of the longitudinal predictors of wellbeing among a cohort of refugee youth over their first eight years in Australia has found that a longer period of schooling prior to arriving in Australia, greater self-esteem and a supportive social environment were positively associated with subjective health status; moving house over the previous year had a negative impact on subjective health status. Stronger ethnic identity was positively associated with levels of happiness. Experiences of discrimination had a negative impact on both subjective health status and happiness. High self-esteem is identified as a significant predictor of wellbeing and happiness (Mann et al., 2004). It is an important indicator of refugee youth's wellbeing (McCarthy and Marks, 2010), and a resilience-promoting factor that protects their psychological health (Montgomery, 2011). Increased self-esteem has been found to protect against depressive symptoms among youth displaced by violence (Tol et al., 2013). A supportive social environment has been identified as a protective factor that facilitates resilience in young refugees (Fazel et al., 2012; Montgomery, 2011). Importantly, “(re)establishing a supportive social ecology in the exile country is of prime importance for the healthy adaptation” of refugee youth (Montgomery, 2011) (p.32). A cross-sectional study of 260 asylum-seeking children living in Denmark found that children who had lived in four or more locations since arrival were three times more likely to have poorer mental health (Nielsen et al., 2008). Housing security has been identified as a key issue for refugee youth (RCOA, 2013) and may be even more important for the wellbeing of refugee young adults as they enter the workforce, find partners and form families of their own. Ethnic identity can be defined as “an individual sense of self in terms of membership in a particular ethnic group” (Phinney et al., 2001) (p.496). A previous study of 647 adult refugees from Southeast Asia living in Canada found an association between strong ethnic identity and high level of psychological distress when participants faced racial discrimination or unemployment (Beiser and Hou, 2006). However, although ethnic identity may be a mediator between other predictors and wellbeing, there is also evidence that a direct but modest positive relationship exists between ethnic identity and wellbeing, and this relationship is stronger among adolescents and young adults (Smith and Silva, 2011).
Importantly, when compared with the previous analysis of this cohort over their first three years of settlement (Correa-Velez et al., 2010), young people's experiences of social exclusion, discrimination in particular, still have a significant impact on their subjective wellbeing eight years after arrival. A longitudinal study of 131 refugee youth from the Middle East who arrived in Denmark in 1992e1993 found that a “stressful life context in exile, including discrimination, predicted psychological problems 8e9 years after arrival, more than did traumatic experiences before arrival” (Montgomery, 2010) (p.480). Perceived discrimination was found to be a strong predictor of depression and Post-traumatic Stress Disorder (PTSD) among a group of 135 Somali refugee adolescents living in the U.S. (Ellis et al., 2008). Studies of immigrant youth have also shown the negative effects of discrimination on their sense of belonging (Khanlou et al., 2008). There is robust evidence that repeated experiences of discrimination among young people lead to physiological and psychological stress responses, and to increased unhealthy behaviours which contribute to mental and physical ill health (Pascoe and Richman, 2009; Priest et al., 2013). Having both a strong ethnic identity and experiences of discrimination as predictors of subjective wellbeing among this cohort of refugee youth may at first appear contradictory. Young people who are exposed to discrimination because of their ethnic origin may have negative feelings toward their ethnicity (Phinney, 1989) and therefore report weaker levels of ethnic identity. Research has shown, however, that “prejudice can indirectly enhance wellbeing by encouraging minority group identification” (Branscombe et al., 1999) (p.143). As stated by McCoy and Major (2003), “high group identification produces an initial, temporary increase in emotional vulnerability in response to group threat but that identifying with the group also provides a source of emotional and tangible support, and hence, emotional resilience as time goes on” (p.1016). In their meta-analytic review of perceived discrimination and health, Pascoe and Richman (2009) found that although high levels of ethnic identity may buffer the effects of discrimination by “making negative stereotypes less likely to be incorporated into one's self-concept, these high levels of identity might also lead to a higher vigilance regarding discriminatory experiences” (p.533). Importantly, this longitudinal analysis shows that perceived discrimination is a predictor of wellbeing after controlling for ethnic identity and the other variables in the model (Table 3). Similarly ethnic identity is a significant predictor of happiness after controlling for perceived discrimination (and the other variables in
