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This is to certify that the dissertation entitled ACCULTURATIVE STRESS AND PSYCHOLOGICAL DISTRESS IN ADULT FEMALE LIBERIAN REFUGEES IN THE UNITED STATES presented by Muthoni Gatwiri lmungi has been accepted towards fulfillment of the requirements for the Ph.D. degree in Social Work W0). 3% Major Professor’s Signature 2 July 2008 Date MSU is an affirmative-action. equal-opportunity employer ACCULTURATIVE STRESS AND PSYCHOLOGICAL DISTRESS IN ADULT FEMALE LIBERIAN REFUGEES IN THE UNITED STATES By Muthoni Gatwiri lmungi A DISSERTATION Submitted to Michigan State University in partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY Social Work 2008 ABSTRACT ACCULTURATIVE STRESS AND PSYCHOLOGICAL DISTRESS IN ADULT FEMALE LIBERIAN REFUGEES IN THE UNITED STATES By Muthoni Gatwiri lmungi Acculturative stress has been identified as a major source of psychological distress in immigrants and refugees (Williams & Berry, 1991; Hovey & Magana, 2002). Acculturative stress is the term used to refer to stressors that are identified as having their source in the process of acculturation (Greenland & Brown, 2005). Acculturative stress does not result in psychological distress for all immigrants or refugees. The relationship between acculturative stress and psychological distress is probabilistic rather than deterministic (Berry, 2005; Williams & Berry, 1991;Berry, Kim, Minde & Mok, 1987). According to the acculturative stress model, five sets of individual and group characteristics moderate the psychological consequences of acculturation for individuals and groups (Berry, 2005; Williams & Berry, 1991; Berry, 1990; Berry et al., 1987). These five sets of individual and group characteristics are the type of acculturating group, mode of acculturation, nature of the host society, demographic and social characteristics, and psychological characteristics. Of these five sets of characteristics, social and demographic characteristics have been the most researched in studies of immigrant and refugee psychological wellbeing (Farver, Nrang & Bhadha, 2002; Lim, Heiby, Brissin & Griffin, 2002; Lieber, Dorothy, Nihira & Mink, 2001). Age at immigration, time spent in the host country, gender, fluency of spoken English, socioeconomic status (SES), social support, religiosity, health, and pre-migration traumatic experiences are some of the social and demographic characteristics that have been found to strongly moderate the relationship between acculturative stress and psychological distress in immigrants and refugees. Research with these conclusions was conducted with mainly larger Hispanic and Asian immigrant and refugee groups in the US. (Takeuchi et al., 2007; Hsu, Davies, & Hansen, 2004). Few of these studies involved African refugees (Rumbaut, 1999). This study used a mixed methods research design that employed both qualitative and quantitative research methods to explore the impacts of social and demographic characteristics on acculturative stress and psychological distress in 27 adult female Liberian refugees living in Lansing, Michigan. Social and demographic characteristics were explored in order to allow for comparison with findings of other similar studies. Social and demographic characteristics that were studied included age at resettlement, time spent in the host country, fluency of spoken English, single female head-of- household status, SES, social support, religiosity, health, and pre-migration trauma. The study found limited fluency of spoken English, poor perception of personal health and pre-migration trauma moderated the effects of acculturative stress, while poor fluency of spoken English, poor perception of personal health, and pre-migration trauma moderated the effects of psychological distress in the study sample. Findings from the study were used to make recommendations for services to better aid the acculturation and adjustment of adult female Liberian refugees in the US. Copy Right by MUTHONI GATWIRI IMUNGI 2008 DEDICATION Dedicated to my parents for their unending, love, support, and encouragement. ACKNOWLEDGEMENTS Completing this dissertation would not have been possible without the support that I received from many people. My family has been instrumental throughout this process. I would like to thank my father for having taught me that foresight, planning, hard work, and dedication were important components of success in any endeavor. A special thank you to my mother her for her emotional support, which was vital in maintaining my sanity while in the Ph.D. program. Thank you also to my brother and sisters for cheering me on when I had little strength or drive left. Thank you also to my dear friends Salome Aringo, Mary Mathenge, and Eva Wesonga for their support, encouragement an “you can do it speeches.” Words cannot express how grateful I am to my doctoral dissertation committee for their support. I would like to thank Dr. Paul Freddolino, my committee chair, for his careful review of my dissertation and his invaluable feedback. Thank you Dr. F reddolino for supporting my unrealistic but "doable” dissertation completion timeline! I must also thank other members of my committee Dr. Margie Rodriguez Lesage, Dr. Barbara Ames, and Dr. Tom Luster for their guidance and advice which helped fine tune my research agenda and dissertation. Thank you Dr. Ames for taking over supervision of my dissertation process in the final days, while my dissertation chair was away on sabbatical. The faculty, staff, and doctoral students at Michigan State University’s School of Social Work have also contributed a great deal to the successful completion of this dissertation. I am especially grateful to Dr. Gary Anderson, Director of the School of Social Work and Dr. Rena Harold, Associate Director of the School of Social Work for the financial support that they extended to me through an Assistantship, Grants and vi fellowships. That financial support freed me from worrying about finances and allowed me to concentrate my dissertation. By extension, I am also grateful to the Field Education Office who took me on as a Graduate Assistant. Jo Ann McFall, Julie Navarre, Mary Lou Jenks (field education office team) thank you for all your support and encouragement! Thank you fellow social work doctoral student colleagues Jim Edwards, Francis Akakpo, Carolyn McAlister-Kobayashi, Kimberly Steed, Rie Kobayashi, and Judy Ravenhorst-Meerman for enriching this journey laughter. A special thanks to Jim Edwards for the energizing support lunches. Most of all, I must thank the women who participated in this study for sharing their life stories with me. Without their participation, this dissertation would not have been possible. Jacqueline Humphrey, my partner in crime, thank you for the support, laughter, friendship, and so much more. We made it, Jacqueline! Last but definitely not least, I am grateful to God because it is only through him that this accomplishment in my life has been possible. vii TABLE OF CONTENTS LIST OF TABLES ................................................................................. xi LIST OF FIGURES ................................................................................ xii CHAPTER 1: ACCULTURATION, ACCULTURATIVE STRESS AND PSYCHOLOGICAL DISTRESS ..................................................... 1 Introduction: Acculturation, Acculturative Stress and Psychological Distress .............................................................................. 1 Theoretical Underpinnings for the Study of Acculturative Stress... . . ........4 The Acculturative Stress Model ..................................................... 5 Factors Moderating the Relationship between Acculturation, Acculturative Stress and Psychological Distress ................................ 9 CHAPTER 2: ACCULTURATIVE STRESS AND PSYCHOLOGICAL DISTRESS IN IMMIGRANTS AND REFUGEES .......................... 14 Impact of Social and Demographic Characteristics ........................... 14 Age at Immigration ....................................................... 14 Time Spent in the Host Country ........................................ 15 Gender ..................................................................... 16 Ability to Communicate in the Language of the Host country. . ...17 Socioeconomic Status (SES) ........................................... 17 Social Support ............................................................ 18 Religiosity ................................................................ 19 Health ....................................................................... 20 Traumatic Pre-migration Experiences ................................ 21 CHAPTER 3: METHODOLOGY .................................................................. 23 Problem Statement ................................................................. 23 ' The Study Sample .................................................................. 24 Hypothesis .............................................................................. 24 Recruiting Research Participants .................................................. 26 Data Collection ................................................................... 26 Instrumentation ................................................................... 27 Sociodemographic Questionnaire ...................................... 27 Social, Attitudinal, Familial, Environmental and Acculturative Stress Scale-Revised (SAFE-R) ....................... 28 Medical Outcome Health Survey Short Form-12 (SF -2) ............ 29 The Harvard Trauma Questionnaire - Revised (HTQ-R) ........... 29 Duke Religion Index DUREL) ........................................... 31 Multidimensional Scale of Perceived Social Support - Revised (MSPSS-R) ........................................ 32 Hopkins Symptom Checklist-25 (HSCL-25) ......................... 33 viii Semi-structured Interview Guide ....................................... 34 Data Analysis ............................................................ 34 CHAPTER 4: RESULTS ........................................................................... 36 Description of the Sample ........................................................ 36 Social, Attitudinal, Familial, Environmental and Acculturative Stress Scale-Revised (SAFE-R) ....................... 41 Multidimensional Scale of Perceived Social Support - Revised (MSPSS-R) .......................................... 43 Duke Religion Index (DUREL) ........................................... 45 Medical Outcome Health Survey Short Form-12 (SF -12) .......... 46 The Harvard Trauma Questionnaire- Revised (HTQ-R) . . . . .47 Hopkins Symptom Checklist -24 (HSCL-25) ........................ 49 Hypothesis testing ............................................................... 51 Hypothesis 1 ............................................................. 51 Hypothesis 2 .............................................................. 52 Hypothesis 3 ............................................................... 52 Hypothesis 4 ................................................................. 53 Hypothesis 5 ............................................................... 53 Hypothesis 6 ................................................................ 54 Hypothesis 7 .............................................................. 54 Hypothesis 8 ............................................................... 55 Hypothesis 9 ............................................................... 56 Qualitative analysis ............................................................... 57 Themes .................................................................... 60 Flight Experiences ...................................................... 64 Asylum Experiences .................................................... 65 Resettlement Experiences ............................................. 73 CHAPTER 5: DISCUSSION .................................................................... 102 Discussion of hypotheses ....................................................... 102 Hypothesis 1 ............................................................. 103 Hypothesis 2 ............................................................ 104 Hypothesis 3 .............................................................. 105 Hypothesis 4107 Hypothesis 5 ............................................................. 110 Hypothesis 6 ............................................................... 112 Hypothesis 7 ............................................................. 113 Hypothesis 8 ............................................................. 114 Hypothesis 9 .............................................................. 116 Limitations and Strengths of the Study ...................................... 118 Implications of the Findings ................................................... 120 Implications for Refugee Resettlement Agencies ........................... 121 Implications for Social Work Education and Practice ...................... 124 Areas for Future Research. .................................................... 125 Conclusion ....................................................................... 127 ix APPENDICES ....................................................................................... 130 Appendix A: Sociodemographic Questionnaire .................................................. 131 Appendix B: Social, Attitudinal, Familial, Environmental and Acculturative Stress Scale-Revised (SAFE-R) 136 Appendix C: Medical Outcome Health Survey Short Form-12 (SF-12)................138 Appendix D: Harvard Trauma Questionnaire (HTQ-R) (Part) .......................... 140 Appendix E: Harvard Trauma Questionnaire- Revised (HTQ-R) (Part 2) ............ 142 Appendix F: Duke Religion Index (DUREL) .............................................. 144 Appendix G: Multidimensional Scale of Perceived Social Support- Revised (MSPSS-R) .................................................................... 146 Appendix H: Hopkins Symptom Checklist (HSCL-25) ................................ 148 Appendix 1: Semi-structured Interview guide ............................................ 150 Appendix J: Table 11: Correlations: Sociodemographic Variables and Acculturative Stress ........................................................... 155 Appendix K: Table 12: Correlations: Sociodemographic Variables and Anxious/Depressive symptomatology ...................................... 157 Appendix L: Table 13: T—test: Sociodemographic Variables and Acculturative Stress ............................................................................ 159 Appendix M: Table 14: T-test: Sociodemographic Variables and Depressive/anxious Symptomatology ...................................... 160 Appendix N: Table 15: Qualitative Data A: Emergent Themes ........................ 161 REFERENCES ..................................................................................... 168 Table 1: Table 2 Table 3 Table 4: Table 5 Table 6: Table 7: Table 8: Table 9: Table 10: Table 11: Table 12: Table 13: Table 14: Table 15: LIST OF TABLES Research Instruments ................................................................. 28 Current Age and Age at Resettlement (N = 27) ................................. 37 Length of Residence in the US. (N =27) .......................................... 37 Schooling Patterns in the Natal, Asylum Country and US. (N=27)............38 Schooling Years in the Natal, Asylum Country and US. (N=27) ............. 39 Employment and Income Patterns (N = 27) ....................................... 4O Proficiency of Spoken English (N = 27) .......................................... 41 Scores on the Multidimensional Scale for Perceived Social Support - Revised (MSPSS-R) (N=26) ............................................ 45 Traumatic Events Most Experienced by Refugees (N = 26) ................... 50 Descriptive Characteristics Comparing Respondents Participating/Not Participating in the In-Depth Interviews (N -27) ................................. 59 Correlations: Sociodemographic Variables and Acculturative Stress .......... 155 Correlations: Sociodemographic Variables and Anxious/Depressive Symptomatology .................................................................... 1 57 T-test: Sociodemographic Variables and Acculturative Stress .............. 159 T-test: Sociodemographic Variables and Depressive/Anxious Symptomatology .................................................................... 1 6O Qualitative Data A: Emergent Themes .......................................... 161 xi LIST OF FIGURES Figure 1: Berry’s Acculturative Stress Model ............................................. 6 Figure 2: Berry’s Acculturative Stress Model as Modified by Hovey and King ..................................................................... 7 Figure 3: Modified Acculturative Stress Model ............................................ 8 xii CHAPTER 1 ACCULTURATION, ACCULTURATIVE STRESS AND PSYCHOLOGICAL DISTRESS Immigration has become a global phenomenon that has fueled interest in research with immigrants (N owlin, 2004). Research with immigrants has focused largely on acculturation and adjustment, because social scientists are interested in the impacts of this movement on various immigrant groups (Greenland & Brown, 2005; Noh & Avison, 1996). Acculturation is the term used to describe the change and adjustment that occurs as one acclimates to a new cultural environment (Chiriboga, 2004; Cabassa, 2003; Williams & Berry, 1990). This chapter introduces the concept of acculturation and provides a theoretical framework for understanding the impacts of acculturation on acculturating individuals and groups. Introduction: Acculturation, Acculturative Stress and Psychological Distress The term acculturation was coined in the mid 1930’s by Redfield, Linton and Herskovits (1936, p. 49) to refer to “those phenomena which result when groups of individuals having different cultures come into continuous first-hand contact, with subsequent changes in the original cultural patterns of either or both groups.” Originally conceptualized as a group-level phenomenon, acculturation is now increasingly also accepted as an individual-level phenomenon commonly referred to as psychological acculturation (Chiriboga, 2004; Cabassa, 2003; Farver, Nrang, & Bhadha, 2002; Berry, 1990; Pham & Harris, 1990; Williams & Berry, 1990; Berry, Kim, Minde & Mok, 1987). Though acculturative changes at both the individual and group level are of interest to social scientists, it is the former that has received the most research attention (William & Berry, 1999). John W. Berry, a leading scholar of acculturation, identified five areas where changes resulting from acculturation can be observed at the individual level (Berry, 2005; Berry et a1, 1987). These five areas are the physical, biological, cultural, relational, and psychological realms. Though scholars of psychological acculturation are interested in all five areas of change, it is the effects of acculturation on the psychological well-being that has received the most attention (Greenland & Brown, 2005; Noh & Avison, 1996). Acculturation is a gradual process that can take days, weeks, years, and at the group level can even occur continually over generations (Greenland & Brown, 2005; Nwadiora & McAdoo, 1996). Reconciliation of cultural differences between the natal country and the host country is one of the main challenges experienced by acculturating individuals and groups (Lieber et al., 2001). Dissonance between the two cultures can be a source of distress for acculturating individuals and groups as they adjust to life in a host country (Oh, Koske & Sales, 2002; F arver et al., 2002). Acculturative stress is the term used to refer to stressors that are identified as having their source in the process of acculturation (Greenland & Brown, 2005). Intensity of acculturative stress varies depending on the cultural similarities and differences that exist between the natal and host country. The more disparate the two cultures, the greater the intensity of acculturative stress that will be endured by the immigrant (Pham & Harris, 2001; Nwadiora & McAdoo, 1996) Scholars of acculturation claim that acculturative stress can result in psychological distress for those experiencing it (Berry, 2005; Hovey & Magaha, 2002). Feelings of confusion, marginality, alienation, heightened psychosomatic symptom levels, and identity confusion that accompany the acculturative process are thought to cause psychological distress, which often manifests as anxiety and depression in acculturating individuals and groups (Greenland & Brown, 2005; Bhattacharya & Schoppelrey, 2004; Chiriboga, 2004; Hovey & Magaha, 2002; Lim et al., 2002; Oh, et al., 2002; Williams & Berry, 1991; Berry, 1990). Studies on the consequences of acculturative stress for psychological wellbeing have reported mixed findings. Some studies have reported that acculturative stress results in acculturating individuals and groups being more psychologically distressed than natives of the host country, while others have negated this claim (Wong, Lam, Yan & Hung, 2004; Chiriboga, 2004; Oh et al., 2002; Miranda & Umhoefer, 1998; Vega, Kolody & Valle, 1987). Acculturative stress does not result in psychological distress for all those involved in the acculturation process. The relationship between acculturative stress and psychological distress is probabilistic rather than deterministic (Berry, 2005). Although acculturation may have a profound effect on a given group, individual members within that group vary considerably in the extent to which they experience or are affected by this phenomenon (Cabassa, 2003). While some will experience acculturation as stressful, others will experience it as a life-changing event which they will resolve without difficulty. Theoretical Underpinning for the Study of Acculturative Stress Studies with the general population have demonstrated that differences in exposure to stress account for much of the variability in psychological outcomes observed across individuals and groups (Turner, Wheaton & Lloyd, 1995). As a result, stress theory has become the dominant framework for conceptualizing differences in psychological outcomes of individuals and groups (Turner & Avison, 2003). Research on the significance of social stress for health and well being can be traced to the 19303 (Turner & Avison, 2003). From the 1930s to the 19705, research on social stress centered primarily on its harmful effects for health and well-being (Ensel & Lin, 1991 ;Lin &, Ensel 1989). Study findings revealed a reliable link between social stress and the occurrence of psychological distress (Turner & Avison, 2003; Ensel & Lin, 1991; Turner et al., 1995; Lin &, Ensel 1989). The stress theory that emerged from these findings was called the stress-distress model (Lin & Ensel, 1989). The stress-distress model hypothesized that there was a reliable link between social stress and the occurrence of psychological distress in individuals. In the 19708, a paradigm shift occurred in theorizing on stress (Ensel & Lin, 1991). Having realized the effect of social stress on individuals, researchers were interested in finding out whether there were resources in an individual’s psychosocial environment that could enhance one’s ability to cope with adverse effects of social stressors (Ensel & Lin, 1991; Lin & Ensel, 1989). Studies revealed that social support and psychological variables acted as mediators or buffers against the psychological consequences of social stressors for individuals. Variables that buffered or mediated the effects of social stress came to be known as coping resources (Noh & Avison, 1993; Lin & Ensel, 1989). Theories that emerged explaining the stress buffering or mediating role of coping resources came to be known as stress-coping theories (N oh & Avison, 1993; Ensel & Lin, 1991; Lin & Ensel, 1989). The first integrated stress-coping model was proposed in the 19803 (Noh & Avison, 1996; Ensel & Lin, 1991). The integrated model mapped out a plethora of social, psychological, biological, and physiological resources that were thought to buffer or mediate the effects of social stress for individuals and groups. According to the integrated stress-coping model, the effects of social stressors vary considerably across individuals and groups, moderated by variations in coping resources. Studies in many disciplines have provided empirical evidence supporting stress mediating or buffering roles of coping resources (Noh & Avison, 1996). Acculturative stress is a special kind of social stress emerging as a result of one’s involvement in the acculturative process. The acculturative stress model posits a framework for explaining variations in psychological distress observed across acculturating individuals and groups. The acculturative stress model views acculturation and its psychological impacts through the theoretical fi'amework presented in the stress- coping model (Mui, Kang, 2006; Cabassa, 2003; Noh & Avison, 1996). The Acculturative Stress Model The acculturative stress model was developed by John William Berry (2005). Borrowing from the stress-coping model, the acculturative stress model, illustrated in Figure], claims that five individual and group characteristics moderate the consequences of acculturation for individuals and groups (Berry, 2005; Williams & Berry, 1991; Berry, 1990; Berry etal., 1987). These five individual and group characteristics are the type of acculturating group, mode of acculturation, nature of the host society, demographic and social characteristics, and psychological characteristics. Figure 1 Berry’s Acculturative Stress Model Acculturation Stressors Acculturative Experience ’ Muih . fires: Much ‘ ”c I Little Little Little Factors moderating the relationship between acculturation and Stress Type of acculturating group Mode of acculturation Nature of the host society Demographic and social characteristics Psychological characteristics 9:59P? Ben'y et a1. 1987 Berry’s acculturative stress model has been used in numerous studies to theorize about the psychological effect of acculturation and acculturative stress on individuals and groups (Ryder, Alden & Paulhus, 2002). The model, however, does not elucidate the link between acculturation, acculturative stress and psychological outcomes. The acculturative stress model as presented by Berry in Figure I only theorizes about the link between acculturation and acculturative stress. In the late 19903, Hovey and King (1997) extended Berry’s acculturative stress model so that it explained the psychological consequences of acculturation and acculturative stress for Mexican immigrants in their study. This modified acculturative stress model, presented in Figure 2, links heightened acculturative stress to depression and suicide. Figure 2 Berry’s Acculturative Stress Model as Modified by Hovey and King Acculturation Acculturative Suicidal Ideation Experience Stress - I I ' Much ’ High ,.."""’4 4 I A I ’15; ..... 4 ' l - r . ' ._ . . _ ..... .’ I ' Depression Little I Low ! ' l | i Variables moderating the relationship between acculturation, acculturative stress, depression, and suicidal ideation Family Cohesiveness Social Support Socioeconomic Status Premigration Adaptive Functioning Prior Knowledge of the New Language and Culture Motives for Move Cognitive variables Age at migration Generation m the new community 10. Degree of cultural pluralism within the new community 998999939?" Retrieved Hovey and King (1997), pp.94 Borrowing from Hovey and King (1997), in Figure 3, I propose an expansion of Berry’s acculturative stress model so that it now explains the empirical link between acculturation, acculturative stress and psychological distress outcomes observed in acculturating individuals and groups. The new model fits with empirical findings from numerous studies of acculturation that have found heightened acculturative stress often becomes psychological distress and manifests as anxiety and depression in acculturating individuals and groups (Berry, 2005; Hovey & Magaira, 2002). Figure 3 Modified Acculturative Stress Model Acculturation Stressors Acculturative Psychological Experience Stress Outcomes Much Much fit ‘ Much ’ ' " Depression A I i I and!” . i . s I 3 WW Little : thtle : : l ' Little ' l ! ! i i i Factors Moderating the Relationship between Acculturation, Acculturative Stress and Mental Health Problems 1. Type of acculturating group 2. Mode of acculturation 3. Nature of the host society 4. Demographic and social characteristics 5. Psychological characteristics Factors Moderating the Relationship between Acculturation, Acculturative Stress and Psychological Distress Five sets of individual and group characteristics are identified by the acculturative stress model as moderating the relationship between acculturation, acculturative stress, and psychological distress outcomes in acculturating individuals and groups. These five sets of individual and group characteristics which are discussed below include the type of acculturating group, mode of acculturation, nature of the host society, demographic and social characteristics, and psychological characteristics. Type of acculturating group. Berry’s acculturative stress model distinguishes among acculturating groups by the voluntariness of movement, the type of movement, and the permanence of contact with the host society (Berry, et al., 1987). Research by Berry found that those immigrating voluntarily (e.g. immigrants) experienced less acculturative stress and psychological distress than those forced to migrate (e. g. refugees and relocated native people), since their attitude towards migration and acculturation was likely to be more positive. The same research also found that those only in temporary contact with members of the host society and those without permanent social support in the host country (e. g. sojoumers) were likely to experience more acculturative stress and psychological distress than ethnic groups that were more permanently established in the host country (Berry, et al., 1987). Made of acculturation. In the past, acculturation was viewed as a unidirectional process which assumed that over time, acculturating individuals abandoned their natal culture, replacing it with the culture of the host country (Pham & Harris, 2001). Today, this view of acculturation has been abandoned for a bidimensional perspective that views acculturation as an interaction of two independent dimensions. The first dimension involves maintenance or rejection of the values of one’s natal culture, while the second dimension involves adoption or rejection of the values of the host culture (Cabassa, 2003; Lieber et al., 2001). The choice made in each of these two dimensions determines not only the mode of acculturation, but also the intensity of acculturative stress that will be experienced by acculturating individuals (Berry, 2005; Berry, 1990) In 1984, Berry proposed a fourfold bidimensional model of acculturation derived from empirical studies of Aborigines in Australia (Chiriboga, 2004; Rudmin, 2003; Rumdin, 2003; Yeh, 2003). Using the bidimensional approach to acculturation, Berry conceptualized four strategies of acculturation which he named assimilation, separation, integration, and marginalization. Assimilation occurs when one rejects his/her natal culture, adopting instead the culture of the host society. Separation is the opposite of assimilation. Separation occurs when one retains his/her natal culture and rejects the culture of the host society. Integration occurs when one maintains his/her natal culture, while also adopting the culture of the host society. Lastly, marginalization occurs when one rejects both his/her natal culture and the culture of the host society (Berry, 2005). Research has shown that those who adapt modes of acculturation that reject the host culture (marginalization and separation) fail to develop the cultural skills necessary to navigate life in the host culture and are therefore prone to experience heightened acculturative stress and psychological distress (Pham & Harris, 2001; Oh, et al., 2002; Ghaffarian, 1998). Those who choose modes of acculturation that reject their natal culture (marginalization and assimilation) also experience heightened acculturative stress and psychological distress because they lack social networks in their natal culture, which 10 have been shown to help buffer the harmfirl effects of acculturation (Ghaffarian, 1998). Integration has been shown to induce the least acculturative stress and psychological distress, because adopting elements of the host culture while retaining elements of the natal culture enables individuals to acquire skills for successful living in the host country, while also affording them social support networks from both the natal and host culture (Oh, et al., 2002; Pham & Harris, 2001). Research has shown that immigrants with social networks in both the natal culture and host culture experience the best adaptation with the least acculturative stress (Pham & Harris, 2001). Of the four acculturation strategies, integration has proved to be the most adaptive and least stressful, followed by assimilation, separation, and marginalization in that order (Berry, 2005; Faver et al., 2002; Lieber, et al., 2001; Lim et al., 2002; Ryder et al., 2000; Miranda & Umhoefer, 1998;). Nature of the host society. The nature of the host society has to do with the level of tolerance for cultural diversity in the host society (Berry, 2005; Williams & Berry, 1991; Berry, 1990). On a continuum, host societies range from those that embrace cultural diversity to those that lack tolerance for it. Pluralistic societies are those that are tolerant of cultural diversity, while monistic societies are those that lack tolerance for cultural diversity (Berry, 2005; Williams & Berry, 1991; Berry, 1990;). Due to a lack of tolerance for cultural diversity, monistic societies are often opposed to immigrants maintaining or practicing their natal culture (Berry, 2005). Pluralistic societies with their tolerance for cultural diversity on the other hand, are not opposed to immigrants maintaining or practicing their natal culture ((Berry, 2005). Research has shown that societies that lack tolerance for cultural diversity induce more 11 acculturative stress and psychological distress in immigrants than societies that are tolerant cultural diversity (Berry, 2005; Berry, 1990). Demographic and social characteristics. Social stress research has shown that demographic and social characteristics moderate the relationship between social stress and psychological outcomes (Turner, et al., 1995). Similarly, studies of acculturation have also found that demographic and social characteristics moderate the relationship between acculturative stress and psychological outcomes for acculturating individuals and groups. Demographic and social variables that have been found to correlate with acculturative stress and psychological distress in immigrants and refugees have included age at immigration aVIiller & Gross, 2004; Cabassa, 2003; Pham & Harris, 2001), time spent in the host country (Pham & Harris, 2001; Ghaffarian, 1998; Riviera-Sinclair, 1997), gender (Miller & Gross, 2004; Ghaffarian, 1998; Nwadiora & McAdoo, 1996), ability to communicate in language of host country (Miller & Gross, 2004; Nwadiora & McAdoo, 1996; McSpadden,l987), SES (socioeconomic status) (Lim et al., 2002; Shen & Takeuchi, 2001; Vega et al., 1987), social support (Miller & Gross, 2004; Chung, Bemak & Wong, 2000; Pham & Harris, 2001; Shen & Takeuchi, 2001; Williams & Berry, 1991; Vega et al., 1987), religiosity (Hovey & Magaha, 2002), health (Miller & Gross, 2004), premigration traumatic experiences (Porter & Haslan, 2005; Steel, Silove, Phan & Bauman, 2002). Psychological characteristics. Though less researched than social and demographic characteristics, psychological characteristics also have been found to moderate the relationship between acculturative stress and psychological outcomes in acculturating individuals and groups (Noh & Avison, 1996). Psychological variables that 12 have been shown to moderate the relationship between acculturative stress and psychological outcomes have included mastery, self-esteem, feelings of personal competence, personal agency, personality negativity, helplessness, and locus of control (Noh & Avison, 1996). 13 CHAPTER 2 ACCULTURATIVE STRESS AND PSYCHOLOGICAL DISTRESS IN IMMIGRANTS AND REFUGEES Not all five variables in Berry’s acculturative stress model have received equal research attention in studies of immigrant and refugee mental health. Of the five variables, demographic and social characteristics have received the most research attention (Faver et al., 2002; Lim et al., 2002; Lieber et al., 2001; Pham & Harris, 2001; Vega, 1989). In the following section, I explore demographic and social characteristics that have been shown to strongly moderate the relationship between acculturative stress and psychological distress in immigrants and refugees. Demographic and social characteristics that will be explored will include age at immigration, time spent in the host country, gender, ability to communicate in language of host country, SES (socioeconomic status), social support, religiosity, health and pre-migration traumatic experiences. Impact of Demographic and Social Characteristics on Acculturative Stress and Psychological distress in Immigrants and Refugees Age at immigration. Adults have been found to exhibit great reluctance to adopting cultural elements of the host society (Ghaffarian 198 8). Research with Iranian (Ghaffarian, 1998) and Cuban (Riviera-Sinclair, 1997) immigrants in the US. found adults more likely than younger immigrants to be monocultural, adhering only to their 14 natal culture. Failure to adopt cultural elements of the host country denies immigrants the opportmrity to acquire cultural skills needed for functioning effectively in their new environment (Miranda & Umhoefer, 1998). Failure to adopt cultural elements of the host society for effective functioning has been identified as an acculturative stressor that places those immigrating as adults at great risk for psychological distress (Miller & Gross, 2004; Ghaffarian 1988). Research by Riviera-Sinclair (1997) with Cuban immigrants, for example, found a positive correlation between older age, monoculturalism, and anxiety. A separate study with Chinese immigrants also found age at immigration to be strongly correlated with major depression. This later study found that Chinese immigrants who immigrated after 20 years of age were between 1.5 and 3.0 times more likely to develop major depression than those who immigrated before age 20 years (Takeuchi et al., 2007). Time spent in the host country. Those participating for the first time in a host culture that is different from their natal culture are likely to experience acculturative stress due to lack of familiarity with the new culture (Lim et al., 2001). Research has shown that the more time spent in a host country, the more familiar individuals become with the host culture, increasing the likelihood that they will adopt cultural elements of the host society (Riviera-Sinclair, 1997). Increased acculturation to the host culture has been shown to result in reduced acculturative stress and psychological distress in immigrants (Oh, et al., 2001; Miranda & Umhoefer, 1998). Research with Cuban immigrants, for example, found that a longer stay in the host county was associated with increased adoption of cultural elements of the host society and a decrease in anxiety (Riviera-Sinclair, 1997). 15 Gender. Women who are married, mothers, and working are usually involved in multiple roles. Research with immigrants finds women more psychologically distressed than men, which is consistent with studies of the general populations (Sandanger, Fygard, Sorensen, & Moum, 2004). In the past, involvement in the world of work and family was thought to be responsible for heightened psychological distress in women, because involvement in the two spheres forced them to participate in two incompatible roles (Kandel, Davies & Raveis, 1985). Empirical research has revealed, however, that increased psychological distress of women emanates not from the contradiction between work and family roles, but from role overload due to involvement in the two spheres (Kandel, et al., 1985). For most women of color and working poor, the spheres of family and work are rarely separate (Kim, Conway-Turner, Sharif-Trask & Woolfolk, 2006). For these women, working was necessary for the economic survival of their families. The same is true of most women from developing countries. Women from developing countries will often have worked outside the home, because low wages that are characteristic of developing counties do not allow the luxury of one breadwinner (Zhou, 2000). What is new about the world of work for immigrant and refugee women is the context of work. In the natal countries, responsibilities for women from developing countries were often lessened because they received assistance from extended family in the domestic sphere (Aroian, et al., 2003). Immigration severs ties with the extended family, leaving them in the natal country (Vega et al., 1987). In the host country, immigrant and refugee women from developing countries find that they have to engage in paid work outside the home, while also performing household and childrearing responsibilities without the 16 assistance from the extended family that they had come to rely on (Espiritu, 1999). This greater role involvement of women poses more demands on immigrant women than immigrant men, leading the former to experience heightened acculturative stress and psychological distress (Aroian, et al., 2003). Studies with immigrants from the former Soviet Union in which gender differences were assessed, for example, often found more psychological distress for women than men (Aroian, et al., 2003). Ability to communicate in the language of host country. The majority of immigrants coming to the US. are from countries where English is not a linguafi'anca (U .S. Department of Commerce, 2000). Immigrants coming from these countries are likely to have limited proficiency in spoken English. Immigrants not fluent in English must learn to speak it to function effectively in mainstream US. society. When immigrants have to practice new language skills, they experience anxiety and self- consciousness commonly referred to as ‘second language anxiety’ (Yost & Lucas, 2002). Second language anxiety has been identified as an acculturative stressor with a strong correlation to psychological distress in immigrants and refugees (Miller & Gross, 2004; Aroian, 2003; Lieber et al., 2001; Miranda & Umhoefer, 1998). For example, a study with Hmong refugees in the US. reported that inability to communicate in English was associated with elevated levels of depression (Organista, Organista & Kurasaki, 1980) Socioeconomic status (SES). When immigrants arrive in the host country, their first priority is finding a job to support themselves and their family (Zhou, 2000). In the host country, professional and skilled immigrants usually prefer to work in the same capacity as in their home country (Wright, 1981). Unfortunately, professional skills and training are not transferable across countries (Guerin, Guerin, Diirye & Abdi, 2005). Due 17 to this lack of transferability, skilled and unskilled immigrants alike are often forced to seek employment in low-skill-low-paying jobs (Guerin et al., 2005; Salant & Luberdale, 2003; Vinokurov, Birman & Trickett, 2000). Immigrant households are often poorer with lower mean household incomes than those of natives in the host country (Beiser, Hou, Hyman & Tousignant, 2002). Lower mean household incomes of immigrant and refirgee families are characteristic of the low-skill-low-paying jobs that most of them occupy (Pumariega, Rothe & Pumariega, 2005). Individuals who occupy a lower SES have been found to exhibit greater psychological distress when compared with those occupying a higher SES (Grzywacz, Almeida, Neupert & Etter, 2004). The life-stress hypothesis attributes heightened psychological distress in low status individuals to differential exposure and vulnerability to stress (Grzywacz et al., 2004; Alder et al., 1994). Poverty associated with low SES households has been identified as an acculturative stressor and has been linked to psychological distress (Gellis, 2003). A study by Shen and Takeuchi (2001), for example, found SES to be negatively correlated with depressive symptoms in a sample of Chinese Americans. Social support. In their natal country, immigrant and refugee men and women ofien enjoyed a high level of social support from their ethnic kin (Vega et al., 1987). Immigration dislocates people from their social support network in the natal country, severely reducing availability of social support (Vega et al., 1987; Noh & Avison, 1996). Research with immigrants often finds them dissatisfied with their level of social support in the host country (McMichael & Manderson, 2004; Vega et al., 1987). Perception of inadequate social support from family and coethnics has been 18 identified as an acculturative stressor and has been linked to psychological distress in immigrants and refugees (Simich, Beiser & Mawani, 2003). Three separate studies with Vietnamese refugees, for example, found a negative correlation between ethnic social support and depressive symptoms (Bisser, 1988; Wright, Tran & Mindel, 1987; Tran, 1987). A separate study with Central American immigrants found that perceived ineffectiveness of social support was linked to elevated levels of depression and suicidal ideation (Hovey, 2000). Religiosity. Studies on the impact of religious involvement for wellbeing can be traced as far back as the 19603. Research by Gurin, Veroff and Field (1960) found a positive relationship between religious involvement and the absence of distress. In the next decade, research by Spreitzer and Snyder (1974) and Clement and Saucer (1976), affirrned the findings by Gurin and his colleagues by also reporting a positive relationship between religious involvement and psychological well being (Fazel & Young, 1988). To date, more than 850 studies have inquired into the relationship between religious involvement and varying aspects of psychological health (Mohr, 2006). Between two-thirds and three quarters of these studies found that people who are . religious adapt better to stress and experience better psychological wellbeing. Religious commitment has been found to have a positive impact on psychological health (Mohr, 2006). A study with 37, 000 Canadians aged 15 years and older, for example, found that higher worship frequency was associated with lower odds of depression (Baetz et al., 2006) Through immigration, immigrants become strangers in a new land. In this new land, they are forced to confront the question “Who am I?” Immigrants often find 19 meaning and identity by reaffirming traditional beliefs and religious faith which they may have taken for granted in their natal country (Hirschman, 2004). The certainty of religious precepts provides an anchor to immigrants who as a result of the acculturative process must change many aspects of their lives and habits. By providing a sense of stability, religion can be psychologically beneficial for immigrants and refugees and can act as ballast against acculturative stress and psychological distress (Hirschman, 2004). Health. A refugee’s journey in search of safety is often long and arduous and can last from a few days to many months. Ethiopian male refugee residing in Utah, for example, reported having traveled between two weeks and a month in the wilderness before reaching the safety of a refugee camp (McSpadden, 1987). During their journey, refugees ofien experience great hardship (Solrna, Singh, Lohfeld, Orbinski & Mills, 1996) Most camps that provide refiige to displaced persons have international relief agencies and nongovernmental organizations (N GOs) working within them (Gild, 1999). These agencies provide basic necessities and services to the displaced. The living conditions in refugee camps differ, with some better than others but none providing an ideal sanctuary. The camps are often overcrowded, squalid, rampant with disease and lacking in clean water and stable shelter (Ying, 2001). It is not unusual for refugees to spend many years in squalid camp conditions before finally being resettled in a third country. Ethiopian male refuges mentioned in the preceding paragraph, for example, reported having spent between 9 months and 7.5 years (an average of 3.6 years) in exile before being resettled in the US. (McSpadden, 1987). Refugees currently being resettled in the US. will have spent on average 17 to 18 years 20 in hostile refugee camp conditions (Limon, 2007). The difficult journey that refugees endure before reaching safety in an asylum country and the difficulties associated with life in a refugee camp can put their health at risk (Palinkas et al., 2006). Refugees who have lived in protracted situations in refugee camps have been found to have higher rates of undiagnosed health conditions (Goetz, 2005). Poor physical health has been identified as a strong predictor of psychological distress in immigrants. For example, poor health was found to be associated with depression in female immigrants from the Former Soviet Union who were living in the US. (Miller & Gross, 2004). Traumatic pre-migration experiences. Migratory experiences can vary from being relatively uneventful to severely traumatic (Vega, et al., 1987). For the majority of legal immigrants, this passage is largely uneventful. For refugees, however, the migratory passage is all too often traumatic and riddled with many dangers (Keller et al., 2006; Jaranson et al., 2004; Spasojevic, Heffer & Snyder, 2000). The refugee migratory experience spans experiences in the conflict zones, flight, and refuge. In each of these three areas, refirgees witness and/or experience traumatic events (V eragara, Miller, Martin & Cookson, 2003; Silove, Steel, McGorry, Miles & Drobny, 2002). Traumatic pre-migratory experiences can have adverse psychological consequences for refugees. Pre-migratory traumatic experiences have been found to predispose refugees to post-traumatic stress disorder (PTSD) (Steel et al., 2002). PTSD is the most frequently reported psychiatric consequence of traumatic events (Silove et al, 2002; de Jong et al., 2001). A study by Thulesius and Haké’mson (1999), for example, found that because of pre-migratory tramnatic experiences, refugees were 68 times more 21 likely than non-refugees to suffer from PTSD. PTSD is not the only psychiatric condition that develops in the aftermath of exposure to traumatic events (kamphkady-Brown et a1, 2006; O’Donnell, Creamer & Pattison, 2004; Noh & Avison, 1996). Those with PTSD symptomatology also often exhibit symptoms of depression and anxiety (O’Donnel et al., 2004; Gerristen et al., 2006). A comprehensive study of 2,104 Bhutanese refugees in Nepal, half of whom had experienced torture found that: 14% of tortured refugees and 3% of non tortured refugees reported symptoms for PTSD; 43% of tortured refugees and 34% of non tortured refugees reported symptoms for anxiety; and 25% of tortured refugees and 14 % of non tortured refugees reported symptoms for depression (Shrestha et al., 1998). Successful acculturation requires individuals to possess effective decision making and problem solving capabilities (Thulesius & Hakanson, 1999). Psychological problems that refugees develop prior to resettlement can become acculturative stressors when they interfere with much needed decision making and problem solving capacities required during acculturation. A study of Tamil asylum seekers in Australia, for example, found that whereas 20% of the PTSD symptoms could be explained by premigration stressors, the remaining 14% was the result of acculturative stressors (de Jong, et al., 2001) 22 CHAPTER 3 METHODOLOGY This chapter provides an overview of the mixed method research design that was used to explore acculturative stress and psychological distress in adult female Liberian refugees living in Lansing, Michigan. The chapter is divided into two sections. Section one provides a statement of the problem, description of the study sample, hypotheses to be studied, description of the research site, and description of qualitative and quantitative data collection methods. Section two discusses the research instruments that were used in data collection and also discusses the data analysis techniques that were employed. Problem Statement Most of the research on immigration and acculturation has been with economic immigrants (Aroian, et al., 2003). Little of this research has been with refugees. When research has been conducted with refugees, it has focused largely on Asian refugees who are the largest refugee group in the US. African refugees were first resettled in the US. in 1980 (Matlou, 1999). So far, approximately 291,943 African refugees have been resettled in the US, which is 11% of the total US. refugee population (U .S. Department of State, 2007). Since 1999, the US. has resettled increasingly more African refugees than any other refugee group. Despite this increase, little research is being done with Afiican refugees in the US (Rumbaut, 1999). This study described below explores acculturative stress and psychological distress in adult female Liberian refugees resettled in the US. The study focuses on 23 women because they too, like refugees, have been neglected from many studies of immigration and acculturation. Findings from the study will provide information that will expand our knowledge of acculturation in not only African refiigees, but also women. The Study Sample Since 1990, approximately 1, 320 (17.4%) of the refugees that have been resettled in Lansing have come from Africa (St. Vincent Catholic Charities [SVCC], 2007). African refugees resettled in Lansing have come from Somalia (688), Sudan (277), Liberia (207), Sierra Leone (51), Ethiopia (39), Rwanda (37), Burundi (14), Congo (7), Eritrea (6), Kenya (6), and Egypt (1). This study draws research participants from the Liberian refugees group, the third largest refugee groups in Lansing. The study explores acculturative stress and psychological distress in adult female Liberian refugees residing in Lansing, Michigan. Adult female Liberian refugees will be defined as any female Liberian refugee who is older than 18 years. To be considered for participation in the study, adult female Liberian refugees would need to have been recognized as refugees by the UNHCR (United Nations High Commissioner for Refugees) and have been resettled in the US. by one of the 10 federally mandated refugee resettlement agencies. Hypotheses Most studies of acculturation have explored the impacts of sociodemographic variables on acculturative stress and psychological distress. To allow for comparison with other studies, this study also explored the impacts of sociodemographic variables on 24 acculturative stress and psychological distress in adult female Liberian refugees. Nine hypotheses presented below were generated for the study. 1. Older age at resettlement will be associated with more acculturative stress and more depressive and anxious symptomatology. 2. More time spent in the host country will be associated with less acculturative stress less depressive and anxious symptomatology. 3. Higher fluency of spoken English will be associated with less acculturative stress and less depressive and anxious symptomatology. 4. Single female African refugee heads-of -households will have more acculturative stress and more depressive and anxious symptomatology than female African refugees living with their spouses or a significant other. 5. Lower SES will be associated with more acculturative stress and more depressive and anxious symptomatology. 6. Greater satisfaction with perceived social support will be associated with less acculturative stress and less depressive and anxious symptomatology. 7. Greater religiosity will be associated with less acculturative stress and less depressive and anxious symptomatology. 8. Better perception of personal heath will be associated with less acculturative stress and less depressive and anxious symptomatology. 9. More experiences with pro-migration trauma will be associated more acculturative and more depressive and anxious symptomatology. 25 Recruiting Research Participants St Vincent Catholic Charities (SVCC) is the primary refugee resettlement agency operating in Lansing. SVCC does not have an effective process for keeping track of refugees, therefore, no accurate sampling frame existed from which to randomly draw research participants for inclusion in the study. Snowball sampling was therefore used to identifying adult female Liberian refugees for inclusion in the study. Initial contact with adult female Liberian refugees was made through personal contacts already established by the researcher in the Lansing Liberian refugee community. From these contacts, were solicited names of adult female Liberian refugees who could be contacted about participation in the study. Those contacted about involvement were used to identify other potential research participants. Thirty-two adult female Liberian refugees were contacted about participation in the study. Twenty-seven of those contacted agreed to participate in the study. Data Collection Both quantitative and qualitative data were collected from research participants. Quantitative data were collected from all research participants through seven surveys. As seen in Table l, the surveys collected information on nine independent variables and three dependent variables. All 27 research participants who completed the surveys were asked about their willingness to participate in an in-depth qualitative interview. Seventeen of the 27 participants agreed to participate in an in-depth interview. The in- depth interviews inquired about participants’ flight and resettlement experiences in order to shed light on how variables under study accounted for low versus high rates of 26 psychological distress. The interview guide that was used in the interviews can be found in Appendix I. The data collection process was divided into two parts. First, surveys were administered to all 27 research participants. Second, in-depth interviews were conducted with 17 participants. A token of $15 was given to all research participants who were administered the surveys, and an additional $15 was given to those who participated in- depth interview. Instrumentation Seven surveys were used to collect quantitative data from the research participants. An in-depth semi-structured questionnaire was used to collect qualitative data. Following is a brief description of the surveys and the in-depth qualitative questionnaire that were used in the study. Sociodemographic Questionnaire A sociodemographic questionnaire (see Appendix A) was created by the researcher to collect personal history information from respondents including: current age, age at resettlement, length of residence in the US, marital status, dependent children, formal education background, employment history, employment status, income and fluency of spoken English. 27 Table 1: Research Instruments Environmental Acculturative Stress (SAFE-R) scale #7 Measurement instrument Variable to be measured Independent variables 1 Demographic questionnaire to be Age at resettlement, fluency designed by researcher. in spoken English, time spent in the host country, single head of household status, and SES 2 Multidimensional Scale of Perceived Social Support Social Support (MSPSS-R) 3 Medical Outcome Study (SF -12) Physical health 4 Duke religion index (DUREL) Religiosity 5 Harvard Trauma Questionnaire (HTQ- Pre-migration traumatic R) experiences Dependent variables 6 Hopkins Symptoms Checklist (HSCL- Depressive and anxious 25) symptomatology 7 Social, Attitudinal, Familial, and Acculturative stress Social, Attitudinal, Familial and Environment Acculturative Stress - Revised (SAFE-R) Acculturative stress and discrimination was measured using the Social, Attitudinal, F arnilial and Environment Acculturative Stress (SAFE) scale. The SAFE scale measures acculturative stress in four contexts: social, attitudinal, familial and environmental. Originally developed as a 60-item scale by Padilla, Wagatsuma and Lindholm (1985), the SAFE scale was modified into a 24-item scale by Mena, Padilla 28 and Maldonado (1987). The 24-item SAFE-R scale has a demonstrated reliability that ranges from .89 to .90 (Hovey & Magafia, 2002; Mena eta 1987; Hovey & Magana, 2002). The shorter 24-item SAFE-R scale (see Appendix B) was used to measure acculturative stress. The SAFE—R utilizes a 5-point scale ranging from 1=“have not experienced” to 5= “extremely stressful.” Scores on the scale range from 0 to 120 with higher scores indicating greater acculturative stress (Hovey & Magafia, 2002). (2002). Medical Outcome Health Survey Short Form - 12 (SF-12) The SF-12 is a brief measure of current perceived physical and mental health. It measures physical and mental health of respondents in the most recent four weeks (Ware, Ksinski & Keller, 1996). The Physical Component Summary (PCS) measures physical health, while the Mental Component Summary (MCS) measures mental health. Questions on the SF-12 include those requiring “yes” or “no” responses and those requiring responses chosen from a likert scale. The SF-12 has a demonstrated reliability of .91 for the PCS subscale and .92 for the MCS subscale (Ware et al., 1996). Physical health of respondents was measured using the PCS subscale of the Sf-12 (see Appendix C). The Harvard Trauma Questionnaire-Revised (HTQ-R) The HTQ was the first reliable and valid instrument to be developed for measuring trauma related psychiatric disorder in refugees (Mollica et al., 2004). The HTQ was initially designed to measure trauma events and trauma symptoms in 29 Indochinese refugees (Mollica & Caspi-Yavin, 1991). Today, the HTQ has been translated into 35 languages and is the most widely used measure of pre-migration exposure to trauma (Marshall, Berthold, Schell, Elliot, Chun & Hambarsoomians, 2006). The HTQ consists of four sections (McDonald, Massagle, Silove, 2007; Farhood, Dirnassi & Lehtinen, 2006; Mollica et al., 2004; Mollica & Caspi-Yavin, 1991). Part I asks about experiences with 38 traumatic events commonly experienced by refugees. Respondents indicate whether they experienced any of the traumatic events by checking “yes” or “no.” Part II is an open ended question that asks respondents to elaborate on their most traumatic experience. Part III asks about sustained head injuries. Finally, Part IV provides a list of 40 symptoms associated with PTSD. The first 16 of the 40 symptoms correspond to DSM-III criteria for PTSD, while the remaining 24 are derived from clinical experiences with Indochinese refugees (Farhood etal., 2006; Mollica et al., 2004; Mollica & Caspi-Yavin, 1991). 