1.4. INTERVENTIONS AND SERVICE PROVISION
1.4.2. Service utilization patterns
1.4.2.1. Service access
There seems to be a general agreement that refugee adolescents with mental health problems do not access care adequately (Griffith & Chan-Kam, 2002). A study by Bean et al. (2006) addressed mental health needs and service access among these young persons. Data was collected from unaccompanied refugee young persons and other professionals, including carers and teachers. Their well-being, mental health need and service utilization were compared with a non-refugee group. The findings suggested that unaccompanied refugee young persons who reported a need to access mental health services also experienced a higher degree of distress than local young persons. Professionals, however, overall failed to detect distress and service needs in the majority of refugee young persons. Their referral to specialist mental health service appeared to be initiated by the professionals’ perceived needs, and not by what these young persons themselves felt. About half of the refugee young persons eventually reported their mental health needs as unmet. In the absence of parents or other family members, the available carers or guardians should be conscious of these young persons’ potentially unmet need to access mental health care, despite their frequently limited information on the past or even recent history.
Sanchez-Cao et al. (2012) investigated the mental health needs and service access pattern among 71 unaccompanied young persons in London through the Harvard Trauma Questionnaire, Impact of Event Scale, Strengths and Difficulties
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Questionnaire and Birleson Depression Self-Rating Scale for Children. Data on service utilization was collected through the Attitudes to Health and Services Questionnaire. Although two thirds (66.2%) of the sample had high levels of post traumatic stress symptoms, only 17% had any kind of contact with specialist mental health services. Symptoms of depression, rather than post traumatic stress disorder, and duration of stay in the host nation predicted contact with mental health services.
This is consistent with the earlier findings of under-utilization of services. Language barriers; lack of knowledge about services; high frequency of relocation; and varied cultural understanding of psychopathology, treatment and attitude towards help-seeking were discussed as underlying factors influencing service access in unaccompanied refugee minors. Bean et al. (2006), as well as Sanchez-Cao et al.
(2012), suggested that the young persons who remained in the host country for longer and had an adequate opportunity to acculturate and be accustomed with local health beliefs and practices, showed a better chance of acknowledging needs and asking for help, thereby accessing and utilizing specialist mental health services better.
Vaage et al. (2007) conducted a case-control study based on a review of clinic records to compare service utilization between refugee and Norwegian children referred to a child psychiatry department in southern Norway. Surprisingly, the authors found no significant difference in referral or service utilization rates between the two groups. This inconsistency could be explained by the methodological limitation of this study such as its retrospective nature or could reflect differences in the quality of service provision in different healthcare systems. Interestingly, compared with Norwegian children, refugee children were diagnosed more
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frequently with post-traumatic stress, affective and other emotional disorders, and less often with pervasive developmental and attention deficit-hyperactivity disorders.
There is a paucity of qualitative research evidence on service utilization and help-seeking patterns. Most research to date has centred on the generic adolescent population, and even this remains limited. De Anstiss and Ziaian (2010) held 13 focus groups in Australia with 85 refugee adolescents aged 13-17 years from Afghanistan, Bosnia, Iran, Iraq, Liberia, Serbia, and Sudan. The findings indicated that most were very reluctant to venture beyond their close friendship networks for help with their psychosocial problems due to a range of individual, cultural, and service-related barriers. Michelson and Sclare (2009) found significant differences in referral pathways and service access between unaccompanied and accompanied refugee minors. Unaccompanied asylum seeking children and young persons were more likely to be referred by social care rather than health agencies. They also attended fewer sessions, and missed a greater proportion of scheduled appointments. Despite their elevated risk of PTSD, they were less likely than accompanied children to have received trauma-focused interventions, cognitive therapy, anxiety management and parent or carer training, and also received fewer types of practical assistance with their basic social needs.
Although many studies have evaluated ways of increasing engagement for hard to reach populations such as at risk youth or the severely and persistently mentally ill, few have examined those for refugees per se. Some researchers suggested a lack of eagerness or capacity of services to address the needs of refugee young persons as a reason for service under-utilization (de Anstiss et al. 2009). A study in Chicago
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(Harris, 2008) examined an outreach model for refugee children in improving access and engagement. Clinicians tended to extend outreach prior to enrolment in treatment more frequently to children and young persons with refugee status, and to those with greater deprivation of basic needs. Findings also suggested that young persons who received outreach prior to enrolment in the clinic were less likely to drop out of treatment. This suggests that clinician outreach may help refugee children and young people overcome barriers to accessing and engaging in treatment. Social workers and paediatricians who have regular contact with unaccompanied refugee young persons are often aware of their psychological difficulties; and so should be well positioned to facilitate their access to mental health services (Sanchez-Cao et al., 2012). It has been recommended that periodical mental health assessments would enhance recognition and appropriate referrals (Bean et al., 2006).
Self-reports should be taken seriously in the decision-making process. Caregivers and teachers, who provide a secure base, should be adequately trained to offer psycho-education and coping strategies to those young persons with a higher level of needs. It is also important that legal guardians and specialist mental health services work in partnership to improve carers’ awareness (Bean et al., 2006).
Overall, there still appears to be a general lack of appropriate mental health services that social care and general practitioners can refer these young people to.
Additionally, there is a gap in appropriate transitional services for refugee young people once they become 18 years old (Chase et al., 2008). Transition can be problematic for all young people, but more so in this group because of restrictions
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imposed by regulations on their further stay in the host country, and also a lack of adult services specific for this population.