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the model). Multiple causally cross-lagged and reciprocal relationships between domains are common in biopsychosocial models of refugee adaptation (Porter, 2007). This study has a number of limitations. First, as this is a nonrandom sample, the findings cannot be generalised to the overall population of refugee youth in Australia. However, the gender and country of birth distributions of the original cohort recruited at wave one were similar to those of the population of refugee youth who settled in Australia between 2003 and 2006 (DIBP, 2014). Second, although exposure to violence is a key risk factor for the mental health and wellbeing of refugee youth (Fazel et al., 2012), pre-migration trauma was not assessed in this study. The reasons are that at the time the study was conceived, most research into refugee youth settlement focused on the impact of torture and trauma on mental (ill)health and included subjects recruited from healthcare or torture and trauma services. This study instead, aimed to identify multiple social determinants of settlement and wellbeing over time and to recruit participants from non-healthcare settings (i.e. ELSs). Also, the study was initially conducted in partnership with a torture and trauma service who advised that we should not risk re-traumatizing young people in their first months of settlement by asking questions about pre-migration experiences of violence. Third, single-item outcome measures used in this analysis, subjective health status and happiness, are only two of many indicators that capture the multidimensional nature of wellbeing (McCarthy and Marks, 2010). Although other measures of wellbeing were used for the first three waves (Correa-Velez et al., 2010), the single-item subjective health status and happiness were the only measures used across the five waves. This reflects the need for responsive and dynamic research questions and methods when conducting longitudinal research with cohorts who traverse life stages, as discussed elsewhere (McMichael et al., 2015). Despite these limitations, this study is one of few that have documented the wellbeing of refugee youth over early to mid-term settlement. These findings have important implications for refugee resettlement countries. Policies and programs that foster refugee young people's self-esteem and positive feelings towards their ethnicity (Mann et al., 2004), minimize relocation and support stable connections to place and community, promote social inclusion through tackling racism and discrimination (Fazel et al., 2012), and promote multiculturalism and support a strong sense of belonging to one's ethnic community are likely to enhance health and wellbeing of refugee youth over the longer term. Importantly, this study provides further evidence of the value of policies that tackle discrimination at the individual, organisational, community and societal levels. This study shows that the predictors of wellbeing among refugee youth that persist over time are not refugee specific; they are similar to factors that predict the wellbeing of other minority groups such as Indigenous youth (Haswell et al., 2013). The impact of perceived discrimination will play out in terms of economic stability, life and work satisfaction, and in raising the next generation. Anti-discrimination policies should be an integral part of a country's refugee settlement program. This study provides strong evidence in support of policies that discourage discrimination and promote social inclusion and cultural diversity and which underpin the wellbeing of resettled refugee youth. Acknowledgements The authors would like to thank the young people who participated in this study, the staff from the English Language Schools, and the research team. We also acknowledge the valuable comments provided by the anonymous reviewers. Funding for the different stages of this study was provided by VicHealth,
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Short communication
The persistence of predictors of wellbeing among refugee youth eight years after resettlement in Melbourne, Australia Ignacio Correa-Velez a, *, Sandra M. Gifford b, Celia McMichael c a
School of Public Health and Social Work, Faculty of Health, and Institute of Health and Biomedical Innovation, Queensland University of Technology, Kelvin Grove, Queensland 4059, Australia b The Swinburne Institute for Social Research, Swinburne University of Technology, PO Box 218 Hawthorn, Victoria 3122, Australia c School of Social Sciences, La Trobe University, Bundoora, Victoria 3086, Australia
a r t i c l e i n f o
a b s t r a c t
Article history: Received 8 April 2015 Received in revised form 9 August 2015 Accepted 11 August 2015 Available online 14 August 2015
This short report assesses the predictors of subjective health and happiness among a cohort of refugee youth over their first eight years in Australia. Five waves of data collection were conducted between 2004 (n ¼ 120) and 2012e13 (n ¼ 51) using mixed methods. Previous schooling, self-esteem, moving house in the previous year, a supportive social environment, stronger ethnic identity and perceived discrimination were significant predictors of wellbeing after adjusting for demographic and pre-migration factors. When compared with a previous analysis of this cohort over their first three years of settlement, experiences of social exclusion still have a significant impact on wellbeing eight years after arriving in Australia. This study contributes to mounting evidence in support of policies that discourage discrimination and promote social inclusion and cultural diversity and which underpin the wellbeing of resettled refugee youth. © 2015 Elsevier Ltd. All rights reserved.