1n this final component, respondents indicate on a scale ranging from “1 = not at all” to 4 = “extremely,” the extent to which they were bothered by listed symptom in the previous week (Gerristen, et al., 2006). Part I (see Appendix D) and IV (see Appendix E) of the HTQ were used to measure pre-migration trauma and their impacts on respondents. Many studies of PTSD have found that the number of traumatic experiences refugees are exposed to is one of the best indicators of psychological distress (Gerrsten, etal., 2006; de Jong et al., 2003; O’Donnel et al., 2004; Fwazi, et a1. 1997). For this reason, only Part I and IV of HTQ that assess traumatic events and traumatic symptoms respectively were used in the study. Part I and IV of the HTQ have been found to have a reliability score that ranges from .90 to .96 respectively (Mollica et al., 2004). 30 Duke Religion Index (DUREL) Religiosity of research participants was measured using the Duke Religion Index (DUREL). The DUREL (see Appendix F) was designed by Koenig, Patterson, and Meador (1997) to measure religiosity in a comprehensive and brief but non offensive way (Hill & Hood, 1999). The DUREL is a five-item instrument that measures three main dimensions of religiousness: organizational (OR), non organizational (NOR), and intrinsic religiosity (IR). The first two items of the scale measure OR and NOR aspects of religion, while the last three items measure IR and are extracted from Hoge’s Intrinsic Religiosity Scale (Hill & Hood, 1999; Hoge, 1972). The questions on the DUREL use two different response scales; a 5-item response scale and a 6-item response scale. The 6-item response scale is used in the first two questions, while a 5-item scale is used for the remaining three questions. Responses for question one range from 1 = “more than once a week” to 6 = “never,” responses for question two range from 1 = “more than once a day” to 6 = “rarely or never,” while responses for question 3 range from 1 = “definitely true for me” to 5 = “definitely not true.” A final score for the DUREL is obtained by summing up scores in each respective subscale. The three items in the IR subscale have demonstrated reliability of .75. Though no normative data exists on the OR and NOR subscales, both items have been administered in over 7,000 studies to persons aged 18 to 90 years old (Hill & Hood, 1999) One minor change was made to the DUREL to make it more compatible for this study. First, a question asking about the religious persuasion of respondents was added and appears as the first question on the scale. Response options for this question include 31 "Christian,” “Muslim” and “other,” because 96% of the Afiican refugees resettled in Michigan are either Christian or Muslim (ORR, 2007b). Multidimensional Scale of Perceived Social Support -Revised (MSPSS-R) In the country of resettlement, refugees receive social support from family, significant other, coethnics, the resettlement agency, and friends from the mainstream culture of the host society (Hsu, Davies & Jansen, 2004). No instrument exists to measure satisfaction with social support from these five contexts. The Multidimensional Scale of Perceived Social Support (MSPSS) was modified so that it captured social support received by refugees from all five domains. The MSPSS is a 12-item scale that assesses adequacy of social support from family (F), friends (FRI) and significant others (SO). Each of the three scales is assessed with four items. The MSPSS uses a 7-point likert response format ranging from 1=“very strongly disagree” to 7= “very strongly agree” (Canty-Mitchell & Zimet, 2000). For purposes of this study, the likert scale used in the MSPSS has been shortened to a 5-point scale to harmonize it with other likert scales being used in this study. The improved likert scale ranged from l= “strongly disagree” to 5= “strongly agree." Two other alterations were made to the MSPSS so that it may capture respondents’ satisfaction with social support from family, significant other, coethnics, the resettlement agency, and friends from the mainstream US. society. First, the FRI subscale was changed to become the Ethnic Friends (EFRI) subscale to assess social support from coethnics. Second, two new subscales were created; the American Friends (AFRI) subscale and the Resettlement Agency (RA) subscale. These two subscales 32 assessed satisfaction of social support American fiiends and the refugee resettlement agency respectively. Four new items were created for AFRI subscale and the RA subscale. The new MSPSS-R comprises 20-items assessing perceptions of satisfaction with social support received from family, significant other, coethnics, the resettlement agency, and American friends. The MSPSS-R (see appendix G) was used to measure satisfaction of social support of the respondents. Adding scores for each subscale provides subscale scores while adding subscale scores together gives an overall score of satisfaction with perceived social support. Higher scores indicate more satisfaction with perceived social support, while lower scores indicate less satisfaction perceived support (Canty-Michael & Zimet, 2000; Eker et al., 2000). In a study among urban adolescents in the US, the MSPSS demonstrated an reliability of .91, .81 and .91 for the Family, Friends, and Significant Other subscales. Overall, the scale had a reliability of .93. (Canty-Michael & Zimet, 2000). Hopkins Symptom Checklist-25 (HSCL-ZS) Psychological distress in respondents was assessed through depressive and anxious symptomatology. Depressive and anxious symptomatology was measured using the Hopkins Symptom Checklist-25 (HSCL-25). HSCL-25 is a well known and widely used mental health screening instrument whose history dates back to the mid-19503 and has been used repeatedly with adult refugee populations (Bean, Derluyn, Eurelings- Bontekoe, Broekaert & Spinhoven, 2007; Mollica, et al., 2004) The HSCL-25 is a symptom inventory which measures symptoms of anxiety and 33 depression. It consists of 25 items; Part I of the HSCL has 10 items for anxiety symptoms, while Part II has 15 items for depression. The HSCL-25 uses a 4-point likert scale response format which ranges from 1 = “not at all” to 4 = “extremely.” A total score for the HSCL is obtained by averaging the score across its 25 items, while scores for the depression and anxiety subscale are achieved averaging scores in respective scales (Mollica etal., 2004). The HSCL-25 was used to assess depressive and anxious symptomatology in the respondents. Semi-Structured Interview Guide A semi-structured interview guide was designed by the researcher to collect qualitative data from respondents. The semi-structured interview guide was divided into three sections that inquired about the respondents’ experiences during flight, in asylum, after resettlement. The first two sections are meant to obtain information about any pre- migration trauma that respondents might have experienced, while the third section obtains information about acculturative experiences of respondents. Data Analysis Quantitative data collected from the study were analyzed using the Statistical Software Package for the Social Sciences (SPSS) v.15.0 for Windows. Descriptive statistics were run for all information collected using the demographic questionnaire in order to provide a description of the sample under study. In testing the hypothesis Pearson’s Product Moment was used to test correlations, while independent t-tests were used to test the difference in means of groups where it made conceptually sense to do so. 34 Additionally, Chronbach’s alpha was used to determine the reliability of six of the survey instruments namely the MPSS-R, SF-12, DUREL, HTQ, HSCL-25, and SAFE-R. Seventeen research participants took part in the in-depth study. All data collected through the in-depth interviews were audiotaped and transcribed by the researcher. Transcriptions of the in-depth interviews produced 17 manuscripts, one for each respondent. No statistical software package was used to analyze qualitative data collected through the in-depth interviews. Instead, the researcher read and coded the 17 manuscripts for emergent themes. A second coder was recruited to offer a second independent coding of all the 17 transcripts which allowed for comparison between generated themes. 35 CHAPTER 4 RESULTS This chapter presents the results of data analysis for the research study presented in Chapter 3. The results are divided into three major sections. Section one presents results of quantitative data analysis. It describes the study sample using data collected with the demographic questionnaire, followed by an overview of data analysis of the remaining six research instruments that were used in the study. Section two provides results of analysis of the nine hypotheses that were studied. Lastly, section three presents the results of qualitative data analysis for 17 of the 27 Liberian refugee women who participated in the in-depth interviews. Section three also presents an analysis of themes that emerged from the in-depth interviews. Description of the Sample A total of 27 Liberian refugee women participated in the study. The mean current age reported by the participants was 31 years (range from 18 to 55 years, SD = 10.6). The mean age at resettlement was 27 years (range from 13 to 46 years, SD = 10.35). Participants had been living in the US. for an average of 3.5 years (range 3 months to 7 years, SD = 1.6). Table 2, provides a breakdown of respondents current ages and age at resettlement, while length of residence in the US is presented in Table 3. Of the 27 respondents, 8 (29.6%) were single, 7 (25.9%) were married, 3 (11.1%) were widowed, 8 (29.6%) had spouses living in Afiica, and 1 (3.7%) lived with a significant other. Twenty of the respondents had dependent children 18 years or younger. 36 Table 2: Current Age and Age at Resettlement (N = 27) Current Age n % Age at resettlement _r_r_ % 18 - 20 6 22.2 11 - 15 4 14.8 21-25 5 18.5 16-20 5 18.5 26-30 3 11.1 21 -25 5 18.5 31 - 35 5 18.5 26 - 30 2 7.4 36 - 45 4 14.8 31 - 35 5 18.5 46-50 2 7.4 36-40 3 11.1 51-55 2 7.4 41 -45 3 11.1 Respondents with children had on average 3 dependent children (range 1 to 9 children, SD = 2.30). Thirteen (68.4%) of those living without a spouse or significant other were single- female heads-of-households with dependent children. Respondents who were single female heads-of-households had been raising children single-handedly for an average of 7 years (range from 2 to 18 years, SD = 2.30). Table 3: Length of Residence in the U.S. (N=27) Lflgth of residence (yrs) n % £1 2 7.4 2 6 22.2 3 7 25.9 4 7 25.9 5 2 7 .4 6 1 3.7 7 2 7.4 37 Nineteen (70.4%) of the respondents have attended a formal learning institution in their lifetime, while 8 (29.6%) have never attended any formal learning institution. For those who have attended a formal learning institution, the average number of schooling years was 8 years (range from 1 to 15.5 years, SD = 4.02). Those with formal schooling experience had attended learning institutions in the natal country, the asylum country, or the U.S. The average number of years spent in formal learning institutions in the natal country, asylum county, and the U.S. respectively were 4 years (range from 0 to 13.5 years, SD = 4.99), 2 years (0 to 12.0 years, SD = 3.86), and 2 years (range 0 to 5.0 years, SD = 1.72). Table 4 shows the respondents pattern of schooling in the natal country, asylum country and the US, while table 5 shows the same distribution by the number of years Table 4: Schooling Patterns in the Natal, Asylum Country and U.S. (N=27) Level of education Natal Coungy Asylum country LS. None ‘ 1 3 1 9 1 8 Some primary 9 3 0 Completed primary 2 2 0 Some high school 1 1 7 Completed high school 2 2 1 Some tertiary (college) 0 0 1 Though most of the respondents have attended a formal learning institution, only five have completed high school. Four of those interviewed were 18 years old and are still 38 working towards attaining their high school diploma. Only three respondents have advanced their education and training while in the U.S. One of these respondents is pursing a diploma in medical billing, while two others have attended Certified Nurse Assistant (CNA) training. Table 5: Schooling Years in the Natal, Asylum Country and U.S. (N=27) Years of schooling Natal Count__r_y Asylum country LLS. 0 18 19 18 1 - 4 1 3 8 5 - 8 3 3 1 9 - 12 2 2 0 > 13 1 0 O Table 6 provides a breakdown of the employment patterns of respondents while in Liberia and the U.S. Thirteen (48.1%) of the respondents were income earners prior to fleeing Liberia. Two of the 13 respondents engaged in paid employment, while the rest were self-employed. Currently, 20 (74.1%) ofthe respondents are employed and seven (25.9%) are unemployed. Of those employed, three (15%) work part time and 17 (85%) work full time. Two of the seven who are unemployed are high school students. None of the respondents work more than one job. Those employed earn an average hourly wage of $8 per hour (range from $7.00 to $13.50, SD = 1.476). Fifteen of those currently employed were able to approximate their gross monthly income. The average gross income reported 39 was $1,150.30 (range from $700 to $1,800, SD = 309.352). Table 6: Employment and Income Patterns (N = 27) .Ir _‘Zq Earned income in Liberia (n = 27) Yes 13 48.1 No 14 51.9 Nature of most recent job in Liberia (n = 27) Did not work 14 51.9 Food and clothes vendor 4 14.8 Food vendor 4 14.8 Textile vendor 1 3.7 Self-employed tailor 2 7.4 Janitor 1 3.7 Postal worker I 3.7 Current employment status in the U.S. (n = 27) Unemployed 7 25.9 Part-time 3 11.1 Full time 17 63.0 Works more than one job 0 0 Most recent job in the U.S. (n = 27) Unemployed 4 14.8 Laundry worker 6 22.2 Sewing 2 7 .4 Janitor 2 7.4 Restaurant worker 3 11.1 Housekeeping 7 25.9 Nurses’ aide 2 7.4 Gym (cleaning) 1 3.7 40 Two questions were used to asses the respondents’ fluency of spoken English. The first question asked respondents to rate their fluency of spoken English, while the second question asked the researcher to rate the respondents’ fluency of spoken English. Most respondents rated their fluency of spoken English as good (14 or 51.9%). Similarly, the researcher also rated most respondents’ fluency of spoken English as good (13 or 48.1%). Table 7 illustrates the language level of respondents from both perspectives. Table 7: Proficiency of Spoken English (N = 27) .13.. 1/2 Respondents’ subjective perception of their fluency of spoken English (11 = 27) Poor 2 7.4 Fair 5 18.5 Good 14 51.9 Excellent 6 22.2 Researcher’s perception of respondents’ fluency of spoken English (11 = 27) Poor 1 3.7 Fair 4 14.8 Good 13 48.1 Excellent 9 33.3 Social, Attitudinal, Familial, and Environmental Acculturative Stress Scale - Revised (SAFE-R) A revised Social, Attitudinal, Familial, and Environmental Acculturative Stress Scale (SAFE-R) was used to measure acculturative stress. The SAFE-R is a 41 24-item scale that measures acculturative stress in four contexts: social, attitudinal, familial and environmental context. The scale uses a 4-point likert response scale that ranges from 1= “have not experienced” to 5= “extremely stressful.” Scores on the scale range from 0 to 120 with higher scores indicating greater acculturative stress (Hovey & Magaila, 2002). Chronbach’s Alpha was used to measure the reliability of the SAFE-R. The scale had a reliability of .87, which is comparable to reliability scores 0.89 to .90 that have been reported in other studies (Hovey & Magana, 2002; Mena et. a1 1987). The data collected using the SAFE-R had five missing values. Three of the missing values were from one respondent, while the remaining two were from different respondents. Since the scale returned a high reliability score, missing values were replaced by the average of the available scores for each respondent. All 27 respondents completed the SAFE-R. The respondents garnered an average acculturative stress score of 56.44 (range from 30 to 100, SD = 16.81). Eighteen respondents (66.7%) had total acculturative stress scores that were 5 60. Nine (33.3%) respondents had total acculturative stress scores that were > 60. Based on the five point likert scale, the average score for the entire scale was 2.35 (range from 1.25 to 4.17, SD = 0.70). Most of the 24 questions had low average scores that ranged between 1 and 2. Four questions achieved scores that were higher than the rest. Question 4, which reads “it bothers me that I cannot be with my family,” received an average score of 4.37 (SD = 1.87). Question 19, which reads “loosing ties with my country is difficult,” received an average score of 4.11 (SD = 1.28). Question 20, which reads “1 often think about my cultural background,” received an average score of 3.07 (SD = 1.57). Lastly, question 7, 42 which reads “it bothers me that so many people use drugs,” received an average score of 3.04 (so = 1.37). Multidimensional Scale of Perceived Social Support - Revised (MPSS-R) A 20-item revised Multidimensional Scale of Perceived Social Support (MSPSS- R) scale was used to assess perceived social support of respondents. The revised MSPSS-R measured social support from five dimensions which were thought to be relevant to the refugee experience. The five dimensions measured satisfaction with perceived social support from family (F), significant others (SO), coethnic friends (EFRI), American Friends (AF RI), and the resettlement agency (RA). Each of these five sub-scales was assessed by four items. Responses were based on a 5-point likert scale that ranged from 1= “strongly disagree” to 5= “strongly agree." Scores on the MSPSS range from 0 to 100 with higher scores representing greater satisfaction with perceived social support. Chronbach’s Alpha was used to measure the reliability of the revised MSPSS-R. Chronbach’s Alpha for the family (F), Significant Others (SO), Ethnic Friends (EFRI), American Friends (AF RI), and the Resettlement Agency (RA) subscales were .62, .73, .84, .90, and .80 respectively. Other studies that have used the MSPSS have reported subscale reliabilities that have ranged from .81 to. 91 (Canty-Michael &~Zimet, 2000). The overall reliability score of the revised MSPSS-R used in our study was .83, compared to .91, which has been reported in other studies (Canty-Michael & Zimet, 2000). Data collected had three missing values, from three separate respondents. Since reliability scores for the subscales ranged from moderate to high, missing values were replaced with 43 the average score for the appropriate subscale for the individual with missing values. Twenty-six respondents completed the MSPSS-R. The respondents achieved an average total score of 68 (range from 28 to 89, SD = 15.03). Scores on the MSPSS-R subscales range from 0 to 20. The significant other subscale received the highest average total score (M = 16.58, range from 6 to 20, SD = 4.32) followed by the family subscale (M = 15.73, range from 4 to 20, SD = 4.07), resettlement agency subscale (M = 12.70, range from 4 to 20, SD = 4.51), coethnic friends subscale (M = 12.12, range from 4 to 20, SD = 5.42), and American friends subscale (M = 10.88, range from 4 to 20, SD = 5.90). Table 6 below shows the means, range and standard deviations for the total scale and the subscales. Based on the 5-point likert scale, the average score for the whole scale was 3.40 (range from 1.40 to 4.50, SD = 0.76). The three questions that scored lowest on the scale were questions 10, 13 and 16. Question 13, which reads “1 have American friends I can talk to about my problems,” received an average score of 2.27 (SD = 1.67). Question 10, which reads “1 can count on my Liberian friends when things go wrong,” received an average score of 2.77 (SD = 1.58). Question 16, which reads “1 have American friends I can count on when things go wrong,” received an average score of 2.46 (SD = 1.77). The three items that received the highest scores were items 15, 8, and 3. Question 15, which reads “There is a special person in my life who cares about my feelings,” received an average score of 4.46 (SD = 1.14). Question 18, which reads “My family is willing to help me make decisions,” received an average score of 4.38 (SD = 1.10). Lastly, Question 3, which reads “There is a special person with whom I can share my joys and sorrows,” received an average score of 4.27 (SD = 1.31). Average scores for the 44 MPSS-R and its subscales are presented in Table 8. Table 8: Scores on the Multidimensional Scale for Perceived Social Support-Revised (MSPSS-R) (N=26) _M_ Ba_ng§ _S_I2 Total social support scale 68.00 28 to 89 15.03 Significant other subscale 16.58 6 to 20 4.32 Family subscale 15.73 4 to 20 4.07 Resettlement agency subscale 12.70 4 to 20 4.51 Ethnic friends subscale 12.12 4 to 20 5.42 American friends subscale 10.88 4 to 20 5.90 Duke Religion Index (DUREL) The Duke Religion Index (DUREL) was used to measure religiosity. The DUREL is a five item instrument that measures three main dimensions of religiosity: organizational (OR), non organizational (NOR), and intrinsic religiosity (IR) (Hill & Hood, 1999; Hoge, 1972). A sixth question added by the researcher enquired about the religious predisposition of respondents. The DUREL has two different response scales; a 5-item response scale and a 6- item response scale. The 6-item response scale, which ranges from 1 = “more than once a week” to 6 = “never” is used in the first two questions that comprise the OR and NOR subscales. A 5-item scale is used for the remaining three questions that comprise the IR. Score for the DUREL are obtained by summing up scores in each subscale (Hill & Hood, 45 1999; Hoge, 1972). Scores for the DUREL were recoded so that higher scores represented greater religiosity. Chronbach’s Alpha was used to measure the reliability of the DUREL. Reliability for the first two independent items (OR and NOR), could not be assessed because each subscale had only one question. The three questions on the IR scale returned a reliability score of .92, which is comparable to reliabilities of .75 to .94 that have been reported in other studies (Sherman et al., 2000; Hill & Hood, 1999). An overwhelming majority of the respondents identified as Christian. Of the 27 respondents who completed the survey 23 (85.2%) identified Christian, while four (14.8%) identified as Muslim. The group’ mean score for the OR, NOR and IR subscales were 3.41 (SD = .80), 4.74 (.53), and 11.04 (SD = 1.32). Medical Outcome Study Short Form - 12 (SE-12) The Medical Outcome Study General Health Survey (SF-12) is brief 12-item scale that is used to assess physical and mental health of respondents in the most recent four weeks (Ware, Ksinski & Keller, 1996). For this study, physical health of respondents was measured using Physical Component Summary (PCS) of the SF-12. Questions on the SF -12 are a mix of those requiring “yes” or “no” responses and those requiring responses chosen from a likert scale. Software provided by Quality Metric was used to analyze data collected using the SF-12. In other studies, reliability for the PCS scale has ranged from 0.94 to 0.97 (Gandek etal., 1998) The first question on the SF-12 asked respondents to rate their health as excellent, very good, good, fair, or poor. Thirteen respondents (48.1%) rated their health as 46 excellent while six (22.2%) rated their health as fair, five (18.5%) rated their health as very good, and three (11.3) rated their health as poor. Scores on the PCS range from 0 to 100, with lower scores indicating lower levels of health. On the PCS scale, the 27 respondents received an average score of 49.53 (range from 21.83 to 65.18, SD = 12.57). Eighteen of the respondents had health scores that were 5 50 (range 21.83 to 50.72), while nine respondents achieved scores that were > 50 (range 51.13 to 65.18) Harvard Trauma Questionnaire - Revised (HTQ-R) The revised Harvard Tramna Questionnaire (HTQ-R) is designed to measure trauma events and trauma symptoms in refugees (Mollica & Caspi-Yavin, 1991). Parts I and IV of the HTQ, which measure trauma events and posttraumatic symptoms respectively, were used in the study. Part I lists 38 trauma events and asks respondents whether they have experienced any of them. Possible responses for Part I are “yes” or “no.” Part IV provides a list of 40 symptoms associated with PTSD. The first 16 of the 40 symptoms correspond to Diagnostic and Statistical Manual for Mental Disorders’ (DSM) criteria for PTSD, while the remaining 24 are symptoms that have been reported by refugees who have endured trauma (Mollica et al., 2004). For part IV, respondents indicate the extent to which they were bothered by listed symptom in the previous week on a scale ranging from '1 = “not at all” to 4 = “extremely.” Part I and IV of the HTQ were completed by 26 respondents. Chronbach’s Alpha was used to measure the reliability of the HTQ-R. The overall reliability for the HTQ-R was .78. Other studies have reported reliability estimates that have ranged from .90 to 96. There were 11 missing values reported for 8 47 of the respondents. Missing values for were replaced with the average of available scores for each respondent. Respondents endorsed having experienced all but one of the 38 traumatic experiences listed in Part 1. None of the respondents endorsed question number 25, that they were forced to harm a family member or friend. The average number of traumatic experiences reported by respondents was 13. Table 9 lists the experiences that were most reported by the respondents. Part IV, which measures post-traumatic symptoms, is divided into two subscales. The first subscale encompasses questions 1 through 16 and provides a PTSD score. The second subscale encompasses questions 17 through 40 and provides a self-perception of functioning score. The first subscale was to measure PTSD symptomatology. A score for the PTSD subscale is calculated by adding the responses across all sixteen items and then dividing by 16 to get an average score. The higher the score on the PTSD subscale, the more likely it is that the respondent has symptoms generally associated with PTSD (Mollica et al., 2004). Scores for the PTSD subscale range from 1 to 4. The average score achieved on the PTSD subscale was 1.85 (range from 1.13 to 3.13, SD = 0.46). Mollica et a1. (2004) recommend that a cutoff score of _>_ 2.0 be considered as an indication that an individual may be "checklist positive " for PTSD. Eight respondents met the criteria for being “checklist positive” for PTSD with scores of >200. 48 Hopkins Symptom Checklist -25 (HSCL-25) The Hopkins Symptom Checklist (HSCL-25) is a 25-item brief screening instrument that has been utilized in many studies to assess psychiatric distress among the highly traumatized (Mollica et al., 2004). The HSCL-25 measures symptoms of anxiety and depression. Anxiety symptoms are measured by the first 10 items of HSCL-25, while symptoms for depression are measured by the latter 15 items. The HSCL-25 uses a 4-point likert scale response format which ranges from 1= “not at all’ to 4= “extremely.” An average score for the HSCL is obtained by averaging the score across its 25 items, while scores for the depression and anxiety subscale are achieved by averaging scores in respective scales (Mollica et al., 2004). All 27 respondents completed the HSCL-25. Chronbach’s Alpha was used to measure the reliability of the HSCL-25. The scale achieved a reliability score of .90, which is comparable to scores of .84 to .87 that have been reported in other studies. Data collected had only three missing values from three different respondents. Due to the scales high reliability, missing values were replaced with the average available score for each respondent. An average score of 1.60 (range from 1.04 to 3.24, SD = 0.48) was attained on the HSCL-25 scale. The anxiety subscale obtained an average score of 1.55 (range from 1.00 to 3.70, SD = 0.58), while the average score for the depression subscale was 1.63 (range from 1.07 to 2.93). The higher the total score on the HSCL-25, the more likely it is that the respondent has a significant emotional illness. A respondent with a total score of _>_1.75 is considered "checklist positive " for emotional distress. Similarly, a respondent with a score of _>_1 .75 on the depression or anxiety subscale is considered "checklist 49 positive " for major depression or anxiety respectively (Mollica et al., 2004). Six respondents (range from 1.84 to 3.24) were found checklist positive for emotional distress, five (range from 1.80 to 3.70) were checklist positive for anxiety and six (range from 1.80 to 2.93) were checklist positive for depression. Table 9: Traumatic Events Most Experienced by Refugees (N = 26) Question n % Forced evacuation under dangerous conditions 24 92.3 Confiscation or destruction of property 24 92.3 Combat situation 23 88.5 Disappearance/kidnapping of family member (other than child or spouse) 22 84.6 Lack of shelter 20 76.9 Lack of food or water 20 76.9 Forced to hide 20 76.9 Other forced separation from family members 19 73.1 Ill health without access to health care 19 73.1 Murder or death of other family member (not child or spouse) or friend 18 69.2 Witness beating to head or body 13 50.0 Extortion or robbery 1 1 42.3 Witness torture 11 42.3 50 Hypothesis Testing Results of statistical analysis of the nine hypotheses that were studied are presented in this section. The hypotheses test the effect of independent variables, namely age at resettlement, time spent in the host country, fluency of spoken English, single female head- of-household status, socioeconomic status (SES), social support, religiosity, perception of personal health, and pre-migration trauma on dependent variables (acculturative stress, anxious symptomatology, and depressive symptomatology). All quantitative analysis were performed using the Statistical Software Package for the Social Sciences (SPSS) v.15.0 for Windows. Pearson’s Product Moment was used to test correlations with categorical variables. Independent t-tests were used to test the mean difference between conceptually meaningful groups. Since the hypotheses being tested were directional, one-tailed tests were used for both the correlations and t-tests. The results were deemed significant if a p value of .01 or .05 was attained. A table of p values for correlations and t-tests can be found in Appendix J through L. Because of the small sample size, correlations and t-tests that approached significance (p value between .06 and .10) are also highghligted in the tables in appendix J through L. Hypothesis 1: Older age at resettlement will be associated with more acculturative stress and more depressive and anxious symptomatology Age is often used as a proxy variable in studies of acculturation. Though many studies have used current age, age at immigration is argued to be a better predictor of acculturative stress and psychological distress (Ghaffarian, 1998; Riviera-Sinclair, 1997). Due to its stronger predictive power, age at immigration rather than current age was used 51 as a variable in this study. A small negative relationship was found between age at resettlement and acculturative stress [r = —.33, p (one tailed) <. 