Policy Brief: Immigrant and Refugee Women’s Mental Health

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Background

This policy brief has been developed by the Multicultural Centre for Women’s Health (MCWH). MCWH is a Victorian-based women’s health service established in 1978 that works both nationally and across Victoria to promote the health and wellbeing of migrant and refugee women through advocacy, social action, multilingual education, research and capacity building.

This policy brief outlines the key issues pertaining to migrant and refugee women’s mental health and wellbeing, as well as considerations for mental health policy, programs and service delivery. The issues outlined in this brief have been obtained from a variety of sources, including a comprehensive literature review of current research on migrant and refugee women’s mental health.[1]

As an organisation with a specific focus on migrant and refugee women’s health and wellbeing, this brief describes the experiences of women who identify as coming from a refugee or migrant background. This includes women living in Australia temporarily or permanently, across diverse visa categories and conditions, as well as first, second and many generation citizens.

Immigrants and refugees are not a homogenous group, and the prevalence of mental health conditions varies widely across populations. While the brief aims to highlight all the issues that are relevant to migrant and refugee women, it may not capture specific experiences, which should be considered and addressed. There is limited research available on the specific experiences of migrant women with disabilities, migrant women who are sex workers, older and younger migrant women and girls, migrant women who identify as LGBTIQA+, migrant women living in remote and rural areas, migrant women experiencing homelessness, unemployment or particular financial disadvantage, and migrant women in detention, including asylum seekers.

The issue

In calling for a Royal Commission into Victoria’s Mental Health System, the Victorian government acknowledges that the system as it currently operates, fails to support those who are most in need. The Royal Commission Interim Report argues that Victoria’s mental health system requires “fundamental transformation” to achieve better outcomes for people experiencing mental health difficulties, and their families and carers.[i] The Royal Commission into Mental Health Services is an excellent starting point for discussions about what strategies are needed to support the mental health of migrant women.

Migrant women make up 29% of the Victorian female population.[ii] Immigrant and refugee women experience structural, institutional and interpersonal forms of disadvantage that significantly impact their ability to experience good mental health. The evidence indicates that migrant women experience poorer health outcomes compared with Australian-born women and that this health disparity is likely to extend to mental health.[iii] As such, it is vital that mental health policy initiatives are informed by the evidence related to the factors that shape migrant women’s mental health, including the ways in which gendered inequalities intersect with migration-related social inequalities.[iv]

However, despite the evidence, little attention has been shown to migrant women by the Royal Commission in both its consultations and Interim Report. In addition, the COVID-19 pandemic has highlighted and accentuated the gendered inequalities that exist in the Victorian community and health system. Migrant and refugee women, already disadvantaged, have now been disproportionately impacted by the COVID-19 pandemic, not only missing out on timely and accurate multilingual information about COVID-19, but also facing increased risk of infection, accentuated social isolation due to the digital divide, significant financial disadvantage and an increased risk of family violence.

The research shows that race and gender inequality, violence against women, settlement stress and trauma, and perinatal mental health are particularly important issues for migrant women. In addition, the evidence confirms that immigrant and refugee communities face multiple barriers to accessing mental health support, at all levels. At the policy and programming level, migrant and refugee populations are often overlooked or treated as a homogenous group, which fails to consider the differing needs of both individuals and communities. Moreover, organisational and sector-level barriers such as lack of cultural and gender responsive policies, lack of trained bilingual practitioners working in health services, lack of flexibility, and unaffordability of services have been found to limit the utilisation of services for migrant and refugee women.[v]

As such, there is an urgent need to create a high quality, gender equitable, accessible and culturally and linguistically responsive mental health system. A gendered, intersectional analysis of the factors that contribute to immigrant and refugee women’s mental health is critical in order to develop the necessary policy reforms required to meet the specific yet diverse needs of migrant and refugee women. A gendered, intersectional lens goes beyond explanations that use single categories such as ethnicity and gender to describe health issues. Instead, it recognises that migrant women’s mental health is shaped by many factors, including the social and political context in which women live their lives.

The following section of this Policy Brief will outline some of the key issues impacting immigrant and refugee women’s mental health. It is important to note that while the issues are presented separately, they are interconnected in important and complex ways and should not be considered in isolation from one another.