Keywords: Australia Refugee youth Wellbeing Settlement Discrimination Social exclusion Longitudinal
1. Introduction In 2010, the predictors of wellbeing among a cohort of refugee youth (aged 11e19) over their first three years of settlement in Melbourne, Australia were reported (Correa-Velez et al., 2010). The authors concluded that predictors of wellbeing were “those that can be understood to promote a sense of belonging, becoming at home, being able to flourish and become part of the new host society” (Correa-Velez et al., 2010) (p.1406). The report stated, “settlement specific policies and programs can ultimately only be effective if embedded within a broader socially inclusive society ( … ) And this requires broader social reform relating to tackling issues of racism, discrimination, bullying, and increased flexibility in the ways these youth can access the social goods to which they are entitled” (p.1407). Two additional waves of data collection were conducted in 2007e08 (wave four) and 2012e13 (wave five). Further analysis of
the predictors of wellbeing is of value given the scarcity of research examining the longer term settlement experiences of refugees (RCOA, 2010; Smyth et al., 2010). International evidence on predictors of migrant health, including refugees, shows a strong and consistent association between social exclusion and poor mental health, subjective health and wellbeing (Beiser et al., 2015; Lecerof et al., 2015; Montgomery and Foldspang, 2008). Conversely, indicators of social inclusion and social participation are consistently associated with positive health and wellbeing (Edge et al., 2014; Lecerof et al., 2015; Sleijpen et al., 2015). This short report asks whether the factors that predict wellbeing in the short term persist over time as these adolescents transition to young adults. It contributes to the evidence that social exclusion, including discrimination, has an adverse impact on the wellbeing of refugee youth not only in the early settlement period but over time. 2. Methods 2.1. Sampling
* Corresponding author. E-mail addresses: [email protected] (I. Correa-Velez), sgifford@ swin.edu.au (S.M. Gifford), [email protected] (C. McMichael). http://dx.doi.org/10.1016/j.socscimed.2015.08.017 0277-9536/© 2015 Elsevier Ltd. All rights reserved.
Immigrant youth typically spend 6e12 months at an English Language School (ELS) during their first year in Australia before
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entering mainstream schools. Participants were recruited through three ELSs that had high numbers of refugee students. 120 young people (55 female, 65 male) were recruited. Ethical clearance was obtained from La Trobe University and from partner organizations. 2.2. Data collection Four annual waves of data collection were conducted between 2004 and 2008. The first three involved completion of a ‘Settlement Journal’ using standardised quantitative measurements of psychosocial health and settlement outcomes, and qualitative methods such as drawings, photos and open-ended questions (Gifford et al., 2007). Data collection was initially conducted in ELSs and facilitated by research assistants, bicultural aides and interpreters. Later waves were conducted by research assistants at participants' homes, schools or public libraries, and without need of interpreters. A fifth wave of data collection occurred in 2012e13, and included in-depth interviews and a short questionnaire which gathered data on settlement and wellbeing. 2.3. Measures Similar to the previous analysis (Correa-Velez et al., 2010), a theoretical model of associations between the demographic/psychosocial factors and outcome measures was developed (Fig. 1). Table 1 shows the wellbeing and psychosocial measures used. Single items assessing subjective health status and happiness were used as outcome measures.