05, n = 27]. As age increased, acculturative stress decreased. No significant correlation, however, was found between age at resettlement and depressive or anxious symptomatology. Hypothesis 2: More time spent in the host country will be associated with less acculturative stress and less depressive and anxious symptomatology Length of residence was measured as the total number of years a respondent has lived in the U.S. No significant correlation was found between acculturative stress and length of residence. Similarly, no correlation was found between length of residence and anxious or depressive symptomatology. Hypothesis 3: Higher fluency of spoken English will be associated with less acculturative stress and less depressive and anxious symptomatology The respondents’ fluency of spoken English was assessed subjectively by the respondents and the researcher. No significant correlation was found between either the respondents’ subjective assessment of their fluency of spoken English or the researcher’s assessment of the respondents’ fluency of spoken English and acculturative stress. There was also no correlation between the respondent’s subjective assessment fluency of spoken English and psychological distress. There was, however, a significant negative relationship between the researcher’s assessment of the respondents’ fluency of spoken English and anxious symptomatology [r = -.32, p (one tailed) < .05, n = 27]. Anxious symptomatology increased as the researcher rating of the respondents’ fluency of spoken English decreased. 52 Hypothesis 4: Single female refugee heads-of-households will have more acculturative stress and depressive and anxious symptomatology than female refugees living with a spouse or significant other Fourteen (51.8%) ofthe 27 respondents were single female heads-of-households raising at least one dependent child under the age of 18. There was no correlation between acculturative stress and single female head-of-household status. Similarly, there was no correlation between single female head-of-household status and psychological distress. Independent t-test of those who were single female head-of-households and those who were not revealed no significant differences in acculturative stress of the two groups. T-tests for the same two groups were also not significantly different among any of the psychological distress variables. Hypothesis 5: Lower SES will be associated with more acculturative stress and more depressive and anxious symptomatology SES of respondents was measured as employment status income and education. Income was measured by hourly wage and net monthly income, while education was measured by the total years of formal schooling a respondent had attained. No significant correlation was found between formal schooling attendance or total years of schooling attained and acculturative stress or any of the psychological distress variables. Similarly, no significant correlation was found between employment status, hourly wage or net income and acculturative distress or any of the psychological distress variables. Nineteen (70.4%) respondents had attended a formal learning institution in their 53 lifetime, while 8 (29.6%) had not. An independent t-test found no significant difference in acculturative stress levels of those who have attended formal schooling and those who had not. T-tests comparing those who were employed and unemployed also found no significant difference in the acculturative stress or psychological distress scores of the two groups. Hypothesis 6: Greater satisfaction with perceived social support will be associated with less acculturative stress and less depressive and anxious symptomatology Total perceived social support was measured using the MSPSS-R. No significant correlation was found between total perceived social support and acculturative stress or psychological distress. The five subscales that comprise the MSPSS-R measure satisfaction with perceived social support from family, significant other, coethnic fiiends, American friends, and resettlement agency. No significant correlation was found between any of the five MSPSS-R subscales and acculturative stress or psychological distress. Hypothesis 7: Greater religiosity will be associated with less acculturative stress and less depressive and anxious symptomatology Religiosity was measured by the DURELL. The DURELL has three subscales which measure organizational (OR), non organizational (NOR), and intrinsic religiosity (IR) (Hill & Hood, 1999). A sixth question was added by the researcher, which inquired about the religious predisposition of respondents. No significant correlation was found between acculturative stress and religious persuasion, intrinsic religiosity, organizational religiosity, or non-organizational 54 religiosity. No significant correlation was found between the psychological distress variables and religious persuasion, non-organized religiosity and intrinsic religiosity. A significant positive correlation, however, was found between organized religion and anxious symptomatology [r =.51, p (one tailed) <. 01, n = 27]. Anxious symptomatology increased as participation in organized religion increased. Respondents reported to being either Christian (23 or 85.2%) or Muslim (4 or14.8%). Independent -test comparisons between Christians and Muslims revealed no significant difference in their levels of acculturative stress or psychological distress. Hypothesis 8: Better perception of personal health will be associated with less acculturative stress and less depressive and anxious symptomatology Personal health was measured using the Medical Outcome Study Short Form-12 (SF- 12). The first question on the SF-12 asks respondents to rate their general health on 4- point likert scale that ranges from “Excellent “to “poor.” Responses to this question were recoded so that higher scores represented better perception of one’s health. Respondents’ general assessments of their health were found to correlate with psychological distress but not acculturative stress. The respondents’ general assessment of their health had very strong negative correlations with both anxious [r = -.52, p (one tailed) < .01, n = 27] and depressive symptomatology [r = -.63, p (one tailed) <. 01, n = 27]. Depressive and anxious symptomatology decreased with less favorable assessment of general health. The PCS subscale which measures physical health was used to measure perceived personal health of respondents. A negative significant correlation was found between perceived personal health as measured by the PCS subscale and acculturative stress 55 [r = -.52, p (one tailed) < .05, n = 27]. No significant correlation, however, was found between perceived personal health as measured by the PCS subscale and anxious or depressive symptomatology. Hypothesis 9: More experiences with pre-migration trauma will be associated with more acculturative stress and more depressive and anxious symptomatology Trauma experienced by the respondents was measured using part I and IV of the Harvard Trauma Questionnaire (HTQ). Part I measures number of trauma symptoms experienced. There was a strong significant positive correlation between acculturative stress and the total number of traumatic experiences [r =.60, p (one tailed) < .01, n = 26] and PTSD symptomatology [r =.53, p (one tailed) < .01, n = 26]. Acculturative stress increased as the number of traumas experienced and PTSD symptomatology increased. The number of traumas experienced and PTSD symptomatology were both positively correlated with psychological distress. Number of trauma experiences was significantly correlated with anxious [r = .27, p (one tailed) < .10, n = 26] and depressive [r = .44, p (one tailed) <01, 11 = 26] symptomatology. Anxious and depressive symptomatology increased as the number of traumatic experiences increased. PTSD symptomatology was moderately positively correlated with anxious [r = .34, p (one tailed) < .05, n = 26] and depressive symptomatology [r = .31, p (one tailed) <. 05, n = 26]. Anxious and depressive symptomatology increased as PTSD symptomatology increased. 56 Qualitative analysis The interview guide provided in Appendix I was used to conduct in-depth interviews with respondents. The interview guide consisted of three broad questions that asked about the respondent’s experiences in three areas: flight, refuge (asylum), and resettlement. The first two questions were meant to elicit information about the respondents’ experiences prior to resettlement, while the final question would elicit information about acculturative experiences alter resettlement. This study was conducted in two stages. The first stage involved the administration of 7 surveys, while the second stage involved in-depth interview with the respondents. At the end of each survey administration, respondents were asked about their willingness to participate in an in-depth interview. Respondents who expressed interest were informed that they would receive a call within a month to schedule an appointment for the in-depth interview. During administration of the surveys, all 27 respondents expressed interest in participating in the in—depth interview. When follow up calls were made, however, only 17 of the 27 respondents were still interested in participating in the in-depth interview. The data that is analyzed below is from in-depth interviews with those 17 respondents. The in-depth interviews with the respondents enable us to understand, from their perspective, how variables under study contribute to acculturative stress and psychological distress. Table 10 provides some basic demographic information describing the 17 respondents who participated in the in-depth interview and the 10 who declined to participate. Qualitative interviews with all the respondents were audiotaped and transcribed by the researcher. The transcribed data were then read and coded by the researcher for 57 themes. Themes identified were those consistent with the study variables. A second person not involved in the study was later enlisted as a second independent coder. This second coder was given a brief background about the study and then informed about how the coding process worked. After a brief introduction, the second coder was then given one of the shorter transcribed interviews to code. The coder was given a pink pen to highlight themes. The coder was instructed to write a title for each highlighted theme in the margins, with similar themes carrying similar titles. Previously, the researcher had coded the same interview that the second coder was asked to code. The researcher had highlighted observed codes in orange and written titles for observed themes in the margins. Results of the two independent codings were compared and discussed, and the second coder was given an opportunity to ask questions. An 85% agreement on coded themes was attained in this first interview, and discussion about coding discrepancies revealed no significant points of difference. Often, coding discrepancies were due to oversights by either the researcher or the coder. After the discussion, the second coder was given the sixteen remaining interviews to code independently. When the remaining sixteen interviews for the second coder and researcher were compared, an agreement of 76% to 87% on coded themes was achieved for each transcribed interview. Here too, discrepancies in coding were found to be due to oversights by either the researcher or the coder. Themes that emerged from the in-depth interview are presented in Appendix M. In the following section, I discuss themes that emerged from in-depth interviews with the 17 respondents. The section is divided into two parts. Part one discusses major themes that emerged as the respondents discussed their flight, asylum, and resettlement 58 experiences. Part two provides narratives from the in-depth interviews that highlight major themes and sub themes that emerged as they discussed their flight, asylum, and resettlement experiences. Table 10: Descriptive Characteristics Comparing Respondents Participating/Not Participating in the In-Depth Interviews (N-27) Variable Participating in the in-depth Not participating in the interview (n=17) in-depth interview (n=10) n n Current age 15 - 25 6 5 26 — 35 4 4 36 - 45 5 1 46 — 55 2 0 Total 17 10 Residence length 0- 3 years 9 4 — 7 years 8 Marital status Single 5 3 Married 3 4 Widowed 3 0 Cohabiting 1 0 Spouse in Africa 5 3 Total 17 10 59 Table 10 (cont’d) Variable Participating in the in-depth interview (n=17) Not participating in the in-depth interview (n=10) n Attended formal schooling No 5 Yes 12 Total 17 Employment status Unemployed 5 Part time 2 Full-time 10 Total 17 Themes 10 10 Several major themes emerged from the in-depth qualitative interviews with the respondents. Major themes that emerged as the respondents discussed their flight, asylum and resettlement experiences are introduced in this section. Flight and Asylum themes. The abrupt and unplanned nature of flight out of Liberia was the first theme that emerged as respondents’ discussed their flight experiences. All but one of the respondents shared that their flight out of Liberian was abrupt and unplanned. The respondents reported leaving Liberia only when their lives 60 were in imminent danger. Many fled only when they received word that the rebels had attacked a neighboring village and were advancing towards their village. Loss was another theme that characterized the flight experiences of the respondents. Narratives about the loss of life, family members, and property were often shared by the respondents. While fleeing, respondents and their family members sometimes had violent encounters with rebels which resulted in the death of loved ones. When the rebels attacked, they looted and burnt houses. Respondents expressed great sadness at the loss of life, property, and livelihood that occurred when civil war broke out in Liberia. The theme of loss also characterized life in asylum. Civil war often broke out in the African asylum countries of Sierra Leone and Ivory Coast to which the respondents had fled for safety. When civil war broke out, it led to separation of families and further loss of life and property. Scarcity was a third theme that dominated the respondents’ narratives about life in asylum. While in the asylum countries, the respondents did not have a source of income and therefore could not afford to regularly buy basic necessities such as food and clothing for themselves or their children. Though relief organizations sometimes provided food to the refirgees in asylum, the food aid was often sporadic and insufficient. Lack of access to basic resources was a fourth theme that characterized the respondents’ life in asylum. In asylum, the respondents lacked access to basic resources such as hospitals. Some of the refugee camps had health centers near them; however, this was not the case for the majority of refugee camps. Respondents who could afford to pay for health care reported that they had to walk for many miles to get to the nearest 61 health center. Resettlement themes. Respondents who participated in the study had lived in the U.S. for an average of 3.5 years and were still facing acculturation and adjustment challenges. Themes emerged from resettlement narratives of the women financial difficulties, concern about family in Afiica, the importance of religion and the supportive role of religious institutions, lack of a well organized ethnic community organization and concerns about discrimination by human service organizations. Every respondent I spoke to mentioned financial difficulty as a major concern. The low-income jobs held by the respondents paid on average a gross income of $1,150.30, which was insufficient to meet their household needs. Most of the respondents received cash and/or food stamps from Department of Health and Human Services (DHS); however, they reported that even with this assistance they still had difficulty meeting their basic household needs. Respondents who were single female heads-of-household found it especially difficult to meet household needs. A second common theme that emerged from the resettlement narratives was worrying about the welfare of family in Africa. All the respondents kept some level of phone communication with family in Africa and were therefore aware of the challenges that these family members were experiencing. Respondents were especially worried about the wellbeing and safety of family living in refugee camps, especially if those family members were their children. The importance of religion and the supportive role of religious institutions was a third theme that emerged from the resettlement narratives. During the in-depth interviews, the respondents shared anecdotes about how prayer or a belief in God or 62 Allah had enabled them live through challenges that they experienced. The respondents had a strong belief that God or Allah would provide for them in difficult times. Such religious belief seemed to help the women through challenges and difficulties that they experienced. Religious institutions also provided practical support. After being resettled, many of the respondents had joined churches and mosques. These churches and mosques often reached out to assist members of their congregation who were refugees with food, furniture and household items. The respondents expressed deep gratitude for this assistance, because their income was insufficient to purchase all the needed household items. A fourth theme was the lack of a well organized ethnic community organization among Liberians. Respondents felt that the limited number of Liberians living in Lansing and ethnic divisions were factors that kept them from forming such an organization; past efforts to start such an organization had been unsuccessful. The respondents felt that such an organization would provide a united voice to advocate for services and programs for Liberian refugees. A final theme emerging from conversations about resettlement experiences was the concerns with discrimination by human service organizations. Some of the respondents interviewed felt that they received differential treatment from human service organizations, especially the resettlement organizations and the local office of the DHS. The respondents felt that they received less support and responsiveness from the resettlement agency when compared to other refugee groups. They also felt that they received less support and responsiveness from DHS as compared to Americans. 63 In addition to the main themes discussed above, many other sub-themes emerged. The following sections provide narratives related to the major themes and sub-themes that emerged from narratives about the respondents’ flight, asylum, and resettlement experiences. Flight Experiences All but four of the 17 respondents fled Liberia during the country’s] 990 civil war. Those who left after 1990, left either in 1994, 1995, 1996, or 1998, when other civil wars broke out in Liberia. All but three of the 17 respondents fled to the Ivory Coast, which borders Liberia to the south. Two respondents fled to Sierra Leone, which borders Liberia to the East. Only one respondent sought refuge in Ghana located to the far east of Liberia. As in most refugee flight situations, the respondents’ departure from their home country was abrupt and unplanned. Many fled only when they were warned that rebel groups were approaching their village. As respondent E explained, “I was in the house with my parents at the time and I went to buy some food. Coming back on my way, you know, fiom getting the food, I saw a group of people running and then among those people someone stopped me and said “do not go back there [to their house] because they just killed your father and they are looking for the family of that man [her father]. [f you get there [go back] they will have to kill you. ” From there, I turned around and ran back [away] filled with fiaar, you know, running to the border [ 0f Ivory Coast and Liberia]. When I got to the border other people {Liberians} were [also making the] crossing [into Ivory Coast]. ” 64 The unplarmed and abrupt nature of the flight from Liberia led to many families being separated. In the mayhem, parents were separated fi'om one another, children were separated from their parents, and brothers and sisters were separated from each other. Once separated, it sometimes took years to locate family members. Respondent E, whose flight situation was described above, was a teenager when she fled Liberia. The abrupt nature of her departure caused her to be separated from the rest of her family and forced her to flee on her own. While respondent E fled to the Ivory Coast, the rest of her family fled to Guinea, which borders Liberia to the North. It was not until recently, almost fourteen years later, that she learned of the whereabouts of her family. Some of the respondents have not been as lucky. Respondent W, for example, is still unaware of the whereabouts of some of her children. Many respondents’ family members and loved ones were killed or gunned down by the rebel forces. Respondent B was lucky enough to flee with her husband and all their children. Unfortunately, as they fled, they lost a daughter and their grandmother to rebel gunfire. She explained: “ We walked, we ran, with all the children. My grandmother, she was living with me and she was bringing [coming with] one of our child when the people [rebels] fired [at] them, so two dropped fi'om us [were killed]. ” Asylum Experiences Once in a neighboring country, some respondents and their families settled in refugee camps while others settled in towns. Those who settled in the towns rented 65 apartments and those who settled in refugee camps built makeshift dwellings. In refuge, the respondents had no stable means by which to earn a livelihood to support their families. Many of them engaged in petty business selling whatever they could i.e. cooked food, charcoal, wood, fish, to earn some money to pay for necessities such as food, clothes, a doctor’s visit, or medicine for a sick child. Respondent A, who had lost her husband in the war, was forced to take care of their nine children on her own. While in the Ivory Coast, she foraged for snails in the forest, which she sold for a modest income. Relief organizations such as the UNHCR and the Intemational Rescue Committee (IRC) sometimes provided non-perishable foodstuffs such as rice, cooking oil, flour, buckwheat, and cornmeal to those living in refugee camps. In some camps, relief organizations stopped providing food after a while leaving it up to the refugees to fend for themselves. When they did provide food rations, they were sporadic and the food so little that it lasted only a couple of meals. Without an income, the respondents often sold some the food they received so that they could make money to buy items that they could sell. The money from the sale of these items was then used to generate more money as well as buy more food and other basic necessities. Respondent C, who lived in a refirgee camp in Ivory Coast wth her five young children, tells about the food supplies that they received. “So the food they call buckwheat, they used to bring to the camp to feed the people there [once] a month. You get [if you have] five children, they give you five kilo [kilograms] of buckweed [and] four bottles of [cooking] oil. [T he food] it not even making [does not last] two days. My own children, they can ’t eat the buckweed because when they eat it, they can have diarrhea. When they give me the buckweed, 66 1 must go I sell the buckweed to the people who like to eat buckweed [so that I can] buy some fish and be making my market [to sell] and buy rice for the children to H eat. Life in refuge was not easy for the respondents or their families. Besides lack of a stable income and lack of adequate food, they also had limited access to essential facilities such as schools or hospitals. All the refugee camps had schools within or near them. Sometimes, aid organizations established schools exclusively for Liberian children. Other times, arrangements were made for Liberian children to attend local schools that were close to the camps. The latter integrated form of schooling often presented an added hardship for Liberian children. Respondent K and V, who are 18 and 21 years old, attended integrated schools of this kind in Sierra Leone and Ivory Coast respectively. According to the respondents, going to the integrated school was a challenge because they were often beaten by local children who teased them about their Liberian accented English. The quality of health facilities available varied from one refugee camp to another. Sometimes, relief organizations provided local hospitals with firnding to provide health care to refugees on a sliding scale. Funding for such services often did not last very long. Nonetheless, when such services were available, few refugees could afford to pay even this subsidized cost of health care. Respondent L lived in a refugee camp where refugees had some access to a health facility. As she explained, the facility did not last for long. “There was hospital [near the refugee camp], you have card when you carry the card to the hospital that is outside [the refugee camp], they give you certain 67 discount but you [still] have to pay [some money]. After certain time, everything just went [services stopped]. Its like when you go to the hospital, the Ivorians [it was a local Ivory Coast health facility] will tell you there is not more facility for the refugees so if you sick, you have to pay your own money. ” Some refugee camps did not have health facilities near them. As explained by respondent B2, in such camps, refugees had to walk for many miles to get to the nearest health center. “We never had a hospital there [in their refugee camp]. The hospital was in another refugees area, farfi'om our village and so when you get sick, if you not able to walk, then that the problem. There was no car to pick [take] a refilge to go to hospital, if you can walk maybe you get up at five (5 a. m. ) in the morning, take your shower, start your journey. Maybe, by nine (9a. m.) or ten (10 a. m. ), you can get to the hospital. ” The hospitals that refugees attended often had limited resources leading to inadequate medical care. Lack of adequate medical resources and lack of accessible and affordable health care meant that refugees regularly went with untreated medical conditions. Respondent W and V (a mother and her daughter), lived in a refugee camp in the Ivory Coast with other members of their family. In 1994, respondent V and W were involved in a car accident. As a result of the accident Respondent W, the mother, sustained serious injuries on her back and arm. The daughter, Respondent V, lost a lot of blood from chest and arm injuries. The two respondents did not receive adequate medical treatment for their 68 injuries. As Respondent V explains, they still suffer from the complications of that accident. “I and her [mother], we have accident in a car, in Africa. We have accident I think in the ending of [1 9] 94 but it hard to go to hospital. When we go to hospital we didn ’t get good treatment. Her [mother ’s] hand break, cut, they just sew it together. My chest everything was swelling, no good medication. Sometimes it [back] it still hurting her [mother]. Sometimes when I [daughter] sit here my anemia [she was recently diagnosed as anemic], I [am] just weak, the whole day I can ’t go nowhere. My chest and my shoulder, I can ’t work that day. I didn ’t take a lot of good medication [in Ivory Coast], no good medication, so sometimes when I [am] working fall down [faint] on the ground [because my head is] spinning. In the morning I get up I can be [am often] tired. ” Respondents were not always well received in the asylum countries where they sought refuges. Liberians, easily identifiable by their brand of “Liberian English” were often discriminated against and victimized as foreigners in the asylum countries. Respondent L who lived in a refugee camp in Ivory Coast explained: “ When you sitting in your gallery [market stall] when you speak English, they just look down on you and they will talk in their language [local dialect]. When you are Liberian you speak English, they will just cuss [at] you up and maybe say something embarrassing [to you]. ” Liberians and Sierra Leonian’s both speak a local dialect called Mende. The dialect, 69 however, sounds different depending on whether you were from Sierra Leone or Liberia. Respondent B who fled to Sierra Leone also experienced discrimination and victimization, because her Mende sounded different and identified her as coming from Liberia Locals in the asylum countries sometimes sought to take advantage of refugees by hiking prices of commodities for those identified as refugees. Sometimes, locals even refused to sell food products to the refugees or let them use some of the local facilities. Mistreatrnent of the Liberians was rooted in feelings of animosity and fear. Animosity towards the Liberians was rooted in anger because they had “invaded” the neighboring countries in large numbers seeking asylum, while feelings of fear were rooted in concern that the Liberians would bring “the war” with them into the neighboring country. One of the respondents who sought asylum in one of the towns in Sierra Leone narrated how she went to the well to draw water and was denied the water bucket to fetch water because she was Liberian. According to the respondent, 3 Sierra Leonian who was at the well cautioned other Sierra Leonians saying: “These Liberian people they are bad people, they not good, so don ’t give her the drawing bucket to draw water. These Liberian people they have war in their country, they want to bring this war to us. ” Two of the respondents, however, reported that they never experienced any mistreatment while in the African asylum countries. Respondent B2, for example, reported that the locals of the villages where their refugee camp was located were always helpful. According to her, the Ivorains and the refugees in her camp lived in harmony. In fact, as she explains below, Ivorians often gave a portion of their land to the Liberian 70 refirgees to farm. Sometimes, this land was given at no cost at all. “We used to make rice farm and go to the French [Ivorian people], you ask for a portion (land), they give it to you, you make your rice farm. They were not selling it to us [asking us for money in repayment for land use]. I will not lie, they were not selling it to us. When we go to them and appeal to them, [we] say [ to the Ivorains] we beg you we want you to help us with a little portion for us to make our rice farm. Then they say okay. Now sometimes, some people, they used to request for money. You have to give them money before they give you the portion. Some ask you to go and work for them before giving you the portion. ” Once in the neighboring countries, respondents were not always safe from danger. Civil war often broke out in countries where they had fled in search of safety. Civil war(s) broke out in the Ivory Coast and Sierra Leone, the two countries where all but one of the respondents sought refuge. When war broke out, respondents found themselves fleeing again in search of safety. Respondents C, E, V, and W told how Liberian males were targeted for attacks during the civil wars in the Ivory Coast. These attacks on Liberians were fueled by Ivorians feelings that Liberians had “brought their war” into their country. Sometimes, as explained by respondent A, Liberian refugees fled back to their home country only to return to the asylum country. “Now then Ivory Coast war, I don’t know [remember] the year but Ivory Coast war came then we ran away, we went Liberia back cause in Liberia. It [the war] was 71 still there but it was not as bad as [in] Ivory Coast. Ivory Coast start killing people, start killing we the Liberians. Some people [Liberians] leave [ran] back [to Liberia]. Some people die [as a result of the war], and some people when they not kill you, they can cut your hand. [Back] in Liberia, [there was] no food. Ivory Coast, we [had] plenty [a lot] food, when we look at the situation, because I am one taking care of children and no food, I say no, we going back to Ivory Coast, if we die we will die there. So I bring my children back [to Ivory Coast] because that place [Ivory Coast] food was there. ” As a result of conflicts in the asylum country, Liberians again endured the trauma of war. One of the respondents’ husband was killed when war broke out in the Ivory Coast. Mothers, fathers, and children were separated again as family members fled for safety in opposite directions. Respondents B2, C, and W were separated from their children when civil war broke out in the Ivory Coast. Respondent W speaks about how civil war in Ivory Coast caused the death of many members of her family. “ War break out again at refugee camp, we didn’t do nothing [were not responsible for the war], they [Ivorians] said they will enter [the refugee camp] and kill all the Liberians. So when they fighting, [any] time they see any [a] Liberian man they can kill you [him]. [The war in Ivory Coast] killed my four brothers, my brother son, my other brother’s son, kill my uncle, it kill nine person [related] to me. ” Respondent C, also remembers the events that occurred when civil war broke out in Ivory Coast. 