Race and gender inequality

There is strong evidence that demonstrates that racism and discrimination are important post-migration factors that impact negatively on migrant and refugees’ mental and physical health.[vi] A recent Victorian study found that people who frequently experience racism are almost five times more likely than those who do not experience racism to have poor mental health.[vii]

Evidence suggests that migrant women and Australian-born women experience higher rates of psychological distress than men, which demonstrates that gendered inequality can be associated with poor mental health. Inequalities such as the gender pay gap, workplace discrimination, the overrepresentation of women in casual and insecure employment, and gendered assumptions about domestic and caring duties put women at risk of physical and mental illness. Two to three times more women than men experience depression and anxiety and women make up over 60% of reported self-harm and attempted suicide.[viii][ix]

Migrant women are impacted by race and gender inequality and discrimination which in turn affects their mental wellbeing.[x] Migrant and refugee women have higher rates of mental distress, PTSD, anxiety and depression than migrant and refugee men, again highlighting the gendered inequalities that underpin mental health.[xi] While it is clear that gender plays a role in determining mental health outcomes of migrant and refugee populations, more research is needed to explore the specific factors and inequalities that shape migrant women’s mental health.

Between 2015 and 2017, MCWH undertook a project called Dealing With it Myself which aimed to support migrant and refugee carers of family members or friends who are frail, elderly, and/or living with a disability, chronic illness or mental illness. Through this project, we found that gendered assumptions about caring influenced the level of informal (from friends and family) and formal (from medical and other human services) support that migrant women are offered. MCWH identified the needs of migrant carers and identified carers as a group who have a higher risk of experiencing poor mental health.[2]

In addition to race and gender inequality, other forms of discrimination, including sexual orientation and gender identity-based discrimination can impact women’s mental health, their health-seeking behaviour and experiences with mental health care providers. Past experiences of discrimination and abuse related to race, religion, gender identity and sexual orientation or fear of such discrimination can prevent migrant and refugee women from seeking appropriate support.

Violence against women

The prevalence of violence against women in Australia is unacceptably high: one in three Australian women have experienced physical or sexual abuse and/or emotional abuse in her lifetime. For migrant and refugee women, there is evidence that prevalence rates are even higher, and that violence is more severe and prolonged.[xii]

Violence against women has serious impacts on women’s mental and physical health, including their sexual and reproductive health. Intimate partner violence contributes to approximately 2.2% to the burden of disease for all women and 5.1% to the burden of disease for women aged between 18-44 years. Depressive and anxiety disorders, suicide and self-harm are among the top ten leading causes of the overall burden in women aged 18-44.[xiii]

The reported health impacts of family violence for migrant and refugee women include reduced or impaired mental health and an increasing and persistent fear of the perpetrator committing further violence, returning after separation, or seeking retribution. For migrant and refugee women, health and wellbeing impacts of family violence occur across a continuum; high levels of stress, fear and anxiety persist, regardless of the frequency or severity of the perpetrator’s violence. Migrant women also experience feelings of isolation, depression, guilt and self-blame, low self-esteem, loss of confidence and suicidal thoughts.[xiv]

Migrant women experiencing family violence are also seriously impacted by conditions on temporary visas, which means they often cannot access income support, public housing, healthcare including mental health support, and childcare services.[xv]

Settlement stress and trauma

Pre-migration trauma[3] is seen to play a role in shaping migrant and refugee women’s mental health, and this trauma can be compounded by post-migration issues and settlement stress.[xvi] Evidence suggests that migrants and refugees born in English-speaking countries generally have better mental health compared with Australian-born populations; however, migrants and refugees born in non-English speaking countries have poorer mental health.[xvii]

Post-migration and settlement impacts on mental health are gendered and relate to a range of employment, material and social issues. Issues are inter-related and include social isolation and loneliness, separation from family overseas, lowered economic status and financial stress, lack of family support, limited English-language proficiency, discrimination and racism, unstable housing, immigration detention and visa status. These are all key stressors affecting migrant and refugee women’s mental health and wellbeing. In contrast, proficiency in the majority languages spoken in the host country, family reunification, increased social support and social integration (a sense of belonging and civic participation) are factors that reduce risk and encourage positive mental health.[xviii]

Perinatal mental health

Evidence consistently indicates that migrant and refugee women experience higher rates of perinatal depression and anxiety. Migrants who are from non-English speaking backgrounds in particular, are at risk of experiencing perinatal depression and anxiety.[xix] Shorter length of residency, social isolation, and socioeconomic or financial insecurity are also key risk factors for perinatal mental health conditions, however these factors are compounded by migration-related stressors including immigration status and family separation. In addition, trauma and family violence also appear to be associated with perinatal mental-ill health among migrant and refugee women.[xx]

A recent study conducted by La Trobe University[xxi] and commissioned by MCWH has found that migrant and refugee women tend not to seek help for perinatal mental health issues. According to this study, the barriers to seeking assistance include: social stigma, complexity of the health system, limited transport options, communication barriers, and the high cost of services, particularly for women on temporary visas who are not eligible or Medicare. However, the study found that the most significant barrier to service access for migrant and refugee women is the lack of relevant or appropriate services. In most of Victoria, there are simply no tailored or targeted services that provide specialist expertise in perinatal mental health for migrant or refugee women.