(Gibbons et al., 2010) and is well suited to address our research question which is to provide an overall picture of the predictors of wellbeing among this cohort over their first eight years in Australia, rather than individual causal pathways or reciprocal relationships between variables included in the model which can be assessed using other statistical approaches (Robins et al., 2000). The two outcome variables were continuous and were modelled assuming a Normal distribution. SPSS (IBM v21) was used to run the statistical analyses. The analyses involved three stages. In stage one, all demographic and predictor factors shown in Fig. 1 were entered into a GEE model for each outcome variable. In stage two, a backwards elimination procedure was applied to the predictor factors leaving in the model only those with a p-value 0.05. Demographic and pre-migration factors were fixed into the model to control for the potential confounding effects of gender (females vs. males), region of birth (Africa vs. Other), age (in years), years of schooling before coming to Australia, time (months since arriving in Australia), and English language proficiency (good vs. poor). In stage three, interaction effects for gender were entered into the models. The R2 statistic was used to estimate overall model fit. Participants' retention into the study decreased from 109/120 (91%) in wave two to 100/120 (83%) in wave three, 80/120 (67%) in wave four, and 51/120 (43%) in wave five. When considering the number of participants at each wave, missing responses on individual wellbeing and psychosocial measures ranged from zero to 7.2% over the five waves of data collection. 3. Results
2.4. Statistical analysis
3.1. Participants' characteristics
Chi-square tests for categorical variables and non-parametric ManneWhitney test for continuous variables were used to estimate differences in demographic and pre-migration factors between males and females at first wave. Generalised Estimating Equations (GEE) (Diggle et al., 2002) were used to model the predictors of wellbeing outcomes over the first eight years of resettlement. GEE is a well-recognised method for longitudinal analysis
Participants' characteristics at each wave are shown in Table 2. When comparing wave one data between respondents to wave five (n ¼ 51) and those lost to follow-up (n ¼ 69), there were no statistically significant differences in terms of gender (p ¼ 0.547), region of birth (p ¼ 0.146), age (p ¼ 0.705), previous schooling (p ¼ 0.550), time in Australia (p ¼ 0.052), and English language proficiency (p ¼ 0.552). Similarly, no statistically significant
Fig. 1. Theoretical model of associations between demographic/psychosocial factors and wellbeing outcomes.
I. Correa-Velez et al. / Social Science & Medicine 142 (2015) 163e168 Table 1 Measures used to predict participants' subjective health and wellbeing over their first eight years of settlement in Australia. Item/scale
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differences in demographic and pre-migration factors were found between males and females at wave one.
Cronbach's alpha
Wellbeing outcomes Subjective health ‘How satisfied are you with your health?’ status (1 ¼ very dissatisfied to 5 ¼ very satisfied) (WHO, 1996) Happiness ‘How happy are you now?’ (1 ¼ not at all happy to 4 ¼ very happy) Psychosocial factors Individual Self-esteem 10-item Rosenberg Self-Esteem Scale (Rosenberg, 1989) Family/Neighbourhood Moved house past ‘How many times have you moved home year in the last year?’ (0 ¼ none; 1 ¼ one or more) Ethnic community Ethnic identity 5-item Affirmation and Belonging subscale e Multigroup Ethnic Identity Measure (Phinney, 1992) Status in ethnic Social status of family in ethnic community e community Adapted from MacArthur Scale of Subjective Social Status (Goodman et al., 2001) (1 ¼ lowest status to 10 ¼ highest status) Broader community Supportive 4-item Supportive Environment subscale e environment Baruth Protective Factors Inventory (Baruth and Caroll, 2002) Status in broader Social status of family in broader Australian community community e Adapted from MacArthur Scale of Subjective Social Status (Goodman et al., 2001) (1 ¼ lowest status to 10 ¼ highest status) ‘The Australian community cares about me’ A caring (1 ¼ not at all to 4 ¼ very much) Australian community Perceived Item from the Experiences of Discrimination discrimination scale (Krieger et al., 2005), ‘Ever experienced discrimination because of your ethnicity, religion or colour?’ (0 ¼ No; 1 ¼ Yes)
3.2. Predictors of wellbeing N/A
N/A
0.75
N/A