72 “T he war, after the war in Liberia, we came in Ivory Coast. We were living, we live in [in Ivory Coast] for four years and then war came [occurred] again to Ivory Coast. The war that came fi'om Liberia ran after [followed] the [Liberian] refugees to Cote D’Ivoire [and] killed some of the Cote D’Ivoire people, so the Cote D’Ivoire began to kill our boys because the war killed some of their Cote D ’Ivoire people so they pay their debt [revenged] on our boys by killing them. Any child they see you [Liberians] with that [is] a boy child they take that child from you and kill the child. They [Ivorians] would go fiom house to house [taking] the Liberian boys carry them and kill them. ” The civil wars that had occurred intermittently in Ivory Coast and Sierra Leone from the late 20th century through to the early 21St century created a very hostile and dangerous living situation for Liberian refugees who were often targeted for aggression. A3 a result, starting in the early 21St century, the UNHCR intervened to coordinate resettlement of some of the neediest Liberian refirgees to the U.S. By the time they were resettled in the U.S. the respondents had lived in towns or camps in asylum countries for between 11 to 18 years. Resettlement Experiences All but two of the refugees were resettled as principal refugees. The two not resettled as principal refugees were resettled through a petition by spouses who were already in the U.S. Those resettled as principal refirgees all received a cultural 73 orientation before coming to the U.S. Pre-resettlement cultural orientation. The pre-resettlement cultural orientation equips those being resettled with information about life in the country of resettlement. According to respondent A, the orientation taught them basics about life in America, i.e. how to interact with Americans, where and how to take the bus, where to buy food, etc. The orientation also gives them advice on how to be successful in America i.e. that they should get a job, children should go to school, and they should make sure their children do not misbehave and fall into trouble with the arms. The pre-resettlement orientation lasted about a week and was provided by Africans who had lived in the US for a considerable amount of time. All those being resettled were mandated to attend the orientation which was conducted in English. No interpreters were provided for those who could not understand English. Individuals like Respondent W who could not understand English therefore did not benefit from the orientation. Respondents who attended the orientation said that they found it beneficial because it gave them information that facilitated their adjustment and resettlement in the U.S. Asked if she found the orientation helpful in facilitating her adjustment in the U.S. Respondent A said, “Yes, because they talk about some things, they tell [you] plenty thing [a lot] about America.” Also speaking about the usefulness of the orientation, Respondent E commented, “I mean it was very helpful, [be ]cause they put you on your guard what to do, what not to do [in the U.S.]” The orientation that they received also informed participants about assistance that they would receive from the resettlement agency once they arrived in the U.S. This part 74 of the orientation went into great detail about resettlement services and resources. Eight of the respondents complained that there was a discrepancy in what they were promised during the orientation and what was actually received after resettlement. Respondent A was informed that all her children would be enrolled in school in the U.S. including her 18 year old but this turned out to not be the case. She explained rather angrily, “The man OPE [Overseas Processing Entity], a white man, they call him X say [said] your children they will send every one of them to school. I asked him question, but my son here he is 18 and he not go to school. He said go [to the US], they will send him [son] to school. So when I came, my son, they not send him to school. And right now'he [is] not going to school. My case worker X [at the resettlement agency], say my son must work because he [is] 18 years, he not able 9 to go to school, that is what he tell me. ’ At the orientation, respondents were informed that on arrival in the U.S., they would be provided with fully furnished living quarters. While all of them received furnished housing, three respondents lamented about the quality and quantity of housing and household furniture and wares that they were provided with. Respondent E who arrived during the winter with her teenage daughter told how she was housed in an apartment without heat. “I came during the winter. When I came, they put me into a house where there was no heat. I slept out of my house for months, cause I never had heat. I used to 75 complain and complain and complain [to the resettlement agency], what they [the resettlement agency] did one day it was to buy an old space heater [for her apartment], it didn’t last even a week, it went off [stopped working]. So I went [moved] out of my house again to live with some other [Liberian] family. " Six respondents expressed anger about the discrepancy in resources and services that they had received. The respondents felt that some resources and services that had been promised to them had not been received. The respondents felt fi'ustrated and deceived. Respondent A angrily expressed that she felt that they had been lured to the U.S. with false promises. She claimed that she was so fi'ustrated that she wanted to call the UNHCR to tell them about this deception. She explained: “U.N. [UNHCR] tell [told] me they say the thing [services] they were going to do to me [I was going to be provided with]. They not help me. America too hard, we the refugee, they fool [lied to] us. They [U.N] bring us here they are supposed to be checking on the people [resettlement organizations] that are supporting us [to see how we are doing] now but they cannot check on them [refugees], they cannot do nothing. ” Coethnics social support in the resettlement country. In the resettlement country refugees receive assistance and social support from various individuals, institutions, and organizations. Among their sources of social support are Liberian coethnics, family, resettlement agency, significant other, and American friends. Respondents interviewed 76 expressed differing levels of satisfaction with these forms of social support. Families, both nuclear and extended, are of tremendous social support for refirgees in the U.S. Respondent V and W are mother and daughter. Respondent V, the daughter, is 20 years old. She lives a few blocks away from her mother with her two children and their father. Despite living apart, respondent V spends most evenings at her mother’s house. Respondent V’s mother is elderly and ailing; therefore the daughter prefers to spend her evenings keeping her mother company and helping her with household chores. It is not only family members that live in close proximity to the respondents that offer social support. Family that lives in other states also offers support and assistance in time of need. Respondent B arrived in the U.S. as a single female head-of—household with 6 dependent children. Before being employed, the resettlement agency gave her only $99 every two weeks to meet her family’s household needs. Though the resettlement agency paid her rent, the $99 was not enough to pay her utility bills and feed her family of seven. Aware of her financial situation, extended family in other states often sent her money. Though there are very few Liberian refugees living in Lansing, coethnics were a significant source of support for respondents. Coethnics often came together to help those who experienced difficulties. Respondent E explains how fellow Liberians rallied around her when she had surgery. “I like our Liberian community, like I see Liberians are not too much [many] in Lansing and that ’3 fine. When I went through my surgery, my Liberian brothers 77 and sisters came to visit me. They always in and out [of her apartment] to see how I am doing, how things are going, we always with one another here. ” Respondent D, a single female head -of- household had to undergo two surgeries shortly after arriving in the U.S. Like with Respondent E, the Liberian community in Lansing rallied around her to give her support and sympathy. She explained: “T hey [Liberians] came here [her apartment] to me, they come tell me sorry [convey their sympathy]. The time I come to [flour] the hospital, all of them [Liberians], they came together to tell me sorry. X [a Liberian man], the time when I went to the hospital, X took two of them [her children] and carry [took] them to the [his] house. [When I was in hospital] if I want see them, sometimes X can carry [bring] them [to the hospital]. ” Coethnics also provide much needed childcare support for one another. This is an invaluable form of support since most Liberian refugee households cannot afford daycare. Respondent E lives in the same apartment complex as Respondent T. Both respondents are single female heads of households with one and two teenage daughters respectively. The two respondents go to work at different times; one works during the day, while the other works at night. They offer each other childcare support. When one parent is working, the other takes care of the three teenage children. Respondent E talked about the childcare arrangement between the two parents. “Yes, she [respondent ’s teenage daughter] always with Respondent T, because I go 78 to work at night and I don’t be [am not at] home at night and she [Respondent’s teenage daughter] doesn ’t want to stay at home she will be with [Respondent T ’s] children. I take them [the three teenagers] to study class when I am going to work and Respondent T bring[s] them home. ” Respondent D, another single female head-of-household, also receives childcare assistance from a Liberian neighbor. Whenever she has errands to run she leaves her two young children with her Liberian neighbor. Only one of the respondents I spoke to seemed to feel that she had not gotten support from coethnics when she most needed it. Like respondents D and E, Respondent A also underwent surgery. Respondent A, however reported that none of the Liberians visited or supported her during that difficult time. As close knit as the Liberian refugee community in Lansing is, it is not without conflict. In talking with the respondents about the support they get from one another, I was made aware of grudges and disagreements that existed between individual members of the community. Sometimes, these grudges and disagreements kept some members of the community from having contact with one another. Respondents I spoke to lamented that the Liberian community in their city was not as united as Liberian communities in other cities. Respondents felt that this was partly because of the small number of Liberians living in their city and also because ethnic rivalries that arose from the Liberia civil wars were still creating rifts among them. Social support from spouse/significant other. Three of the 17 respondents who 79 participated in the in-depth interview were married, while three were in a relationship with a significant other. Of the remaining 11, two were still teenagers (18 years old), while the rest were single female heads-of—households. The three respondents who were married felt that having their husbands with them was invaluable in enabling their adjustment to living in the U.S. The married respondents cited as most beneficial the household income that came from being a dual income household. When asked about the challenges of raising their families alone, all single female heads-of-households mentioned limitations associated with being a single-income-household. Social support from the resettlement agency. Resettlement agencies are charged with the responsibility of helping resettle refugees in the U.S. Initial responsibilities of resettlement agencies include picking up newly arriving refugees from the airport and making sure that they have a furnished apartment to live in, as well as food and clothing when they first arrive. Resettlement agencies also help refugees find jobs and connect them to human service organizations such as DHS so they can receive necessary assistance (ORR, 2007a). All but two respondents felt that the assistance they got from the resettlement agency was important in helping them initially resettle in the U.S. However, seven respondents expressed dissatisfaction with the quality of service received. For example, though all the respondents were provided with a fully furnished apartment when they first arrived, three respondents expressed dissatisfaction with the type of housing and furnishings that were provided. When respondent A first arrived, she was resettled in a house that had a faulty drainage system. As she explains below, she complained to the 80 resettlement agencies only to be moved to another house that was in poorer condition. “T hen the house that they put me in, the bathroom was upstairs so when we take bath, the water can go on the floor downstairs to the basement [the water trickled through the bathroom floor down into the basement]. I went to the oflice [resettlement agency], I tell them, they do nothing. [Finally] they take [moved] me to the place [a house] that [she laughs] bad more [was worse than the first]. I telling [tell] you. The house had rat[s] and roach [cockroaches]. When I tell them [complained tot the resettlement agency], they can’t do nothing, [they] say [they] not get [do not have] time. ” ' Frustrated about the poor living conditions and the lack of support that she got on the matter from the resettlement agencies, Respondent A successfully found suitable housing with the help of an American friend. The resettlement agency is also required to provide newly arrived refugees with clothes to wear. Provision of clothing upon arrival was especially important, because refugees often arrive in resettlement countries with nothing but the clothes on their back. Two respondents claimed that they did not receive clothing in a timely manner. Respondent D explained: “T he time we come, we not met [did not find] clothes there [in the house]. The time when I came I used to wear my African clothes and my sister clothes [Respondent D was resettled in the same town as her sister who had been resettled in the U.S. earlier]. That her [sister ’3] clothes I used to wear, my daughter was not 81 having clothes. ” Resettlement agencies pay rent and provide financial assistance to newly arrived refirgees for the first eight months or until they start working, whichever comes first. If after the eight months a refugee still has no job, they are connected to the Department of Health and Human Services so that they can continue to receive financial support until they find a job. Two respondents, however, complained that they had their financial assistance cut off by the resettlement agency before they had a job and before the eight month period had elapsed. Social support fiom American friends. All but one of the respondents reported having at least one close America friend. Eight of the respondents met their American friends through church, while six met them through college, school, or work. Only two of the respondents reported having more than one American friend. The respondents felt that their American fiiends were instrumental in helping them adjust to living in the U.S. Eight of the respondents who took part in the in-depth interview could read and write at a comfortable level. Those who could not read or write and did not have children old enough to read or write often requested their American friends to read to them letters and documents that they received. Respondent B2 and her husband can read and write on an elementary level. When they have difficulty understanding written documents, they call on one of their two American fiiends for help. Respondent B2 explained: 82 “Sometimes they send us some letters, when my husband [does] not understand it [letter], he send for him [the American fiiend] and he make[s] it to [so we] understand. ” Sometimes, respondents encounter situations and events that that they cannot comprehend. In such cases American fiiends often act as cultural brokers, helping respondents make sense of the situations and events. For example, Respondent B2’s home, like most American homes, was plagued by calls from credit card telemarketers. Not knowing anything about telemarketers or credit cards, respondent B2 and her husband turned to one of their American friends for help. Respondent B2 explained: “If we have anything where sometimes we don ’t’ know we asked him [American friend]. Sometime, people call over the phone, like the credit card groups and we don ’t know what to do. We cannot do anything [respond to the telemarketers] now except when [until] we meet our sponsor [American friend]. [When] we call him [American fiiend], he don’t hesitate. He come here [their home], he always come to us and see what is our problem and we put it before [explain it to] him, he tells us no, this one is not yet time for you people to do that [get a credit card] and when [if] you do that you will fall in this [sort of a] problem. ” The respondents are all low income earners. At times, therefore, they lacked money to buy essential necessities for their home and children. American fiiends sometimes stepped in to help respondents with their material and financial needs. 83 Respondent A, for example, was resettled as a single female head-of-household with nine children. The resettlement agency gave her minimal firrniture, household wares, bedding, and clothing. An American friend she was introduced to solicited donations of gently used household wares, bedding, and clothing which she gave to the respondent and her children. Another American friend, meanwhile, gave the respondent $2,000 so that she could buy essential pieces of furniture for her house. . The relationships that the respondents formed with their American friends have endured over time. American friends still offer the respondents assistance even though most of them have been in the U.S. for a few years now. Eight of the respondents shared how their American fiiends regularly buy them foodstuff and gifts during holidays like Christmas and Thanksgiving. Religiosity. All but three of the youngest respondents expressed a high level of religiosity. In our conversation, the respondents often attributed their survival through the conflict to God or Allah. Going to church on Sunday was very important to the Christian respondents. Respondent L, for example, refirsed to take a job that would have her work when she should be attending church service. In speaking about the importance of going to church, she said: “I have to go to church. If you knew what I went through [after conflict broke out in Liberia] you will not tell me not go to church. I have a reason for which I want to go to church, to tell God thank you for all the things he did for me. ” In speaking with the respondents, it was apparent that their faith helps them cope 84 with the challenges that they continue to experience as refugees. Thirteen of the respondents reported that they turn to religion for assistance with day to day problems and challenges. As respondent B put it: “You have to put your problem to God, you pray. God will answer you. So if I have problem, when I pray, I ask God for [to] do me this, or do this for me. ” Respondent D told a story to demonstrate how God answers prayer requests. As she tells it, one morning she decided to pray because she needed diapers for her child but had no money. Later that day, her prayers answered and diapers for her son were delivered to her house. She narrated: “I don ’t have a diaper for my son, only one diaper remaining. That morning I wake up I sit down, I pray. I say, God, just bring someone here to buy diaper for my son. A man [a case worker at the resettlement agency] came to pick up S [Liberian neighbor living near the respondent]. Because he know me I said [told him] I don’t have a diaper for my son, he say okay, I will go buy it [diaper]. He went to the place [office] and [later] bought the diaper[s]. If I pray, if I put my heart in God, God can help me for it. ” Respondent E also prays about her problems. Talking about the importance of prayer she said, “I can take everything to God.” Submitting their cares, concerns and problems to a higher being gives the respondents a sense of relief and frees them from worrying about their problems. Talking about the utility of prayer in her life, respondent 85 E said “It ’s helpful, its helpful, it is yeah, I mean, [when I pray] I just feel I [am] not even suflering. I went through hardship [since fleeing Liberia] but I thank God. Sometimes when I am home I turn my television on, I turn to a Christian station you know, listen to the gospel and maybe calling the 800 [I -800—] number you know for some prayers, it ’s helpful. ” In reality, it is not always that the respondents’ prayer requests are granted. When asked what it means when God doesn’t grant their requests respondent C said: “God cannot make mistake, so anything that I pray for when not agreed [granted] then is God [ ‘s will] so I cannot worry over it. ” Four respondents felt that if God does not grant your prayer requests, it is because that is not His will for you. This belief gave the respondents some comfort with unrequited prayers. Most of the Christian respondents attend religious services regularly. The churches they attend are very supportive to refugee congregants often providing financial and material assistance to the respondents and their families. Shortly after resettlement, Respondent E found herself without a job and without money to pay rent. When she turned to the resettlement agency for help, they were unresponsive. A Liberian friend advised her to talk to her church, which she did. She explains: 86 “It was you know it was just this time when I first came and I loose my job. I was in problem with my landlord [because she had no money to pay for her rent] and the resettlement organization [agency] could not come in and [help] I[ was] not give any waiting time [an extension to pay rent]. This is the time where I asked the church to help me pay my rent and they did it. ” Respondent BZ received not only financial but also material assistance from the church that she attends. When they were first resettled, the church gave her husband a bicycle to help him get to work. Since he could not use the bicycle to get to work during the winter the church again stepped in to help. Respondent BZ explains: “Okay, when we came [to the U.S.] and my husband start working we never [did not] have a car or bike. The church gave him a bike [so he could get to work]. Now, little after the snow stared. The snow was very heavy and he could not go to job [work] with the bicycle. So we wanted to get a car and at that time we never had much money and the church help us with $500. We pay [added] the [another] $500 dollars and we have $1000 and we give it to our sponsor [American fiiend] and he went and bought this car. ” Respondent B, one of Muslim respondents in the group, does not attend the mosque regularly. Despite not going to the mosque, she described herself as a devout Muslim. Respondent B, was resettled in the U.S. two years ago. Even though she does 87 not go to the Mosque, for the past two years the Mosque near where she lives has sent her financial assistance amounting to $ 635. Ten other respondents reported having been given material assistance by the church including furniture, bedding, towels, clothing, etc. The respondents were always very happy to receive these items because many of them did not have financial resources to purchase such items. When they were newly resettled respondent H and her family of eight got much needed material assistance from their church. They were given furniture, baby clothes, children clothes, dishes, pots, pans, a washing machine and a dryer. Four of the respondents reported that they recently received material and financial asistance from the churches they attend. A Lutheran church that attracts many of the Afiican refugees to its international service has been particularly helpful to the respondents and their families. The church regularly gives material assistance to refugee congregants. To help with their financial needs, the church extends interest-free loans to refugees to be repaid when funds become available. Another church, a Baptist church, has also been very helpful to the respondents. A female member at the Baptist church has created a program that assists refugees living in Lansing. The program solicits for gently used clothing, household items, and furniture, which are then provided to refugee families in need. The program also solicits cash donations which are used to help refugee families purchase household items. During holidays such as Thanksgiving and Christmas the program always delivers food baskets to refugee families. Nine of the respondents were regular beneficiaries of the holiday food baskets given away by the program. In addition to providing material and financial assistance, churches also provide 88 emotional support. Respondent L’s husband was resettled in the U.S. before his wife. To provide support and encouragement to the separated couple, for example, the Lutheran church pastor regularly called Respondent L in Africa to pray with her. The emotional support the respondents receive as church members comes not only come from the pastors but also the congregation. Eight respondents reported that the congregations at the churches they go to also provide emotional support. When respondent D was undergoing surgery, the congregation sent her cards wishing her a quick recovery. It is not only the pastors of the churches that are supportive of the respondents. Seven respondents reported that members of the congregations always make them feel welcome and accepted, thereby giving them a feeling of group membership. Talking about her church experience, respondent B said: “The church I am in now, you know I just feel, I find love, you know whenever I go people will embrace me, oh my God, so I just love it. ” Talking about their family’s experience and involvement at church, respondent BZ said “The whole church love us, anything happening, like going on in the church, like program, like party, we always among [join] them, they don ’t divide us to say, this African, this white, no we all join [socialize] together and do everything. ” 89 Health . Six respondents reported to having health problems, while 11 reported no health problems. Three of the respondents reported that they currently take medication for their health problems; two of these three take medication for high blood pressure. Three other respondents report having undergone surgery for medical conditions. One more respondent reported that she will soon undergo surgery for a health-related problem. Eight respondents reported that health complications rarely keep them from working unless they were very serious. They reported that missing work would mean lost income, which would further affect their meager household income. Respondent C, for example, has a health complication for which she needs surgery. She remains reluctant to schedule a date for the operation despite the fact that the doctor has impressed upon her the need for urgency. As a single female head-of-household, she worries about lost income once she is hospitalized. The respondents’ health can affect their ability to adjust to life in the U.S. Respondent D, for example, had to have two surgeries for a serious medical condition almost immediately after being resettled in the U.S. As a result of these surgeries, she has been unable to work and she spends most of her time at home taking care of her children. Working outside the home provides a great way for refugees to acculturate to their new environment, because it allows them to interact in the new culture. Because Respondent D has not held a job in the U.S., she has been denied a very useful medium of acculturation. 