MCWH Recommendations

  1. Investing in and strengthening intersectional policy development and analysis to ensure that Victorian government policy at all levels impacts positively on migrant and refugee women’s mental health. For example, analysis and evaluation of the mental health system and service delivery options should address the multiple forms of disadvantage and barriers to accessing services experienced by migrant and refugee families (including racism and discrimination in service delivery, and language barriers).
  2. Ensuring that mental health services are high quality, gender equitable, accessible and culturally and linguistically responsive by:
    • providing ongoing investment to multilingual and ethno-specific organisations to facilitate innovative, tailored education and advocacy mental health interventions. These programs would be delivered by trained bilingual health educators and work to promote gender and racial equality, increase understanding about women’s mental wellbeing, and decrease stigma around women’s mental health;
    • ensuring all mental health prevention, early intervention, support and treatment services, as well as interpreting services, are available to migrant women free of charge, regardless of migration status;
    • training mental health service staff and the interpreting workforce in gendered, cross-cultural awareness.
    • providing ongoing investment to mental health services to offer comprehensive, culturally and linguistically appropriate support and case management to migrant women;
    • recognising that many technology-based modes of service delivery further exacerbates the digital divide as it excludes women of non-English speaking backgrounds from accessing timely early intervention services;
    • ensuring that migrant and refugee women have access to multilingual information about women’s mental health and wellbeing and related services.

3)   Conducting further participatory action research to increase the evidence-base for migrant and refugee mental health and wellbeing in Victoria.

Footnotes

[1] MCWH commissioned researchers from the University of Melbourne, School of Population and Global Health to conduct a literature review on migrant and refugee women’s health. The review was published in October, 2020.

[2] A summary of our findings and recommendations can be accessed here: https://www.mcwh.com.au/publications/#project-reports

[3] Pre-migration trauma can include experiences of violence and war, family separation, sexual and gender-based violence, torture, imprisonment and immigration detention and the denial of basic living essentials.

[i] State of Victoria, Royal Commission in Victoria’s Mental Health System, Interim Report, Parl Paper No. 87 (2018-2019).

[ii] ABS (2016) The Census Population and Housing, Australian Government.

[iii] Sullivan, Vaughan and Wright. (2020). Migrant and refugee women’s mental health in Australia: a literature review. School of Population and Global Health, University of Melbourne.

[iv] Ibid.

[v] Ibid.

[vi] DHHS (Department of Health and Human Services) (2017). Racism in Victoria and what it means for the health of Victorians, State Government of Victoria, Melbourne.

[vii] Ibid.

[viii] Department of Premier and Cabinet. (2016). Safe and Strong: A Victorian Gender Equality Strategy. State Government of Victoria, Melbourne.

[ix] Yu, S. (2018).  ‘Uncovering the hidden impacts of inequality on mental health: a global study.’ Translational Psychiatry. 8(1): 98.

[x] Delara, M. (2016). ‘Social Determinants of Immigrant Women’s Mental Health.’ Advances in Public Health, vol. 2016, Article ID 9730162, 11 pages.

[xi] Sullivan, Vaughan and Wright. (2020). Migrant and refugee women’s mental health in Australia: a literature review. School of Population and Global Health, University of Melbourne.

[xii] Lum On, M. et. al. (2016). Examination of the health outcomes of intimate partner violence against women: State of knowledge paper (ANROWS Landscapes, 03/2016).

[xiii] Ayre, J. et. al. (2016). Examination of the burden of disease of intimate partner violence against women in 2011: Final Report (ANROWS Horizons, 06/2016). Sydney: ANROWS.

[xiv] Vaughan, C. (2016). Promoting community-led responses to violence against immigrant and refugee women in metropolitan and regional Australia: The ASPIRE Project: Key findings and finding directions. ANROWS: Sydney.

[xv] Ibid.

[xvi] Sullivan, Vaughan and Wright. (2020). Migrant and refugee women’s mental health in Australia: a literature review. School of Population and Global Health, University of Melbourne.

[xvii] Ibid.

[xviii] Jurado, D. et. al. (2017). ‘Factors associated with psychological distress or common mental disorders in migrant populations across the world.’ Revista de Psiquiatria y Salud Mental (Barc). 10: 45-59.

[xix] Shafiei, T. et. al. (2018) Identifying the perinatal mental health needs of immigrant and refugee women. La Trobe University.

[xx] Sullivan, Vaughan and Wright. (2020). Migrant and refugee women’s mental health in Australia: a literature review. School of Population and Global Health, University of Melbourne.

[xxi] Shafiei, T. et. al. (2018) Identifying the perinatal mental health needs of immigrant and refugee women. La Trobe University.