Objective Adolescent refugees encounter traumatic stressors and are at risk of developing psychosocial health problems; limited research data exist internationally. This study aims to identify health risk behaviours among adolescent refugees resettling in Western Australia and assess the feasibility of using a standardised adolescent health questionnaire for this purpose.
Design Refugees aged 12 years and above attending a tertiary Refugee Health Service (RHS) were recruited over 12 months. Sociodemographic data were collected. Psychosocial assessments based on the ‘Home, Education/Eating, Activities, Drugs, Sexuality, Suicide/mental health’ (HEADSS) framework were undertaken utilising interpreters where required. Health concerns identified were managed through the RHS.
Results A total of 122 adolescents (20 ethnicities) participated; 65% required interpreters. Median age (range) was 14 (12–17) years. Most (80%) had nuclear family separation. Almost half (49%) had a deceased/missing family member. A third (37%) had lived in refugee camps and 20% had experienced closed detention. The median time (range) since arrival in Australia was 11 (2–86) months. Every adolescent had at least one health concern identified during the psychosocial assessment. Frequency of health concerns identified in each domain were 87% for home, 66% for education, 23% for eating, 93% for activities, 5% for drugs, 88% for sexuality and 61% for suicide/mental health. Most adolescents (75%) required intervention, consisting of counselling for health risk behaviours and/or referral to health or community services.
Conclusion It is feasible to use a standardised adolescent health questionnaire to identify health risk behaviours among a cohort of ethnically diverse adolescent refugees. Use of the questionnaire identified a large burden of psychosocial health issues requiring multidisciplinary intervention.
- adolescent health
- health risk
- asylum seeker
Statistics from Altmetric.com
What is already known on this topic?
The protracted refugee crisis is resulting in a rising number of young people seeking asylum worldwide.
Adverse experiences in childhood and adolescence can increase the predisposition to future health problems. Adolescent refugees have often experienced multiple traumatic events.
Health risk behaviours are associated with mortality and morbidity in young people. Psychosocial assessment tools can enable early identification and management of these behaviours.
What this study adds
Ethnically diverse adolescent refugees resettling in Western Australia report multiple complex health risk behaviours compounded by previous trauma.
Health risk behaviours among adolescent refugees can be feasibly identified using a standardised adolescent health questionnaire, conducted during independent consultations with young people.
Multiple services are required to manage health risk behaviours in adolescent refugees, highlighting the need for multidisciplinary clinical service provision for this cohort.
International concern exists regarding the large number of people displaced worldwide by persecution and war.1 Ongoing conflicts in Africa and the Middle East are resulting in an unprecedented rise in the numbers seeking asylum globally. The exodus of Syrians fleeing a civil war continues to challenge nations to seek durable resettlement solutions.2 Concerns regarding the psychosocial health of young people who are forcibly displaced have prompted international calls for research to guide the development of support services for this vulnerable population.3 4
Approximately half of all refugees worldwide are aged under 18 years.1 The proportion that constitutes adolescents remains unknown, as these data are not collected separately.3 Adolescents have unique healthcare needs compared with younger and older age groups.5 Research data in refugees have largely been collected with adolescents being grouped within paediatric or adult cohorts.3 Many research studies are also limited to specific ethnic groups. Comprehensive population data are lacking.
Exposure to traumatic experiences during childhood and adolescence is associated with poor physical and mental health outcomes in later life, including increased participation in adverse health risk activities.6 Refugees have often experienced multiple, repeated and prolonged trauma.7 Many have been exposed to poverty, persecution, war, physical violence and sexual abuse. After fleeing their home country, they may have lived in transit countries, refugee camps and detention centres. Many experience the death or separation of family members. Resettlement processes bring additional acculturation stressors. Integrating into a society with different cultural values and gender roles is challenging. Enrolment into educational programme, interaction with peers, material disadvantage and risk of discrimination lead to further psychological stress.
Health risk behaviours contribute to the majority of morbidity and mortality in young people worldwide.8 Evidence suggests that identification and management of these behaviours promotes healthier lifestyles among adolescents.9 The need to improve our understanding of the psychosocial and demographic factors that affect the health of resettling adolescent refugees has been highlighted.3
This study aimed to identify the burden of health risk behaviours among culturally diverse resettling adolescent refugees using a standardised adolescent health questionnaire, and to investigate the feasibility of this approach.
Patients and methods
Study sample and patient recruitment
The tertiary multidisciplinary Refugee Health Service (RHS) at Princess Margaret Hospital (PMH) assesses the majority of humanitarian refugee children and adolescents resettling in Western Australia (WA) following initial screening at the Humanitarian Entrants Health Service.10 Referrals are also received from other health, community and educational professionals. The RHS aims to manage the initial complex medical and psychosocial healthcare needs during resettlement. However there is no established standardised international process to conduct comprehensive psychosocial assessments on adolescent refugees in this context.