90 Fluency of spoken English. The respondents interviewed seem to be adjusting to living in the U.S. fairly well. All of them interact in the mainstream U.S. society without much difficulty. Since the Liberian culture is so different from the American culture, they have experienced some challenges adjusting to life in the U.S. Mentioned most often was the difficulty understanding and communicating in Standard English that is spoken by most Americans. All but three of the respondents interviewed had limited education. All but six of the respondents did not speak Standard English when they were first resettled; rather they spoke a Pigeon English often referred to as Liberian English. Though it is a form of English, Liberian English is very different from Standard English. Most of the respondents, therefore, had tremendous difficulty understanding or communicating in Standard American English. Consequently, many of them experienced second language anxiety as explained by respondent L: “Some of them [Americans] understand me, but some of them, its like when I talk [they ask], its like what you say, and I have to take my own time to repeat it, I feel discouraged I say ha, how can you speak and then somebody asked you what you say, like its not English you are speaking. ” Reflecting on the same issue, respondent D said: “IfI talking [talk] to them [Americans], they cannot understand me [she laughs]. Their own [English is] dijfirent, my own [English is] diflerent. So if I among them 91 [Americans] when they talking they can hear [understand] me but small [little] because if [when] I talking [talk] to them they cannot hear [understand] me. ” All the respondents reported that they now understand Standard English without much difficulty. Respondent A, for example, arrived in the U.S. not being able to speak a word of English. Today she is conversant in Standard English and is able to communicate without difficulty. Though all the respondents have learned to speak Standard English, they are at different levels of fluency. All but four of the respondents speak fluently in Standard English. These respondents report that Americans sometimes experiences difficulty understanding them when they speak English. Those most fluent in Standard English are those who have attended a learning intuition in the U.S. such as respondents V, M, X, J, and R. Adjustment challenges. Limited education of the respondents has interfered with their ability to adjust to life in the U.S. Respondents who are not literate or those who can only read and write at an elementary level seem to have greater difficulty adjusting. Since they are not literate, they have less confidence about interacting in mainstream U.S. culture. As a result, most of the uneducated respondents prefer to interact with their coethnics, which directly impacts their ability to acculturate to their new environment. Discrimination is another challenge that the respondents face as they try to adjust to life in the U.S. Some of the respondents felt that because they were not American they were treated differently by some human service organizations. 92 Respondent V, for example, felt that because of their accents they were singled out as “non-Americans” which negatively affected the quality of services that they received from human service organizations. Five of the respondents I spoke to also felt that they were discriminated against by the resettlement agencies. A recurring theme was the complaint that some refugees from some countries got better treatment and more support than other refugee groups. These five respondents felt strongly that felt that Liberian refirgees received less resources and services than did some other refugee groups. Five of the respondents who had attended elementary or high school in the U.S. also reported having experienced discrimination. They reported being teased by other children in school and being called derogatory names such as African monkey and Afiican bushcrasher. Speaking about her high school experiences, respondent M said: “Sometimes, because I was new so, and I am from Africa so, they, you know the American children they sometimes they make fim with [of] African children. So they say like in Afiica we don’t have no clothes, to wear, we walk on our bare feet, we don ’t have no clothes, no food to eat that ’s what they used to say every time. When I be walking going for lunch sometimes, they just talk about me, say some funny funny stufl ” Since most of the respondents have limited education, they can work only at manual jobs which pay minimum wage. Another stressor that the respondents talked 93 about was constant worry because the money that they earned was not enough to meet their household needs, even in dual income households. Two respondents expressed concern that living hand to mouth meant that they were unable to save any money. Respondent E who is a single female head-of-household lamented: “I [have been] living in America for four years now. The work that I doing, I cannot see [do not earn enough] money [therefore I am] facing whole lot of problems every day. I cannot keep [save] money. Even if you looking [look] at my house now good four years I been here in America going the store I [cannot] say let me buy chair, let me buy this.” Respondent A is employed and receives food stamps to help her feed her seven children, but still has difficulty meeting household needs. She shared how all the money that she earns goes into paying her bills with nothing left over to meet other household needs: “I just working for the place where I live -- for me to get light, heat, that the only thing I working for [all her pay goes to pay rent and utility bills]. Sometimes when my children they need something to wear I will take money to go buy, nowhere [I do not even have money to buy my children clothes]. ” Respondent D, who is unemployed but receives both cash assistance and foods stamps from DHS, also has difficulty meeting even basic household expenses. She explained: 94 “T he government [DHS] giving [gives] me [money] I pay my house rent, I pay my heat bill, I pay my phone bill, buy son[ ’3] diaper, and diaper expensive, everything [money] can finish. Sometimes I cannot even get money to wash my clothes [to do laundry]. [Right now] my clothes are packed inside there [bedroom] I cannot get money to buy soaps and wash my sons clothes. ” Another acculturative stressor that the respondents experience has to do with being separated from their children. During the war, some of the respondents were I separated from their spouses and children as family members fled for safety in different directions. Some of the respondents were not able to locate the separated family members until after they were resettled. Respondent B2, for example, was resettled with her husband and two children. Six of their children, all of whom are below the age of 18, were separated from them and are in the Ivory Coast. Respondent D was resettled with four of her children but four other children aged 15, 13, 9 and 8 years, however, were separated from her and are also in Ivory Coast. Being separated from their children causes these respondents a great deal of stress because the constantly worry about the welfare of their children living in Afiica. Refugees have the opportunity to petition to have immediate family members resettled with them in the U.S. The process to do this, however, is long and expensive. The respondents who left family members behind felt fi'ustrated because they lacked information on how to petition to bring their separated family members to the U.S. The resettlement agency has a department that deals with refugee family reunification. The respondents claimed, however, that the department was not especially useful in 95 informing them about such processes. When I interviewed Respondent A, she had just found out that time had elapsed within which she could have petitioned through an easier process to bring her nine year old son to the U.S. She expressed great anger at the resettlement agency because they had not informed her that a time-limited process was in place which she could have taken advantage of to reunite her with her son. All the respondents have family and friends in Liberia and the other African asylum counties. Thirteen respondents talked about the stress associated with financially providing for their family members who were still displaced and who had no source of income. The respondents, however, did not consider this responsibility a burden. They considered it an obligation borne out of love and an understanding of the difficulties of life in asylum. Sharing her thoughts on this obligation, Respondent E said: “Well I grew up with my family with love then we went apart [were separated by the civil war] and it really hurt my feelings. I could not see them [did not know where they were]. Later on I heard they were alive, I was so thankful to God. So, it is not hurting me by sending money to them, I think I [am] supposed to do more than that [sending money]. ” Having lived in asylum countries before, the respondents are well aware of the hardships their fiiends and family members were enduring. The respondents, therefore, send money to family members and friends in Africa as often as they can. Thirteen respondents reported that they receive phone calls very often from family and 96 friends in Afiica asking for money to buy food, pay rent, take a sick person to the hospital etc. When asked about requests for money, respondent V said: “Oh yes [she laughs] we have lot of family, every time they call [flom Africa], [they tell us] I am hungry. In Africa it is hard, very hard, hunger are [is] there [in] plenty, people die from hunger. [We have] many people -- friends, family, most of them [when] they [are] hungry they can call you [us]. ” When I conducted the in-depth interview with respondent D, she received an international phone call which requested her friend to respond to. Later, the respondent informed me that the phone call had come from Afiica and was from someone asking for money. She explained that she had not wanted to answer the phone, because she did not have any money to give. The respondents who sent money to Afiica all talked about how hard it was for them to support not only the family they have here, but also the family and friends back in Africa. The strain of having to provide for numerous households invariably puts a strain on the respondents. Talking about this challenge Respondents V said: “When we working like that we get money then we have to send back [to family in Afiica]. We have two bills to pay, we pay our own bills here in America then we send it [money] back in [to] Africa for people [family and fiiends ] to buy food I, eat. 97 The respondents send whatever little money they can whenever they can. Sometimes the respondents go for months without sending money because they have none to spare. When they are unable to send money they constantly worry about the welfare of their loved ones. The respondents know all too well that failure to send money may mean that that their loved ones may go homeless or hungry. When they do send money to loved ones in Africa, it can be as little as $20. When she first arrived in the U.S. two years ago, respondent A sent the $700 she received as a federal tax refund to help her extended family in Afiica with their numerous needs. Since, then, she has infrequently sent small amounts of money. Traumatic experiences. The respondents interviewed have all witnessed and/or endured unspeakable trauma since they fled their home country. As I spoke to the respondents, they told harrowing tales of their traumatic experiences in flight and asylum. These traumatic experiences have affected the respondents differently. Among all the respondents, it was respondent W who was most affected by her traumatic experiences. The respondent’s husband and child were killed when war broke out in Liberia. The civil war in Liberia also caused her to be separated from some of her children who fled for safety in a different direction. Later, when war broke out in the asylum country she lost nine other close family members. In talking about her health, Respondent W described symptoms that are very similar to those associated with PTSD. She reported that the slightest noise startles her. Talking about this she said, “So now when these children holler [shout] like that, oh, [my] heart starts beating fast and I start sweating. ” The respondent also often 98 suffers from panic attacks. Last year, she was rushed to hospital when she suffered severe panic attacks. The respondent worries so much about the safety and welfare of her children and grandchildren in Africa that she often cannot sleep. Respondent D also reported to having been affected by her traumatic experiences. The respondent suffers from high blood pressure, which she feels developed after war broke out in Ivory Coast. Talking about the origin of her high blood pressure she said: “ I got pressure, high blood pressure, I get it fi'om Ivory Coast, the war that take us from X [a town in Ivory Coast], that the one that give me high blood pressure. Because I think too much, my ma [mother], my other sister, I cannot see them [I did not know where they were] so I think too much [about the mother and sister], that the one that give high blood pressure in the Ivory Coast. ” All the respondents reported excessively worrying about the safety and well- being of family members and friends in Africa. They worried mostly about children, elderly parents, and brothers and sisters that they left behind. Respondent A recently found out that her nine year old son who was left behind was homeless because the woman who took care of him no longer wanted to do 30. Talking about her concern about her son she said: “I can worry too much. Sometimes when I sit down [thoughts of] my child get in my heart and I enter [go to] the [bed] room and I can be [stay] in the room all day. When I go to work, sometimes I can be thinking [about her son]. ” 99 Quantitative data were analyzed using Pearson’s Product Moment was used to test correlations with categorical variables, while independent t-tests were used to test the difference in means of groups where it made conceptually sense to do 30. Given this analysis, hypotheses that were confirmed or denied are as follows: 1. Older age at resettlement was not associated with more acculturative stress nor was it associated with more depressive symptomatology. 2. More time spent in the host country was not associated with less acculturative stress nor was it associated with lower depressive and anxious symptomatology. 3. Higher fluency of spoken English as assessed by the respondents’ and the researcher was not associated with less acculturative stress. Similarly, higher fluency of spoken English as assessed by the respondents’ was not associated more depressive or anxious symptomatology. Higher fluency of spoken English as assessed by the researcher, however, was associated with less depressive symptomatology. 4. Single female heads-of-households did not have more acculturative stress or depressive or anxious symptomatology than female refugees with spouses or significant other. 5. Lower SES was not associated with more acculturative stress nor was it associated with more depressive and anxious symptomatology. 6. Greater satisfaction with perceived social support was not associated with less acculturative stress nor was it associated with less depressive and anxious symptomatology 7. Greater religiosity was not associated with less acculturative stress or less depressive 100 symptomatology, however, it was associated with more anxious symptomatology. 8. Better perception of personal health as measured by the PCS subscale was associated with less acculturative stress but not less depressive or anxious symptomatology. Better perception of personal health as measured by respondents general health assessment, however, was associated with less acculturative stress and less depressive and anxious symptomatology, but not less depressive symptomatology. 9. More experiences with trauma (number of trauma experiences) was associated with more acculturative stress and more anxious but not depressive symptomatology, while more experiences with PTSD was associated with more acculturative stress and more depressive but not anxious symptomatology. The qualitative data that emerged from the in-depth interviews provided information to help better understand the outcomes of the hypothesis testing. 101 CHAPTER 5 DISCUSSION This study examined the effects of sociodemographic variables on acculturative stress and psychological distress in adult female Liberian refirgees living in Lansing, Michigan. This chapter begins by providing an interpretation of results of the nine hypotheses that were studied. Later, the chapter discusses the limitations of the study, addresses implications of the findings and identifies areas for future research. Discussion of Hypotheses Only a limited number of studies have explored acculturative stress and psychological distress in refugees. Those that have done so have focused almost exclusively on Asian refugees (Salant & Lauderdale, 2003; Yeh, 2003). Few of these studies have focused on Afiican refugees. This study aimed to increase the body of knowledge on acculturative stress and psychological distress for Afiicans by studying acculturative stress and psychological distress in Liberian refugees. Most studies of acculturation have focused on the impact of sociodemographic variables on acculturative stress and psychological distress. To allow for comparison with other studies, this study also explored the impact of sociodemographic variables on acculturative stress and psychological distress in adult female Liberian refugees. Nine hypotheses were generated for this study and a discussion of the results of the tests of 102 these hypotheses follows. Hypothesis 1: Older age at resettlement will be associated with more acculturative stress and more depressive and anxious symptomatology Older adults often have a well formed cultural identity and behavioral repertoire that draws primarily from their natal culture. Due to this well formed identity, the literature supports that older adult immigrants are more likely to hold onto their natal culture and manifest greater reluctance in adopting behavioral and cultural elements of the host society (Ong & Madden, 2000; Phinney& Ghaffarian 198 8). Reluctance in adopting behavioral and cultural elements of the host society is thought to cause acculturative stress and psychological distress because it leads to lack of appropriate skills-sets for navigating the host society (Miranda & Umhoefer, 2000). This study found age at resettlement to be negatively correlated with acculturative stress, which means that younger, not older age, was associated with higher levels of acculturative stress. Though contrary to assumptions about age at immigration and acculturative stress, this finding is supported by a study by Godowsky & Lai (1997), which also found that younger and not older age at immigration was associated with acculturative stress. Despite this finding, narratives from older respondents indicate that they do indeed experience acculturative stress. Asked about experiences of stress while living in America, respondent W said “oh, oh, life in America is too too hard, it causing me too much trouble [stress] is harder than living in Africa. Life in America is very very dijfkrentfiom Liberia. ” Studies that have looked at the relationship between age at immigration and 103 psychological distress in immigrants have reported mixed findings. While some find older age at immigration is associated with psychological distress (Yeh, 2003; Hovey & Magana, 2002), others find no such relationship (Miller & Gross, 2004; Thomas and Suris, 2004). Although the study found no significant correlation between older age at resettlement and psychological distress, older respondents reported experiencing more distress because of childrearing and household responsibilities associated with having more dependant children. Descriptive statistics revealed that respondents who were resettled at age 30 years or more had on average more children (M = 4, range from 1 to 9) than those resettled at age 29 or younger (M = 1, range from 0 — 3). Hypothesis 2: More time spent in the host country will be associated with less acculturative stress and less depressive and anxious symptomatology Research has shown that time spent in the host country leads to familiarity of the host culture, which reduces acculturative stress'and psychological distress associated with immigration and living in a new culture (Oh, et al., 2001; Miranda & Umhoefer, 1998). In studies of acculturation, time spent in the host country has been shown to be a predictor of acculturative stress and psychological distress (Sue & Chu, 2003; Shen & Takeuchi, 2001; Takeuchi et a1. 2007). This study found no significant correlation between length of residence and acculturative stress or psychological distress. The lack of diversity in the number of years that respondents had spent in the U.S. and the small sample size might have contributed to the non-significant findings. Despite the non-significant finding, narratives from the respondents suggest that those who have been in the U.S. longer experience less acculturative stress and 104 psychological distress than those who have been in the U.S. for a shorter period of time. Respondent L had spent the least amount of time in the U.S. compared to all the respondents. She had been in the U.S. for only 3 months when she participated in the study. Asked about her experience in the U.S., she shared that she was still confused about what to do and how to behave around people. Not having interacted with many people of Caucasian background, she also shared that she got very anxious when she was in a room that was comprised of predominantly Caucasian individuals. She explained, “I was really really afraid because you can imagine sitting among white and you are the only black, I must admit, I was afiaid. ” Talking about living in the U.S. respondent D, who had been in the U.S. for three years said that she felt comfortable being in the U.S. and had adjusted well. Relating to her current experiences of being in the U.S. she said 1 “no, there is nothing bothering me no more, I fizel I settle [ have adjusted] well now. ’ Hypothesis 3: Higher fluency of spoken English will be associated with less acculturative stress and less depressive and anxious symptomatology Very few of the respondents spoke Standard English when they were first resettled in the U.S. The vast majority either spoke no English or they spoke Liberian English, which is very different from the Standard English spoken in the U.S. Respondents not fluent in Standard English had to learn it in order to function in mainstream U.S. society. Research has shown that immigrants experience anxiety and self-consciousness commonly referred to as ‘second language anxiety’ when they have to practice new language skills (Yost & Lucas, 2002). Second language anxiety has been identified as a strong correlate of acculturative stress and psychological distress 105 in immigrants and refugees (Miller & Gross, 2004; Aroian, 2003; Lieber et al., 2001; Miranda & Umhoefer, 1998). The study found no correlation between either the respondents’ assessment of their fluency of spoken English or the researcher’s assessment of the respondents’ fluency of spoken English and acculturative stress. Though respondents" fluency of spoken English was not associated with acculturative stress, narratives from the respondents clearly suggest that inability to speak English was an acculturative stressor. Respondent L, one of the most fluent in English, described the stress she experiences when she communicates in English in mainstream society. “When I talk [speak in English] its like what [have] you say [said], and I have to take my own time to repeat it, I feel discouraged I say ha, how can you speak [English] and then somebody asked you what you say, like its not English you are speaking. ” No significant correlation was found between the respondents’ assessment of their fluency of spoken English and any of the psychological distress variables. A significant negative relationship, however, was found between the researchers’ assessment of the respondents’ fluency of spoken English and anxious symptomatology. According to this finding, respondents’ anxious symptomatology decreased as their fluency in spoken English increased. This finding is confirmed by a study by Greenland and Brown (2005) and Miranda and Umhoefer (1998) which also found that increased fluency in English was associated with less psychological 106 distress. Differential findings in the significance level for correlations between psychological distress and fluency of spoken English as assessed separately by the respondents and the researcher can be attributed to differential scoring by the respondents and the researcher. In 77.8% (21) of the cases, there was an agreement between respondents’ and researcher’s rating of proficiency of spoken English. Different scores, however, occurred in 22.2% (6) of the cases. In 18.5% (5) of the cases, the researcher scored the respondent higher in their fluency of spoken English. Only in one case (3.7%) had a respondent given themselves a higher score than the researcher. A likely explanation for the discrepancy in the scores is that respondents may have judged themselves more harshly, focusing more on their accents rather than vocabulary. Hypothesis 4: Single female African refugee heads-of—households will have more acculturative stress and depressive and anxious symptomatology than female African refugees living with a spouse or significant other As a general stereotype, women in developing countries are thought to endure greater oppression when contrasted against women in developed countries who are said to enjoy greater rights and liberties (Zhou, 2000). It has been argued, therefore, that women immigrating from developing countries to developed countries such as the U.S. enjoy greater liberties, freedom, equality, and greater opportunities for advancement. Recentresearch has shed doubt on this reasoning. Recent studies are revealing that though immigration provides some opportunities for women, it also 107 poses significant constraints (Espiritu, 1999). The constraints posed by immigration are said to disadvantage women and cause them significant acculturative stress and psychological distress (Aroian, et al., 2003). Further, immigrant women who are without spouses or significant others in a host country have been found to be more distressed than those with spouses or significant others (Hsu etal., 2004; Beiser, Johnson & Turner, 1993). This study found no correlation between single female head-of—household status and acculturative stress or psychological distress. Independent t-tests comparing single female heads-of-households with spouses or significant others and those without spouses also found no difference in acculturative stress or psychological distress between the two groups. Failure to find a significant difference in distress levels of the female heads-of-households and those with significant others could be because of the financial and material support that refugee respondents receive from DHS. Refugees who are single female heads-of-households often do not make enough money to meet their household needs. The average gross monthly income for the respondents in the study, for example, was approximately $1,155.30. This amount of is insufficient to adequately support the household needs of respondents with several dependent children. Single female refugee heads-of-households who make limited income and have dependent children often qualify to receive cash and/or food stamps assistance from DHS. Cash and food assistance given to these families is available through the Temporary Assistance to Needy Families (TANF) program (Administration of Child and Family Services, 2007). 108 Many of the single female heads-of-households that I interviewed received food stamps and/or cash assistance through TANF. For example, Respondent A who is raising 8 dependent children, for example, gets $400 in food stamps and an unspecified amount of cash assistance every month through TANF. Respondent C, another single female head-of-household with 5 dependent children, described the assistance she gets from DHS: “1 working [am employed] now, I pay my own rent but FIA [DHS] still helping [paying for] me [to] sending [send] my children to the daycare. They [DHS] giving me foods stamps for the children, sometimes they give me cash [money]. [When] the school open to buy the children clothes. ” Single female heads-of—households I spoke to said that the assistance they received from DHS was instrumental in helping them meet heir household needs. Many of them also mentioned as beneficial the free education that their children were able to benefit from. Given their limited income, many of the respondents would not have been able to afford to pay tuition for their children to go to school. Talking about the importance of free education, Respondent E said: “I am really really really thankful to God for being in America. You know to [in] America here, my daughter is here going to school, learning you know, one cent, not coming fi'om out of my pocket, that ’s a very great help for me, that one of the greatest things in life here [ U. S. ]. ” 109 Most of the studies that found high levels of distress in the women were conducted with economic immigrants (Munet-Vilaro, folkman & Gregorich, 1999; Aroian, Norris, Patsdaughters & Tran, 1998; Aroian, et al., 2003). Even though some economic immigrants earn low wages, unlike refugees they, are not considered eligible for TAN F until 5 years post- immigration. Support provided through TANF takes away some of the financial stress associated with being a single female head-of- household, which may help explain why single female head-of-household status was not found to be a significant predictor of acculturative stress or psychological distress in the respondents. Hypothesis 5: Lower SES will be associated with more acculturative stress and more depressive and anxious symptomatology SES has been a potent predictor of acculturative stress and psychological distress in immigrants (Hovey & Magana, 2002; Thomas & Suris, 2004). Low SES, particularly, has been found to predictor of psychological distress or the lack of it. Shen and Takeuchi (2001), for example, found higher SES to be associated with less severe depressive symptoms among Chinese Americans. This study operationalized SES as respondents’ income (hourly wage and net monthly income) and education (total years of formal schooling). Neither the variables that measured income nor education were found to correlate significantly with acculturative stress or psychological distress. T-test comparing those earning more versus less income and those with more versus less education similarly revealed no 110 significant relationship between income or education and acculturative stress or psychological distress. Findings of this study showing no significant relationship between SES and acculturative stress or psychological distress are contrary to other studies which have found SES to be negatively correlated with acculturative stress and psychological distress (Hovey & Magana, 2002; Thomas & Suris, 2004). The bulk of studies that have returned these significant findings, however, have been with economic immigrants (V inokurov et al., 2000). Economic immigrants are often more educated than refugees. When they come to the U.S. many economic migrants frnd that they must work in low income jobs, because previous skills and training are not transferable to the U.S. This loss of occupational status has been linked to distress often found in economic immigrant groups (Yost & Lucas, 2002). For example, highly educated Korean immigrants working at low income jobs in the U.S. were found to have high rates of depression which were linked to fi'ustration with their economic circumstances (Salant & Lauderdale, 2003). Refugees, on the other hand, are generally less educated than economic immigrants (Salant & Lauderdale, 2003; Hsu et al., 2004). In our study, for example, only five of the respondents completed high school with only one of those five going on to pursue a post-secondary education. Low education level of the respondents means that most of them did not suffer loss of occupational status when they came to the U.S. and were employed in low income jobs. The low level of education of the respondents and the consequent absence of occupational loss from working in low income jobs may explain the study’s failure to finding a significant relationship between SES and acculturative stress or psychological distress. 