0.81
N/A
0.80
N/A
N/A
N/A
At wave one, no statistically significant differences for any of the wellbeing outcomes or psychosocial factors shown in Fig. 1 were found between males and females. Table 3 shows the final GEE models for subjective health status and happiness. Gender interaction effects were not statistically significant. After adjusting for demographic and pre-migration factors, previous schooling, self-esteem, moving house in the previous year, and a supportive social environment were significant predictors of subjective health status over time. For every year of schooling prior to arrival in Australia, young people's subjective health status score increased by 0.04 on average (95% CI [0.00, 0.09]; p ¼ 0.038). Participants with greater levels of self-esteem scored 0.03 higher on average in their subjective health status (95% CI [0.01, 0.05; p ¼ 0.013); those who had moved house at least once in the previous year reported a lower subjective health status (0.41 lower on average; 95% CI [0.63, 0.18]; p < 0.001). Respondents with a greater supportive social environment rated significantly higher in their subjective health status (0.05 higher on average; 95% CI [0.00, 0.10]; p ¼ 0.041). A stronger ethnic identity was positively associated with happiness after adjusting for all other remaining variables in the model (Table 3). For every unit increase in ethnic identity score, the happiness score increased by 0.05 on average (95% CI [0.01, 0.09]; p ¼ 0.021). Perceived discrimination was also a significant predictor of wellbeing; refugee migrant youth who had experienced discrimination scored significantly lower in both subjective health status (0.32 lower on average; 95% CI [0.59, 0.05]; p ¼ 0.022) and levels of happiness (0.37 lower on average; 95% CI [0.57, 0.17]; p < 0.001).
Table 2 Profile of participants at each wave.a
Year Number of participants (retention rate) Gender Female Male Region of origin Africa Middle East Eastern Europe Southeast Asia Age Mean ± SD (years) Range (years) Schooling before coming to Australia Mean ± SD (years) Range (years) Time in Australia Mean ± SD (months) Range (months) English language proficiencyb Good Poor a
Wave 1
Wave 2
Wave 3
Wave 4
Wave 5
2004/05 120 (100%)
2005/06 109 (91%)
2006/07 100 (83%)
2007/08 80 (67%)
2012/13 51 (43%)
55 (46%) 65 (54%)
52 (48%) 57 (52%)
47 (47%) 53 (53%)
42 (53%) 38 (47%)
25 (49%) 26 (51%)
86 (72%) 29 (24%) 3 (2%) 2 (2%)
76 (70%) 28 (25%) 3 (3%) 2 (2%)
69 (69%) 26 (26%) 3 (3%) 2 (2%)
56 (70%) 22 (28%) 1 (1%) 1 (1%)
33 (65%) 16 (31%) 2 (4%) 0
15.2 ± 1.6 11e19
16.4 ± 1.6 12e20
17.4 ± 1.9 13e21
18.4 ± 1.9 14e23
22.8 ± 2.0 18e27
5.7 ± 3.0 0e15
5.8 ± 3.0 0e15
6.0 ± 3.0 0e15
5.8 ± 2.9 0e15
5.9 ± 3.1 0e15
5.6 ± 4.4 0e19
19.9 ± 4.8 12e33
32.9 ± 7.3 22e56
45.6 ± 10.0 27e68
96.9 ± 9.2 81e114
10 (8%) 108 (92%)
89 (82%) 19 (18%)
83 (87%) 13 (13%)
75 (94%) 5 (6%)
49 (96%) 2 (4%)
Valid responses. Single-item used by ABS (2006): ‘How well do you speak English now? (not at all; not well, well, very well). A different question, ‘How much English did you know before you came to Australia?’, was asked in Year 1, and has been used as a proxy for level of English language proficiency for the first year of data collection. Item was dichotomised into ‘good’ (well; very well) versus ‘poor’ (not at all; not well) for analytical purposes. b
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Table 3 Predictors of subjective health status and happiness among refugee migrant young people during their first 8 years of resettlement in Melbourne, Australia.a Outcome
Predictor
Mean change
95% CI
P-value
Subjective health status (R2 ¼ 0.139)
Gender (females) Region of birth (Africa) Age (years) Previous schooling (years) Time in Australia (months) English language proficiency (good) Self-esteem Moved house previous year (yes) Supportive environment (higher) Experienced discrimination (yes) Gender (females) Region of birth (Africa) Age (years) Previous schooling (years) Time in Australia (months) English language proficiency (good) Ethnic identity (stronger) Experienced discrimination (yes)
0.03 0.13 0.01 0.04 0.00 0.05 0.03 0.41 0.05 0.32 0.01 0.11 0.04 0.01 0.00 0.09 0.05 0.37
0.24, 0.18 0.10, 0.36 0.08, 0.06 0.00, 0.09 0.01, 0.01 0.18, 0.28 0.01, 0.05 0.63, 0.18 0.00, 0.10 0.59, 0.05 0.23, 0.21 0.38, 0.17 0.11, 0.03 0.03, 0.06 0.00, 0.01 0.10, 0.28 0.01, 0.09 0.57, 0.17
0.786 0.273 0.712 0.038 0.589 0.680 0.013 <0.001 0.041 0.022 0.938 0.457 0.274 0.557 0.349 0.361 0.021 <0.001
Happiness (R2 ¼ 0.091)
a
Wave 1 n ¼ 120; Wave 2 n ¼ 109; Wave 3 n ¼ 100; Wave 4 n ¼ 80; Wave 5 n ¼ 51.
4. Discussion This analysis of the longitudinal predictors of wellbeing among a cohort of refugee youth over their first eight years in Australia has found that a longer period of schooling prior to arriving in Australia, greater self-esteem and a supportive social environment were positively associated with subjective health status; moving house over the previous year had a negative impact on subjective health status. Stronger ethnic identity was positively associated with levels of happiness. Experiences of discrimination had a negative impact on both subjective health status and happiness. High self-esteem is identified as a significant predictor of wellbeing and happiness (Mann et al., 2004). It is an important indicator of refugee youth's wellbeing (McCarthy and Marks, 2010), and a resilience-promoting factor that protects their psychological health (Montgomery, 2011). Increased self-esteem has been found to protect against depressive symptoms among youth displaced by violence (Tol et al., 2013). A supportive social environment has been identified as a protective factor that facilitates resilience in young refugees (Fazel et al., 2012; Montgomery, 2011). Importantly, “(re)establishing a supportive social ecology in the exile country is of prime importance for the healthy adaptation” of refugee youth (Montgomery, 2011) (p.32). A cross-sectional study of 260 asylum-seeking children living in Denmark found that children who had lived in four or more locations since arrival were three times more likely to have poorer mental health (Nielsen et al., 2008). Housing security has been identified as a key issue for refugee youth (RCOA, 2013) and may be even more important for the wellbeing of refugee young adults as they enter the workforce, find partners and form families of their own. Ethnic identity can be defined as “an individual sense of self in terms of membership in a particular ethnic group” (Phinney et al., 2001) (p.496). A previous study of 647 adult refugees from Southeast Asia living in Canada found an association between strong ethnic identity and high level of psychological distress when participants faced racial discrimination or unemployment (Beiser and Hou, 2006). However, although ethnic identity may be a mediator between other predictors and wellbeing, there is also evidence that a direct but modest positive relationship exists between ethnic identity and wellbeing, and this relationship is stronger among adolescents and young adults (Smith and Silva, 2011).