111 Hypothesis 6: Greater satisfaction with perceived social support will be associated with less acculturative stress and less depressive and anxious symptomatology Social support has been identified as an important factor in psychosocial adjustment and mental health of immigrants and refugees (Chung et al., 2000). Social support is often found to buffer the impact of distress in immigrant and refugees. Social support, for example, was found to buffer the impact of stress among older Asian immigrants in the U.S. (Mui, 1996). In another study, social support was found to be associated with lower depression in Mexican migrant farm workers (Hovey & Magana, 2002) Satisfaction with perceived social support was measured using the revised MSPSS-R, which had five subscales measuring satisfaction with perceived social support from significant other, family, coethnic friends, American friends and the resettlement agency. This study did not find a significant correlation between social support and acculturative stress or psychological distress. Failure to find a significant relationship between social support and acculturative stress or psychological distress may be due to the study’s small sample size. In spite the non-significant finding, narratives from in-depth demonstrated that lack of social support was a source of distress. Lack of social support, especially from a significant other, was often identified as a source of stress among single female heads-of- households. Respondent D was resettled in the U.S. without her husband. Asked about the impact of not having her husband with her in the U.S., Respondent D replied “Yes, its hurting me, too bad,” after which she broke down sobbing. The respondent shared that she experienced great distress because her husband was not around to help her with childrearing and household responsibilities. 112 Lack of social support from coethnics was another source of distress among the respondents. Liberian refirgees in Lansing have not been successful in forming an ethnic community organization. Respondents lamented the lack of such an organization among Liberians. The respondents felt strongly that if such an organization existed, it could mobilize Liberian refugees living in Lansing so that they could be source of support for one another. Hypothesis 7: Greater religiosity will be associated with less acculturative stress and less depressive and anxious symptomatology Religiosity has been found to protect against the negative effects of stress thereby having a positive impact on psychological well being (Mohr, 2006; Yi., et al., 2006; Ghang, Skinner & Boehmer, 2001). No significant correlation was found between acculturative stress and religious persuasion, organized religion, non-organized religion or intrinsic religiosity. Similarly, no significant correlation was found between religious persuasion, non-organized religion or intrinsic religiosity and anxious or depressive symptomatology. In spite the non-significant findings, narratives from in depth interview with the respondents indicate that religiosity helps buffer the effects of distress. During the in-depth interviews, many of the women shared that they believed that God or Allah would helped them overcome whatever challenges they faced. Below, respondent BZ shares how she believes that prayers for assistance with problems would be answered. “Well, as for me. I cannot read [the bible], but I can pray. And when I pray to God, sometimes I say [to] God, here [the city she lives in] I don ’t have any relative 113 [family] and you are my relative and so my life is being taken care of by you. Sometimes, [when I pray for help with] something I don ’t know about, [God can send] somebody from the church [to help me]. I believe my prayer, God always 1 answer my prayer and get onto somebody to do something for me. ’ A surprising finding was the positive correlation between organized religion and psychological distress. Church attendance was found to be correlated with depression in the respondents. This is contrary to other studies that have found church attendance to be correlated with lower odds of depression (Baetz et al., 2006). It is difficult to interpret this finding, since church attendance was not discussed in detail with the respondents. More research is needed to find out factors that would have caused this variable to have a positive relationship to depressive symptomatology. Hypothesis 8: Better Perception of Personal Health will be Associated with Less Acculturative Stress and Less Depressive and Anxious Symptomatology Poor physical health has been identified as a predictor of psychological distress in immigrants (Mui & Kang, 2006; Shen & Takeuchi, 2001). A study of Mexican American farm workers, for example, found reduced health status was associated with high levels of psychological distress (Hovey & Magana, 2002). A separate study with female immigrants from the Former Soviet Union living in the US found health status also to be associated with depression (Miller & Gross, 2004). The respondents’ general assessment of their health did not have a significant correlation with acculturative stress. Health of the respondents as measured by the 114 Physical Component Summary (PCS) subscale, however, was found to be negatively correlated with acculturative stress. According to the PCS subscale, poorer health was associated with elevated acculturative stress. The study also returned mixed findings on the correlation of psychological distress to health of the respondents. Though the PCS subscale was not significantly correlated with psychological distress, the respondents’ general assessment of their health was found to be negative correlated with both anxious and depressive symptomatology. According to the general assessment of health measure, poorer perception of health was correlated with higher depressive and anxious symptomatology. This later finding is similar to that of Miller and Gross (2004) which also found health to be negatively related to psychological distress. Respondents who were ill often expressed concerns about their illness during the in depth interviews. Respondents worried particularly about how their illness would affect their ability to earn an income. One of the respondents, for example, was reluctant to schedule an appointment for an operation because she was afraid that she would loose income if she could not work. Another respondent who had undergone two surgeries since coming to the U.S. was so worried about her health that she asked the researcher if she was going to die as a result of the illnesses. Preoccupation with the consequences of illness might explain the negative relationship that the study found between the respondents general assessment of their health and psychological distress. 115 Hypothesis 9: More Experiences with Pre-Migration Trauma will be Associated with More Acculturative Stress and More Depressive and Anxious Symptomatology PTSD is the most frequently reported psychological consequence of traumatic events (Silove et a1, 2002; de Jong et al., 2001). Pre-migratory traumatic experiences have been found to predispose refugees to PTSD (Steel et al., 2002). Refugees with PTSD symptomatology are often found to have concurrent disorders of depression and/or anxiety (Gerristen et al., 2006; O’Donnell et al., 2004). Psychological problems such as PTSD that refugees develop prior to resettlement can become acculturative stressors when they interfere with decision making and problem solving capacities that are needed during acculturation. In the present study, the number of trauma experiences was found to be positively correlated with acculturative stress and depressive and anxious symptomatology. The more experiences with trauma that one had, the more elevated their acculturative stress and depressive and anxious symptomatology was likely to be. This finding is similar to that of Steel et a1. (2002) which found experiencing trauma increased the risk of psychological distress in Vietnamese refugees. When t-tests were conducted between those reporting fewer versus more traumas, no significant difference was found in acculturative stress. Among respondents in the present study, PTSD symptomatology was found to be positively correlated with acculturative stress and psychological distress. T-test between those who were less bothered by PTSD symptoms and those more bothered by the same symptoms found a significant difference in acculturative stress. Those more bothered by PTSD symptoms were found to exhibit more acculturative stress. A t-test comparison 116 also found a significant difference in the psychological distress of those who were less bothered by PTSD symptoms and those more bothered by the same symptoms. Those more bothered by the PTSD symptoms were found to have higher depressive and anxious symptomatology than those less bothered by the same symptoms. In speaking with the respondents it seemed that those who experienced more traumas also experienced difficulty adjusting to life in the U.S., which might explain the positive correlation trauma experiences and PTSD have with acculturative stress and psychological distress. Respondent W, for example, lost her son and husband when war broke out in the Liberia. Later, she lost nine additional family members when war broke out in the asylum country that she fled to. While fleeing conflict in the asylum country, she was separated from three of her young children and was involved in a serious car accident which left her with serious health complications. Respondent W suffers from many symptoms related to PTSD i.e. anxiety, panic attacks, sleeplessness, and excessive worry. Theses symptoms affect her ability to work and interact in mainstream society and therefore might have an impact on the acculturative stress and psychological distress that she experiences. Berry’s acculturative stress model was used to provide a framework for this study. Berry’s acculturative stress model identified five sets of individual and group characteristics that moderators of the relationship between acculturative stress and psychological distress outcomes in acculturating individuals and groups. These five sets of individual and group characteristics are the type of acculturating group, mode of acculturation, nature of the host society, demographic and social characteristics, and psychological characteristics. Demographic and social characteristics are the most 117 studied of the five variables and were therefore chosen for further research in this study. . Utility of acculturative stress model for this study This study found the acculturative stress model to be effective at identifying variables associated with elevated levels of acculturative stress and psychological distress in the respondents. Using the acculturative stress model, the study found personal health and pre-migration trauma to be moderators of acculturative stress in the study sample, while fluency of spoken English, personal health, and pre-migration trauma emerged as moderators of psychological distress. The fact that the study found only a limited number of sociodemographic variables were moderators of acculturative stress and psychological distress might be related to the study’s small sample size. Limitations and Strengths of the Study The study was comprised of a small non-randomized sample that was drawn from women of one ethnic group living in one city. Findings from the study, therefore, can only be considered exploratory and cannot be generalized to larger or different populations. Despite the small sample size, study findings still provide information that can be used to understand issues related to acculturative stress and psychological distress in Afiican refugee women. African refugees and women have often been absent from studies of immigration and acculturation (Rumbaut, 1999; Pedraza, 1991). By studying adult female Liberian refugees this study adds to the body of knowledge on acculturation of not only African refugees but also female immigrants. Second, many of the instruments that were used in this study were not normed for 118 research with refugees. Only the HSCL and the HTQ have been used widely with refugee populations from diverse cultures (Mollica et al., 2007). It is impossible to be sure whether the data collected was compromised by using instruments that were not normed for this population. Increasingly more research is being undertaken with refugees and it is to be hoped that researchers will make standardizing research instruments commonly used with refugees a priority. Third, the limited education level of the respondents was another obstacle in this study. When I was recruiting research participants, 1 telephoned the respondents and asked if they would be willing to participate in the study. If the respondent was manied, I made sure that I received ‘permission’ from the husband to visit the home and conduct an interview with his wife. In African households, men are considered the heads of the households and therefore it was both imperative and a sign of courtesy that I informed husbands of my intent to conduct research with a member of their family. On one occasion, one of the respondents’ husband asked ‘why are you speaking to our women and not the men; you know they are not educated and they don ’t know that much. ” During the in-depth interviews, I realized that the respondent’s perspectives on some of the issues were often limited. Though all the respondents understood the questions and gave appropriate responses, answers to questions that were outside their every day discourse sometimes lacked depth and insight. The limited perspective of some of the respondents might have affected the quality and quantity of data that was collected during the in-depth interviews. Finally, the researcher is an African who has worked in refirgee resettlement. The researcher has witnessed first hand the challenges that Afiican refugees experience as 119 they adapt to life in the U.S. Though the researcher tried to be as unbiased and objective as possible, there is no guarantee that the researcher’s personal bias did not have an effect on the study. The study had some strength. First, though the study had small sample size, it utilized a mixed methods research design which enriched the data collected. The study collected both quantitative and qualitative data from research participants. Surveys were used to collect quantitative data, while in-depth interviews were used to collect qualitative data. The qualitative data proved to be especially important in interpreting findings that emerged from the quantitative data analysis. Second, the researcher’s identity was invaluable in gaining access to research participants. The researcher shares an Afiican female identity with the respondents. This shared identity made it easier for the researcher to recruit and create rapport with the research participants. Implications of the Findings This study explored the impact of demographic variables on acculturative stress and psychological distress in a group of adult female Liberian refugee living in Lansing, Michigan. Demographic variables that were studied include age at resettlement, time spent in the host country, single female head-of-household status, SES (education and income), social support, religiosity, health, and pre-migration trauma. The study found limited fluency of spoken English, poor perception of personal health and pre-migration trauma moderated the effects of acculturative stress, while poor fluency of spoken English, poor perception of personal health, and pre-migration trauma moderated the 120 effects of psychological distress in the study sample. Following, the implications of these findings for refugee resettlement agencies and social work education and practice are discussed. Implications for Refugee Resettlement Agencies Psychological problems affect the mental health of refugees and can also affect their acculturation and adjustment to new environments by interfering with decision making and problem solving capacities that are needed during acculturation. It is imperative, therefore, that refugee resettlement agencies become aware of factors that might lead to elevated acculturative stress and psychological distress in refugee populations so that they can develop programs and services that might mitigate the effects of these stressors. Limited fluency of spoken English as assessed by the researcher was found to be associated with anxious symptomatology. Respondents who were limited in their fluency of spoken English experienced more anxiety. Resettlement agencies view learning to speak English as of secondary importance (McSpadden, 1987). Primary importance is placed on the refugees finding employment and becoming self sufficient. Intensive language programs are not provided for refugees, because it is assumed that they will learn English through working and interacting in U.S. society. Though economic self- sufficiency is important, these findings indicate that more attention needs to be paid to language acquisition in order to prevent psychological distress associated with limited fluency in spoken English. Studies often find that religiosity acts a buffer against distress. Quantitative 121 analysis did not find religiosity to be a buffer against acculturative stress or psychological distress in this study. During the in-depth interviews the women, however, shared anecdotes that demonstrated the supportive role that religion played in their lives. Respondents who took part in the in-depth interviews shared that they always turned to their religious beliefs for support during difficult times. The centrality of religion in the lives of the women points to the need for resettlement agencies to connect newly resettled refugees to welcoming churches where they can receive spiritual nourishment that can sustain their faith. Many studies have found social support to be a buffer against distress. This study, however, did not find social support to be a significant buffer against acculturative stress or psychological distress among refugees. During the in-depth interviews, however, respondents often expressed distress with the low level satisfaction with social support received from coethnics. In in-depth interviews, respondents especially lamented the lack of a coethnic organization which could be supportive of Liberian refirgees. Resettlement agencies need to help refugees develop a coethnic organization that will not only be supportive of their refugee group but also be a voice of unity that can advocate for the needs of their refugee community. Coethnic organization might help foster a sense of community, which in turn can buffer psychological distress in refugees. Prior to coming to the U.S., refugees undergo medical testing to ensure that they do not have any communicable diseases. When they arrive in the U.S., refugees are taken for further medical checks and if any health concerns are uncovered, refirgees receive referrals for treatment (V eragara, Miller, Martin & Cookson, 2003). As a federal mandate, refugees receive free medical attention for only the first eight months after they 122 arrive in the U.S. Medical attention during that first eight months is provided through Medicaid. After the eight months are over, it is the responsibility of every refirgee to find their own health care coverage. The limited income of refugees means that many never purchase a health care plan. Without health care, refugees are unable to seek treatment for medical conditions. In this study, poorer perception of health was associated with acculturative stress and depressive and anxious symptomatology. Resettlement agencies need to work with the federal government to come up with programs that allow refugees to purchase health care for a nominal fee in order to prevent psychological distress that is associated with poor health as well as negative health effects. The study found more experiences with pre-migration trauma and PTSD to be associated with more acculturative stress and psychological distress. The health assessment that refugees receive when they are resettled in the U.S. focuses mainly on physical health (V eragara, et al. 2003) with little attention paid to mental health assessments. Eight (36.3%) of the respondents had PTSD scores that were considered symptomatic for PTSD. These individuals are not receiving mental health care for PTSD. Resettlement agencies need to ensure that newly arrived refugees receive adequate mental health assessment, so that those affected by trauma can receive treatment. In addition to developing psychological distress from trauma, refugees can also develop psychological distress from stressors associated with immigration. Refugees who may have fairly good mental health at resettlement can develop depressive and anxious symptomatology due to acculturative stress. Results from the HSCL, which measured psychological distress found that five (18.5%) of the respondents had scores 123 that are considered symptomatic for anxiety, while six (22.2%) had scores that were considered symptomatic for depression. None of these individuals were receiving treatment for psychological distress. Resettlement agencies should educate refirgees about psychological distress and the need to seek treatment for it. Further, resettlement agencies should collaborate with local mental health facilities to provide culturally appropriate mental health services to refugees who are psychologically distressed. Implications for Social Work Education and Practice In its preamble, the NASW code of ethics states that, “the primary mission of the social work profession is to enhance human well-being and help meet the basic human needs of all people, with particular attention to the needs and empowerment of people who are vulnerable, oppressed, and living in poverty” (National Association of Social Workers [NASW], 2008). The history and experiences of refugees make them a vulnerable group in need of attention by social workers. The NASW recognizes refugees as a population of interest that social workers should be serving. Despite this recognition, the profession of social work has been slow to infirse refugee related content into its curriculum. Refugees often receive services from a variety of human service organizations. Social work students employed in human service organizations may therefore find themselves working with refugee clients. There is a need to provide basic education about refugees to social work students so that those who are employed in hmnan service organization may be culturally competent to intervene with refugees. The UNHCR estimates that more than half of any refugee population are children (McBrien, 2005). Significant refugee populations are found in schools across the U.S., 124 because school-age refugees join the U.S. school system. Refugee children may have had traumatic experiences that can hinder their learning (McBrien, 2005). Negative personal and family experiences with acculturation can also cause distress among refugee children. Four of the in-depth interview respondents were school-going minors (18 years old). These respondents talked about the challenges they experience attending schools in the U.S. including being bullied and teased by other children because of their national background, not being able to read or write like their peers which in turn affected their leaming, and lack of adequate learning material (i.e. school back, books, pens, etc). These challenges can cause psychological distress for school-going refugee children and further affect their learning. School social workers need to be aware of the experiences and challenges of refuge children and develop appropriate interventions. By extension, schools of social work need to teach students majoring in school social work content that focuses on refugee children in order to develop culturally competent professionals able to develop or adapt successful interventions to meet the needs of refugee children. Areas for Future Research Most research in acculturation has been conducted with economic immigrants with relatively little of it conducted with refugees (Hsu, et al., 2004). Research that has been conducted with refugees has focused mainly on Asian refugees who are the largest refugee group in the U.S. (Hsu, et al., 2004). Only a limited amount of research has focused on refugees Africans (Rumbaut, 1999). African refugees first started being resettled in the U.S. in 1980. Since then approximately 200,000 Afiican refugees have been resettled in the U.S. (U .S. Department of State, 2008). Acculturation research needs 125 to be conducted with Afiican refugees in order to add to the body of knowledge on acculturation of Afiican refugees. Most studies have focused on male immigrants, and women, like refugees, have often been neglected from studies of acculturation and immigration (Pedraza, 1991). The UNHCR prioritizes resettling single women because of the special protection problems and challenges that arise for displaced women and girls separated from their usual forms of support (UN HCR, 2004). A significant proportion of the refirgees resettled in the U.S. are single female heads-of-households. In this present study almost an equal number of the respondents were resettled in the U.S. with (7 or 25.9%) or without (8 or 29.6%) their spouses. Research needs to be conducted with refirgee women in order to understand how their resettlement and acculturation experience differs from that of men. Further, research needs to explore the difference in resettlement and acculturation experiences of refugee women resettled with and without their spouses or significant others. Research that looks at the resettlement experiences of women can be used to develop gender specific programs that support resettlement and acculturation of women. Most of the research instruments that were used in this study have not been normed for use with refugees. Only the HTQ and the HSCL-25 have demonstrated validity and reliability when used with refugee populations. Since 1975, approximately 2.6 million refugees from around the world have been resettled in the U.S. (U.S. Department of State, 2008). Increasingly more research is being done about various aspects of refugee lives, yet few instruments have been normed to explore those aspects. As researchers begin to explore more aspects of refirgee life, it is imperative that existing instruments be normed for use with refugees or new culturally sensitive research 126 instruments be developed for exploring these aspects Most research in psychological distress of refugees occurs in western countries. Little research attention has been given to psychological distress of refirgees in asylum countries prior to resettlement. Given this shortcoming, it is difficult to say with certainty that psychological distress observed in refugees after resettlement is due to wholly acculturative stressors. It is important that research be conducted on psychological distress among refugees prior to resettlement so that a clearer understanding of psychological distress and its relationship to acculturation and resettlement can be teased OUT. Conclusion This study explored acculturative stress and psychological distress among a sample of Liberian refugees resettled in Lansing, Michigan. The study explored the impact of sociodemographic variables on acculturative stress and psychological distress in adult female Liberian refugees. Despite its small sample size, the study returned several significant findings. The study found that particular sociodemographic factors contributed to acculturative stress and psychological distress in the sample. More acculturative stress was found to be related to younger age at resettlement, poor fluency of spoken English, low religiosity, more pre-migration trauma experiences and elevated PTSD symptomatology. Psychological distress on the other hand was found to be related to older age at resettlement, poor fluency of spoken English, poor perception of one’s personal health, more pre-migration trauma experiences, and elevated PTSD 127 symptomatology. The study findings provide information that can inform resettlement agencies on the development of interventions that are supportive of resettlement and acculturation in Afiican female refirgees. First, resettlement agencies need to develop programs that are supportive of women resettled at older ages, especially those with many children because stressors associated with childrearing could be responsible for anxious symptomatology among women resettled at older age and who also have many children. Second, resettlement agencies also need to focus on supporting refugees to develop fluency in spoken English in order to avoid psychological distress associated with limited fluency. Third, religion emerged as a buffer against psychological distress; therefore it is important that resettlement agencies link resettled refugees to supportive religious organizations where they can receive spiritual nourishment. Fourth, lack of social support among coethnics was identified as a psychological stressor among refugees. Resettlement agencies need to build capacity among refugees to enable them to form sustainable coethnic organizations that foster a sense of community and support. Lastly, resettlement agencies need to assess and treat pre-migration trauma in refugees so that distress due to pre-migration trauma does not interfere with refugee acculturation and adjustment. The study findings also provided implications for social work. Refugees are a vulnerable group that warrant attention from social work. The profession of social work needs to play a greater role in improving service delivery to refugee populations. Social work researchers also have a responsibility to conduct additional research with African refugees in order that study findings might not only expand the body of knowledge on 128 African refugee resettlement and acculturation but also inform the delivery of services to this population. 