Importantly, when compared with the previous analysis of this cohort over their first three years of settlement (Correa-Velez et al., 2010), young people's experiences of social exclusion, discrimination in particular, still have a significant impact on their subjective wellbeing eight years after arrival. A longitudinal study of 131 refugee youth from the Middle East who arrived in Denmark in 1992e1993 found that a “stressful life context in exile, including discrimination, predicted psychological problems 8e9 years after arrival, more than did traumatic experiences before arrival” (Montgomery, 2010) (p.480). Perceived discrimination was found to be a strong predictor of depression and Post-traumatic Stress Disorder (PTSD) among a group of 135 Somali refugee adolescents living in the U.S. (Ellis et al., 2008). Studies of immigrant youth have also shown the negative effects of discrimination on their sense of belonging (Khanlou et al., 2008). There is robust evidence that repeated experiences of discrimination among young people lead to physiological and psychological stress responses, and to increased unhealthy behaviours which contribute to mental and physical ill health (Pascoe and Richman, 2009; Priest et al., 2013). Having both a strong ethnic identity and experiences of discrimination as predictors of subjective wellbeing among this cohort of refugee youth may at first appear contradictory. Young people who are exposed to discrimination because of their ethnic origin may have negative feelings toward their ethnicity (Phinney, 1989) and therefore report weaker levels of ethnic identity. Research has shown, however, that “prejudice can indirectly enhance wellbeing by encouraging minority group identification” (Branscombe et al., 1999) (p.143). As stated by McCoy and Major (2003), “high group identification produces an initial, temporary increase in emotional vulnerability in response to group threat but that identifying with the group also provides a source of emotional and tangible support, and hence, emotional resilience as time goes on” (p.1016). In their meta-analytic review of perceived discrimination and health, Pascoe and Richman (2009) found that although high levels of ethnic identity may buffer the effects of discrimination by “making negative stereotypes less likely to be incorporated into one's self-concept, these high levels of identity might also lead to a higher vigilance regarding discriminatory experiences” (p.533). Importantly, this longitudinal analysis shows that perceived discrimination is a predictor of wellbeing after controlling for ethnic identity and the other variables in the model (Table 3). Similarly ethnic identity is a significant predictor of happiness after controlling for perceived discrimination (and the other variables in
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the model). Multiple causally cross-lagged and reciprocal relationships between domains are common in biopsychosocial models of refugee adaptation (Porter, 2007). This study has a number of limitations. First, as this is a nonrandom sample, the findings cannot be generalised to the overall population of refugee youth in Australia. However, the gender and country of birth distributions of the original cohort recruited at wave one were similar to those of the population of refugee youth who settled in Australia between 2003 and 2006 (DIBP, 2014). Second, although exposure to violence is a key risk factor for the mental health and wellbeing of refugee youth (Fazel et al., 2012), pre-migration trauma was not assessed in this study. The reasons are that at the time the study was conceived, most research into refugee youth settlement focused on the impact of torture and trauma on mental (ill)health and included subjects recruited from healthcare or torture and trauma services. This study instead, aimed to identify multiple social determinants of settlement and wellbeing over time and to recruit participants from non-healthcare settings (i.e. ELSs). Also, the study was initially conducted in partnership with a torture and trauma service who advised that we should not risk re-traumatizing young people in their first months of settlement by asking questions about pre-migration experiences of violence. Third, single-item outcome measures used in this analysis, subjective health status and happiness, are only two of many indicators that capture the multidimensional nature of wellbeing (McCarthy and Marks, 2010). Although other measures of wellbeing were used for the first three waves (Correa-Velez et al., 2010), the single-item subjective health status and happiness were the only measures used across the five waves. This reflects the need for responsive and dynamic research questions and methods when conducting longitudinal research with cohorts who traverse life stages, as discussed elsewhere (McMichael et al., 2015). Despite these limitations, this study is one of few that have documented the wellbeing of refugee youth over early to mid-term settlement. These findings have important implications for refugee resettlement countries. Policies and programs that foster refugee young people's self-esteem and positive feelings towards their ethnicity (Mann et al., 2004), minimize relocation and support stable connections to place and community, promote social inclusion through tackling racism and discrimination (Fazel et al., 2012), and promote multiculturalism and support a strong sense of belonging to one's ethnic community are likely to enhance health and wellbeing of refugee youth over the longer term. Importantly, this study provides further evidence of the value of policies that tackle discrimination at the individual, organisational, community and societal levels. This study shows that the predictors of wellbeing among refugee youth that persist over time are not refugee specific; they are similar to factors that predict the wellbeing of other minority groups such as Indigenous youth (Haswell et al., 2013). The impact of perceived discrimination will play out in terms of economic stability, life and work satisfaction, and in raising the next generation. Anti-discrimination policies should be an integral part of a country's refugee settlement program. This study provides strong evidence in support of policies that discourage discrimination and promote social inclusion and cultural diversity and which underpin the wellbeing of resettled refugee youth. Acknowledgements The authors would like to thank the young people who participated in this study, the staff from the English Language Schools, and the research team. We also acknowledge the valuable comments provided by the anonymous reviewers. Funding for the different stages of this study was provided by VicHealth,
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