129 APPENDICES 130 Appendix A Sociodemographic Questionnaire Please answer the following questions as accurately as possible. Where options are provided, please choose the response that best describes your situation. A. Basic demographic information 1. Current age (years): 2. Age (years) at resettlement: 3. Length of residence (years) in the U.S.: Marital status 4. Check one box that best describes your marital status Single Married Divorced Widowed Separated, spouse in another western asylum country Separated, spouse in Africa Other, please explain 7. If you are a single head of household, for how long (years) have you been a single household-head: years 131 Dependents 8. How many dependent children do you have give their ages and relation to you Child’s age Relationship to respondent Educational Background 9. In your lifetime, have you attended any formal learning institutions? If yes, proceed to question 10. If no, proceed to question 11. Yes No 10. Please describe the formal education you have received so far, check appropriate boxes to show what country the schooling occurred. Natal African Asylum USA Country Country Some primary school Completed primary school Some high school 132 Completed high school Some tertiary education Completed tertiary education Some undergraduate education Completed undergraduate degree Some masters degree schooling Completed a masters degree Other, please explain 10. How many years of formal schooling have you complete in Your natal country years An African asylum country years In the U.S. years 11. Qualification currently being pursued in the U.S. G E D Bachelors degree Masters degree Professional certification Other 133 Employment history 12. Did you engage in paid employment outside the home in your natal country? If yes proceed to # 13, if no proceed to # 14. Yes No 13. What was the last paid job outside the home you held in your natal country? 14. What is the nature of your most recent paid job in the U.S.? 15. What is your current employment status? Unemployed Part-time Full-time 13. At your most recent job, how much did you earn per hour (USD)? 14. At your most recent job, what was your monthly income (in USD)? Works more than one job 15. What was your most recent net (after taxes) monthly household income (in USD)? 134 Fluency of Spoken English Question 16 (a) is a subjective assessment of personal proficiency of spoken English to be completed by research participant. Question 16(b) is to be completed by the principal researcher as their assessment of the research participant’s proficiency in Spoken English. 16. (a) What is your current fluency of spoken English Poor Fair Good Excellent (b) What is the research participant’s fluency of spoken English. Poor Fair Good Excellent 135 Appendix B Social, Attitudinal, Familial, and Environmental Acculturative Stress Scale (SAFE-R) The following statements indicate how you perceive culture stress. For each statement below, please circle one number to the right that best corresponds to your answer. Have not Not al all Somewhat Moderately Extremely experienced stressful stressful stressful stressful 1 2 3 4 5 1. I feel uncomfortable when others make jokes about or 1 2 3 4 5 put down my ethnic background. 2. l have more barriers to overcome than most people. 1 2 3 4 5 3. It bothers me that family members close to me do not understand my values. 1 2 3 4 5 4. Close family members and I have conflicting expectations about my future. 1 2 3 4 5 5. It is hard to express to my friends how I really feel. 1 2 3 4 5 6. My family does not want me to move but I would like to. 1 2 3 4 5 7. It bothers me to think that so may people use drugs. 1 2 3 4 5 8. It bother me that I cannot be with my family. 1 2 3 4 5 9. In looking for a job, I sometime feel that my ethnicity is a limitation. 1 2 3 4 5 10. I do not have any close friends. 1 2 3 4 5 11. Many people have stereotypes about my heritage culture or ethnic group and treat me as if they were true. 1 2 3 4 5 12. I do not feel at home. 1 2 3 4 5 13. People think I am unsociable when in fact I have trouble communicating in English. 1 2 3 4 5 14. I often feel that people actively try to stop me from 1 2 3 4 5 136 advancing. 15. It bothers me when people pressure me to assimilate. 16. I often feel ignored by people who are supposed to assist me. 17. Because I am different, I do not get enough credit for the work I do. 18. It bothers me when I have an accent. 19. Loosening the ties with my country is difficult. 20. I often think about my cultural background. 21. Because of my ethnic background, I feel that others often exclude me from participating in activities. 22. It is difficult for me to “show off” my family. 23. People look down upon me if 1 practice customs of my culture. 24. I have trouble understanding when others speak English. 137 y—ap—s—aj—o NNNN N MWUJUJ AAA-b MMMM Appendix C Medical Outcome Study Short Form-12 (SF-12) This survey asks for your views about your health. This information will help keep track of how you feel and how well you are able to do your usual activities. Please answer each question by circling one answer among the response options provided. If you are unsure about how to answer, please give the best answer you can. 1. In general would you say your health is Excellent Very good Good Fair Poor The following are about activities you might do during your typical day. Does your health now limit you in these activities? If so, how much? Yes, limited Yes, limited No, not A lot a little limited at all l. E] El DModerate activities such as moving a table, pushing a vacuum cleaner. 2. El 1] DClimbing several flights of stairs During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as; result of your physical health. Yes No 3. Accomplished less than you would like 4. Were limited in the kind of work or other activities 138 During the past 4 weeks, have you had any of the following problems with your work or other regular activities as a result of emotional problems (such as feeling depressed or anxious). Yes No 5. Accomplished less than you would like 6. Didn’t do work or other activities as carefully as usual During the last 4 weeks, how much did pain interfere with your normal work (including outside the home and housework) Not at all A little bit Moderately Quite a bit Extremely These questions are about how ,you feel and how things have been with you during the past 4 weeks. For each question, please give the one answer that comes closest to the way you have been feeling. How much of the time during the past 4 weeks. All of Most of A good bit Some of A little of None of The time the time of the time the time the time the time 7. Have you felt calm and Peaceful? 8. Did you have a lot of Energy? 9. Have you felt sad? During the past 4 weeks, how much of the time has your physical heglth or emotional During the past 4 weeks, how much of the time has your phvsicalfiheajth or emotiofl problems interfered with your social activities (like visiting with friends, relatives, etc)? 10. All of Most of Some of A little of None of the time the time the time the time the time 139 We would like to ask you about your past history. Please indicate whether you have Appendix D Harvard Trauma Questionnaire (HTQ) (Part 1) experience any of the following events. Question Yes No Lack of shelter Lack of food or water 111 health without access to medical care Confiscation or destruction of property Combat Situation (e. g. shelling and grenade attacks) Forced evacuation under dangerous conditions Beating of the body Rape 99°99999’1‘9'." Other types of sexual abuse or humiliation 10 . Killing or knifing 11 systematic infliction of physical or mental suffering . Torture i.e. while in captivity you received deliberate and 12 . Serious physical injury from combat situation or landmine 13 . Imprisonment 14 . Forced labor (like animal or slave) 15. Extortion or robbery 16. Brainwashing l7. Forced to hide 18. Kidnapped 19. Other forced separation from family members 20. Forced to find and bury bodies 22. death or injury Someone was forced to betray you and place your life at risk of 140 Question Yes ‘No 23. Prevented from burying someone 24. Forced to desecrate or destroy the bodies or graves of deceased persons 25. Forced to physically harm a family member or friend 26. Forced to physically harm someone who was not a family member or friend 27. Forced to destroy someone else’s property or possessions 28. Forced to betray a family member, or fiiend placing them at risk of death or injury 29. Forced to betray someone who was not a family member or friend placing them at risk of injury or death 30. Murder or death due to violence of a spouse 31. Murder or death due to violence of a child 32. Murder or death due to violence of a family member or friend 33. Disappearance or kidnapping of a spouse 34. Disappearance or kidnapping of a child 35. Disappearance or kidnapping of a family member or fiiend 36. Serious physical injury of a family member or friend due to a combat situation 37. Witness beatings to the head 38. Witness torture 141 Appendix E Harvard Trauma Questionnaire (HTQ) (Part II) The following are symptoms that people sometimes have after experiencing hurtful or terrifying events in their lives. Please read each one carefully and decide how much the symptoms bothered you in the past week. Recurrent thoughts of the most hurtful or terrifying events Feeling as though you the events is happening again Recurrent nightmares Feeling detached or withdrawn from people Unable to feel emotion Feeling jumpy and easily startled Difficulty concentrating Trouble sleeping towflg‘ihPPN!‘ Feeling on guard Hu—si—ri—a—su—ni—su—u—nt—a NNNNNNNNNN wwwwwwwwww h-b-bA-hA-h-bA-h y—n O . Feeling irritable or having angry outbursts _r H . Avoiding activities that remind you of traumatic or hurtful events 1 2 3 12. Inability to remember parts of the most hurtful or & traumatic events 13. Less interest in daily activities 14. Feeling as if you don’t have a future 15. Avoiding thoughts or feelings associated with the t—il—It—ID—lI—i NNNNN wwwww h-fi-b-b-fi traumatic or hurtful event 16. Sudden emotional or physical reaction when reminded of the most hurtful or traumatic evens 1 2 3 4 17. Feeling as if you have less skills than you have before 1 2 3 4 18. Having difficulty dealing with new situations 1 2 3 4 19. Feeling exhausted I 2 3 4 142 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. Bodily pain Troubled physical problem(s) Poor memory Finding out or being told by other people that you have done something that you do not remember Difficulty paying attention Feeling as if you are split in two people and one of you is watching what the other is doing Feeling unable to make daily plans Blaming yourself for things that have happened Feeling guilty for having survived Hopelessness Feeling ashamed of the hurtful or traumatic events that have happened to you Feeling that people do not understand what happened to you Feeling others are hostile to you Feeling that you have no one to rely on Feeling that someone you trusted betrayed you Feeling humiliated by your experience Feeling no trust in others Feeling powerless to help others Spending time thinking why these events happened to you Feeling that you are the only one who suffered these events Feeling a need for revenge 143 N NNNNN NNNNNNN wwwwm mmwwwww & AA-b-b-h #A-hh-h-h-b Appendix F Duke Religion Index (DUREL) The following survey asks about your religious participation. Please read each statement carefully and check the box next to the response that best describes you. 1. What is your religious preference? Christian Muslim Other 2. How often do you attend church or other religious meetings? More than once a week Once a week A few times a month A few times a year Once a year or less Never 3. How often do you spend time in private religious activities, such as prayer, meditation, or bible study? More than once a day Daily Two or more times a week Once a week A few times a month Never or rarely 144 The following section contains three statements about religious beliefs or experiences. Please mark the extent to which each statement is true or not true for you. 4. In my life, I experience the life of the Devine (i.e.) God. Definitely true of me Tends to be true Unsure Tends to not to be true Definitely not true 5. My religious beliefs are what really lies behind my whole approach to life Definitely true of me Tends to be true Unsure Tends to not to be true Definitely not true 6. I try hard to carry my religion over into all other dealings in my life Definitely true of me Tends to be true Unsure Tends to not to be true Definitely not true 145 APPENDIX G Multidimensional Scale of Perceived Social Support - Revised (MSPSS-R) We are interested in how you feel about the following statements. Please read each statement carefully. Indicate how you feel about each statement by circling one of the options provided on the left. Interviewer: Replace the word coethnics with the ethnic group of the respondent i.e. Somali, Dinka, etc Strongly Disagree Neutral/ Agree Strongly Disagree Depends Agree 1 2 3 4 5 1. There is a special person who is around 1 2 3 4 when I need them 1 2 3 4 2. I feel comfortable approaching the resettlement agency when I have a problem and need assistance 1 2 3 4 3. There is a special person with whom I can share my joys and sorrows 1 2 3 4 4. The resettlement agency is responsive to my requests for help 1 2 3 4 5. I have American friends who really try to help me 1 2 3 4 6. My family really tries to help me 1 2 3 4 7. My coethnics fiiends really try to help me 1 2 3 4 8. I get the emotional help and support I need from my Family 1 2 3 4 9. I have a special person who is a real source of comfort to me 1 2 3 4 10. I can count on my coethnic fiiends when things go wrong 1 2 3 4 11. I cant talk about my problems with my family 1 2 3 4 12. I can count on the resettlement agency for help In time of need 1 2 3 4 13. I have American friends who I can talk to about my Problems 1 2 3 4 146 MEAL/IL]! {lit/11.11% 14. I have coethnic friends with whom I can share my joys and sorrows 15. There is a special person in my life who cares about my feelings 16. I have American fiiends I can count on when things go wrong 17. The resettlement agency really helps me 18. My family is willing to help me make decisions 19. I can talk about my problems with my coethnic friends 20. I have American friends with whom I can share my joys and sorrows 147 NNNNN wwwww hAh-k-Ié UtLJtLII‘JILII Appendix H Hopkins Symptom Checklist - 25 (HSCL-25) Listed below are symptoms of problems that people sometimes have. Describe how much the symptoms have bothered you in the last week; including today by circle the response that best corresponds to your answer Not at all A little Quite a bit Extremely 1 2 3 4 17. Feeling hopeless about the future 18. Feeling sad 1. Suddenly feeling scared for no reason 1 2 3 4 2. Feeling fearful 1 2 3 4 3. Faintness, dizziness, or weakness 1 2 3 4 4. Nervousness or shakiness inside 1 2 3 4 5. Heart pounding or racing 1 2 3 4 6. Trembling 1 2 3 4 7. Feeling tense or keyed up 1 2 3 4 8. Headaches 1 2 3 4 9. Spell of terror or panic 1 2 3 4 10. Feeling restless or can’t sit still 1 2 3 4 11. Felling low in energy or slowed down 1 2 3 4 12. Blaming yourself for things 1 2 3 4 13. Crying easily 1 2 3 4 14. Loss of sexual interest or pleasure I 2 3 4 15. Poor appetite 1 2 3 4 16. Difficulty sleeping, staying asleep 1 2 3 4 1 2 3 4 2 3 4 2 3 4 p—Ap—a 19. Feeling lonely 148 20. Thought of ending your life 21. Feeling of being trapped or caught 22. Suddenly scared for no reason 23. Feeling no interest in things 24. Feeling everything is an effort 25. Feeling worthless 149 r—sr—sp—aHr—Ip—a NNNNNN wmmwww ##hA-h-h Date: Appendix I Semi-Structured Interview Guide PRE-MIGRATION AND FLIGHT EXPERIENCES a. What life was like in your home like for you and your family before fled? 0 Talk about work life (self/husband) 0 Home life (household chores, child rearing, extended family) Which year did conflict break out in the home country? Tell me a little bit about how life changed for your and your family once violence broke out in your home country. How long after the conflict started did your family decided to flee? What factors finally made you decide to leave your home in search of a safer living situation? How did you decide where to flee to for safety? Tell me a little about your journey to refuge once you left your home? 0 How did they travel (car/bus/on foot/in groups)? 0 How long did the journey take? 0 What did you witness/experience (traumatic events and others) during this journey? 150 LIFE IN REFUGE a. Before you crossed the borders of your home country, did you seek refuge in your home country (where, with whom, for how long)? b. Tell me a little bit about what life in the refugee camps was like? 0 How many different refugee camps did you stay in, for how long and in how many different countries? 0 What was your experience like in the refugee camps? 0 How long was it between the time you left your home country and when you were finally resettled RESETTLEMENT Acculturative stress a. What U.S. city were you first resettled in? Have they moved since? b. Tell me about your resettlement experiences since you arrived? c. What have been some of your most stressful experiences? d. What have been some of your most rewarding/memorable experiences? Life as a single female household head a. What is life like for you as a Single female Afiican refugee heads-of-household in the U.S.? b. What are some of the challenges that you experience that you think are unique Single female African refirgee heads-of-households resettled in the U.S.? 151 Social support a. During your time here in the U.S. whom have you received help from with resettlement challenges/ issues? - Resettlement agency 0 Coethnics - Family 0 Significant other 0 American fiiends What kind of assistance have you received from the above groups of people? b. Have all those whom you received help from been equally helpfirl or have some groups been more helpful than others. c. Do you value help/assistance from any one group more than the other? Interacting in Mainstream U.S. culture a. What have been your experiences have been trying to interact in mainstream American society been like? b. Where do you work? What kind of work do you do? What are your responsibilities? What ethnicities are the ethnicities of your workmates? c. Socially, who do you interact with (coethnics, etc) Discrimination a. Do you think you have ever been treated differently because of your skin color/ethnicity? 152 b. Tell me a little about such an experience where you felt you were treated differently (because of your skin color/ethnicity). c. Do you often have these kinds of experiences? d. How do those experiences make you feel? Religiosity a. Do you consider yourself a religious person? b. What religion are you? How often do you attend religious activities? c. Do you feel well received and a part of the religious institution you go to? d. Has the religious institution helped you with your resettlement/ any problems or challenges you have adjusting here in the U.S.? e. 13 your religion helpful to you in any way in coping with the challenges/stress of living in another country? If so, how? Health a. How would you describe your health (good, fair, bad, etc)? b. Did you have any medical problems when you first came to the U.S.? If you did, were you able to receive treatment for them? c. Do you have any medical problems now? Are you currently receiving medical attention for these problems? d. If you have any medical problems, do they prevent you from working (household/paid). e. Do the medial conditions cause you to feel stressed? Explain. 153 CONCLUDING QUESTIONS Traumatic experiences a. Do the traumatic experiences you had before resettlement affect you now in any way now? b. Do you think about what happened? Do those thoughts bother you? c. Services Additional assistance a. What kinds of assistance from did you not get (from coethnics, resettlement agency, mainstream society, religious institutions) but which you think would be useful in helping Single female African refugee heads-of-households like yourself in resettling and adjusting to life in the U.S. b. Is there anything about your pre-migration and resettlement experiences that we have not discussed and which you would like to share with me? 154 Appendix I Table 11: Correlations: Sociodemographic Variables and Acculturative stress Variable Acculturative stress 1' P Age at resettlement -.29 .05xx More time spent in the host country .19 .17 Self-rated fluency of spoken English .19 .17 Interviewer-rated fluency of spoken English .21 .15 Single female head-of-household status -.11 .29 Formal schooling I .15 .23 Total years of schooling attained .09 .33 Employment Status -.19 .17 Hourly wage .18 .21 Net income -.1 1 .32 Social support Social support scale .14 .25 Resettlement agency subscale -.02 .46 American friends subscale .12 .27 Family subscale .15 .23 Special person subscale .17 .20 Liberian friends subscale .02 .46 El ° Significant at .01 ** Significant at .05 "*Neared significance (.06 - .10) 155 Variable Acculturative stress r P Religiosity Religious persuasion .22 .14 Organized religious (OR) practices .08 .36 Non organized religious (NOR) practices -.11 .30 Intrinsic religiosity (IR) -.46 . 10*“ Health General health assessment .09 .31 Physical component summary .35 . 04* Trauma Number of traumatic experiences .60 .00’ PTSD subscale .53 .00* Cl ' Significant at .01 ** Significant at .05 "*Neared significance (.06 — .10) 156 Appendix K Table 12: Correlations: Sociodemographic Variables and Anxious / Depressive Symptomatology Variable Anxious Depressive Symptomatology symptomatology r p l‘ P Age at resettlement .23 .12 .14 .25 More time spent in the host country -. 13 .26 -.02 .46 Self-rated fluency of spoken English .10 .30 -.05 .40 Interviewer-rated fluency of spoken English -.32 .05" -.25 .10*** Single female head-of-household status -.17 .21 -.08 .36 Formal schooling -.20 .16 -.07 .36 Total years of schooling attained -.17 .20 -.30 .44 Employment status -.29 .08*** -.07 .37 Hourly wage .12 .29 -.01 .47 Net income -.06 .40 -.001 .50 Social support Social support scale .12 .27 .10 .31 Resettlement agency subscale .16 .22 .03 .45 American friends subscale .26 .10* . 29 .07. Family subscale -.13 .27 .06 .38 E] ' Significant at .01 "”" Significant at .05 "*Neared significance (.06 - .10) 157 Table 12 (cont’d) Variable Anxious Depressive Symptomatology symptomatology 1' P r P Special person subscale .14 .25 .04 .43 Liberian friends subscale -.09 .34 -.13 .26 Religiosity Religious persuasion -. 17 .21 -.17 .20 Organized religious (OR) practices .50 .01* .26 .09*** Non organized religious (NOR) practices .07 .36 .04 .42 Intrinsic religiosity (IR) .17 .18 .10 .32 Health General health assessment -.52 .01* -.63 .01* Physical component summary .13 .24 - .19 .16 Trauma Number of traumatic experiences .27 .08*** .44 .01. PTSD subscale .60 .04** .31 .06*** D * Significant at .01 158 ** Significant at .05 "*Neared significance (.06 ~ .10) Appendix L Table 13: T-test: Sociodemographic Variables and Acculturative Stress Variable Acculturative stress P Age at resettlement (529 or >30) .07.“ Single female head-of-household status .29 Has or has not attended formal schooling .23 Number of schooling years (59 or >9) .27 Employment status . .24 Religiosity Religious persuasion .14 Cl ' Significant at .01 “' Significant at .05 "*Neared significance (.06 - .10) 159 Appendix M Table 14: T-test: Sociodemographic Variables and Depressive/anxious Symptomatology Variable Depressive Anxious symptomatology symptomatology P P Age at resettlement (529 or >30) .10**‘ .50 Single female head-of—household status .23 .22 Has or has not attended formal schooling .36 .25 Number of schooling years (59 or >9) .39 .29 Employment status .32 .18 Religiosity Religious persuasion .19 .21 Cl ‘ Significant at .01 ** Significant at .05 "*Neared significance (.06 - .10) 160 Appendix N Table 15: Qualitative Data A: Emergent Themes country THEME OCCUREN CE Pre-migration Experiences Death of a family member or friend All Death of children B2 &W Family separation All except Z & H Lack of clothing All Found out about missing family recently V, W, L &E Forced to leave abruptly without planning All except Z Heard stories of killings B Left with children from extended family B Life in refuge Returned briefly to Liberia after war broke out in asylum A Living conditions in asylum country were often dangerous A,B,C,D,E,V&W Liberians males were being killed in the asylum country C, B & E Were treated well in the asylum country H & B2 Life was difficult; meeting household needs All except Z Lived in a refugee camp All except Z, C, D& B Lived in a city/town Z, C, D, B Engaged in petty business to make money to buy food All except K, J, I, M (were very young) & Z 161 Table 15 (cont’d) THEME OCCURENCE Life in refuge (cont) Sold food given by relief organizations to make money All except K, J, I, M (were very young) & Z Discriminated against because they were Liberian B, K, L &Z Food prices hiked or denied food because were Liberian Z, V& L Lack of adequate health care V, W, L & M Lack of adequate food All except Z Hurt/injured during flight from conflict in asylum country E, V&W Heard the citizens of the asylum country say that Liberians B, C, D, V& W would bring war to the country of asylum Were treated well in African asylum country BZ & E Fled again when civil war broke out in African asylum A, B, H, , V&W country Separated from children when war broke out in asylum W, C & D country Spouse killed when ware broke out in asylum country D Spouse missing when ware broke out in asylum country C Separated from brothers and sisters when war broke out in W asylum country Untreated medical conditions V &W Were resettled by the UNHCR because the situation in V, W & D asylum countries had become really bad for Liberians in the ivory coast Resettlement Not resettled as a principal refugee Z & L 162 Table 15 (cont’d) THEME OCCURENCE Orientation in Africa Attended pre-resettlement cultural orientation All except Z & L Found it helpfirl V, W, A, B, E, M &J No interpreters were provided at orientation for those who could not understand Standard English V&W Informed about resettlement services All except J, I, K, X, Z& L Discrepancy between services promised at orientation and those received after resettlement A, B, B2, D, E, H, V&W Received poor housing A,E&Z Received poor firmiture and furnishings A,V&W Frustrated by discrepancy in resources promised and given A, B, BZ, E, , V&W Wanted to call UNHCR to complain about discrepancy in services promised and those received A Social Support Social support from Liberians (coethnics) Help in completing important paperwork A Provided with material things A, B, C, D, V, W& Z Family in other states offer financial help B Not helpful A Talk together, visit one another, are fiiendly A, E, B & B2 Conflict among Liberians A, V& W Talk about problems together D & A Provided assistance during surgery C, D & E Was not provided assistance dming illness A 163 Table 15 (cont’d) THEME OCCURENCE Child care assistance M, X, C, B& E Liberians not united A, B, C, V & W Liberian fiiends help them read documents C & D Share information about available resources B American Friends Met them at church B2, C, D, E, E, W& Z Met them at school K, X, J, R, Z&E American friends helpful All except C (currently has no American fiiend) American friends help them read documents B2, D, W & H Receive gifts during the holiday from American friends A, B, B2, L, P. W, V &Z Respondents bought material things by American friends A, B & C Respondents given money by American fiiends A & B2 American friends act as cultural brokers B2 American friends Help them read documents B2 & H Significant Other Having a husband is helpful for financial reasons B2, H & L Husband is helpful in problem solving H Financial challenge of being a single female head-of- A, B, C, D& E household Resettlement Organization Provided useful initial resettlement support A &Z Provided inadequate support A, D, E, H, L, V&W Dissatisfied with housing A, E & Z Found themselves better housing A, Z & E 164 Table 15 (cont’d) THEME OCCURENCE Financial assistance cut off before employment began B, C American fiiends Met them at church B2, C, D, E, E, W, Z Met them at school K, X, J, R, Z, E American fiiends helpful All except C American fiiends help them read documents B2, D, W, H Receive gifts during the holiday from American friends A, B, B2, L, P. W, V, Z Religiosity Consider themselves religious All Go to church on Sunday All except B (Muslim), K, X (Muslim), M Prays but does not go to the mosque B Attend the Lutheran church A, H, L, P, V & W Turn to religion for help with problems A, B, B2, C, D, E, H, L, M, P, V, W & Z If your prayers are not answered, it is not Gods will B2, C, D, E & L Church/Mosque Provided financial assistance A,B,B2,E,W,V& Z Provided material assistance A, B, B2, D, H, L) V9 W,X&Z Interest-free loans provided by Lutheran church V&W Helped by the Baptist church A, B, B2, D, L, P, V, W&Z Emotional support provided by church A, 32, E, H, L, W, Z & D Feel welcome at church B2, E, K, L, V, W& Z 165 Table 15 (cont’d) THEME OCCURENCE Still receive material and financial assistance from the church B, Z, W& D Personal Health Have health problems A, B, C, D, V& W Taking medication B, D & W Needs surgery for medical condition C Health problems usually do not keep them from working A, B, B2, C, D, E, V& W Not working means income 1033 B, C, D & W Surgery and hospitalization A, D& E Socioeconomic Status (SES) Money not enough to meet household needs Cannot save money A & C Receive cash assistance A, C& W Literacy Can read and write well J,R,Z,X,V,L,E&K Cannot read or write at a comfortable level A, B, B2, C9 D, H, M, P& W Fluency of spoken English Still has some difficulty speaking English C, D, H &W Spoke at least some Standard English when first resettled E. K, L, Z &J Literacy Adjustment challenges Interact mainly with Liberian coethnics A, B, BZ, D, E, M, P& W Treated differently by human service organizations V 166 Table 15 (cont’d) THEME OCCURENCE Discrimination by resettlement organization A, B, V, W & Z Refugees from other nations got better treatment from A, B, V, W & Z resettlement organization Discrimination in school K, x, J, I (18 years old), M Separated, some children in Africa A, B2, C &W Felt were not given information to help immigrate family members A,B2,C,W&L Stress of providing financially for family in Afiica All except K, X, J, I (18 years old) & M Receive phone calls from family and fiiends in Afiica All except K, X, J & I asking for money (18 years old) Worry about safety and welfare of family back home All respondents Send money back to Afiica whenever they have it All except K, X, J & I (18 years old) Does cannot make ends meet therefore receive foods stamps A, C, D, E, L &W Traumatic experiences Witnessed/endured trauma All Affected by the trauma B, B2, H, V &W 167 REFERENCES 168 REFERENCES Administration of Child and Family Services (2008). 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