All adolescent refugees confirmed to be aged 12 years and above attending the RHS over a 12-month period (February 2015–2016) were approached for recruitment. Informed consent was obtained from the young person’s guardian and assent from the young person. Professional interpreters (onsite or telephone) were used in all aspects of communication with participants who had limited English proficiency (LEP), based on the WA Language Services Policy recommendations.11
Data collection and analyses
A standardised data collection form was used to obtain sociodemographic information. This included information regarding origin country, primary language, refugee journey to Australia (including experiences in refugee camps and closed/community detention), length of resettlement and family structure. Psychosocial assessments were conducted by a single interviewer utilising a standardised four-page adolescent health questionnaire based on the ‘HEADSS’ framework, focusing on the domains of Home, Education/Eating, Activities, Drugs, Sexuality and Suicide/mental health problems (online supplementary appendix 1).12 Confidentiality and its limitations were discussed. Young people were offered an interview alone (with an interpreter as appropriate) for at least part of the consultation. All interviews were conducted as per the Royal Australasian College of Physicians recommendations.13
Supplementary file 1
The feasibility of the HEADSS questionnaire was assessed in the following ways: (1) the proportion of families willing to participate in the study; (2) the number of participants willing to be interviewed alone; (3) the ability of participants to respond to questions within the HEADSS framework domains; and (4) the length of time taken for the interview.
Any issue identified by the interviewer, young person or family member as having a detrimental impact on the medical and/or psychosocial health of the young person at the time of interview or having the potential to do so in the future, in the absence of any intervention, was classified as an area of health concern. All health concerns were addressed appropriately with counselling and/or referral to relevant health and community services following discussion with the RHS consultants. Descriptive statistics were used to analyse the data using SPSS V.22.
During the study period, 128 eligible adolescent refugees attended RHS appointments. Over half were follow-up patients (55%) who had been seen in the clinic a median number of two times (range 1–7). Families were approached for recruitment on the day of the appointment or subsequently contacted by telephone. Of the 128 eligible patients, 122 (95%) were approached. The remaining six were unable to be contacted by telephone on multiple days. All 122 patients approached agreed to participate; subsequent interviews were arranged and completed.
Table 1A highlights the personal and family demographics of the group. Families were ethically heterogeneous, originating from 15 countries and speaking 20 primary languages (table 1B). The median age (range) was 14(12–17) years with an even gender distribution. The majority (80%) were separated from one or more family members and approximately half (49%) reported at least one family member being deceased or missing, and therefore presumed deceased. Although 8% were orphaned, all of these adolescents had an extended family member allocated as their legal guardian. The majority of adolescents had lived in at least one transit country, with over a third having lived in a refugee camp. One in five had experienced mandatory, closed detention. While most (86%) had completed the process of refugee status determination and granted a permanent Australian visa, 14% had an insecure status.
All 122 adolescents interviewed reported at least one issue of health concern. Health concerns were identified in a median (range) of 4 (1–6) HEADSS domains in each adolescent. A high proportion of issues were identified within the domains of home, education, eating, activities, sexuality and suicide/mental health (figure 1). Specific themes are represented in figure 2. A small number of male adolescents (5%, n=6) reported issues related to alcohol consumption or cigarette smoking within the drug domain .
Previously unrecognised issues of health concern were identified in almost all (n=120, 98%) participants. A median (range) of new issues were reported within 2 (1–6) HEADSS domains in each individual. One or more new areas of concern requiring intervention were identified in 75% of adolescents (n=92). These were managed through health risk counselling during the interview (total 42%; 19% male, 23% female), and/or referral to other services for further management (total 66%; 34% male, 32% female) (table 2).
Feasibility of the HEADSS questionnaire
All invited refugee families were agreeable to conducting the psychosocial interview. The majority had LEP; 65% of adolescents and 79% of guardians required an interpreter. Only one adolescent was unable to be interviewed alone. An interpreter was not available for the single language spoken by this adolescent, requiring a family member to act as an interpreter. All adolescents completed the entire interview, answering every question in all domains. The mean (range) time taken to conduct a HEADSS interview with the adolescent was 33 (25–60) min with an interpreter and 30 (25–40) min without.
To our knowledge, this is the first study describing the frequency and range of health risk behaviours among resettling adolescent refugees, identified using a standardised questionnaire. These data highlight the traumatic and prolonged refugee journeys of this ethnically diverse cohort.
This study builds on previous work using the HEADSS questionnaire. In comparison to a group of adolescent surgical inpatients at our institution, the refugee cohort reported a much higher frequency of health risk behaviours requiring intervention (75% vs 30%).14 In keeping with a study of adolescents seen in a child protection unit, the current data demonstrate that use of the questionnaire leads to the identification of previously unrecognised health concerns.15 Current literature comparisons for individual HEADSS domain findings are discussed below.
The majority of participants reported issues of concern at home, with half requiring referral to social services. Concerns regarding finances, lack of appropriate housing and fragmented family units among resettling refugee families have previously been raised.16 17 This study defines the extent of these issues among adolescents. Poor relationships and conflict within refugee families can cause further psychological stress.18 19 Contributing factors include reconfigured family roles, reunification after prolonged separation and intergenerational acculturative stressors. Fathers, who traditionally fulfil the role of financial providers in their country of origin, were commonly deceased. These issues may potentially have a negative impact on the economic outcomes of refugees.17
High rates of interrupted education have previously been reported among a cohort of Western Australian school-aged refugees.20 This study describes similar rates within an adolescent-specific cohort. The majority were enrolled in school at the time of interview. However, those who were not were all on Bridging visas (a temporary visa allowing a person to reside in Australia while applying for a substantive visa, with potential future refoulement if unsuccessful).21 There is limited access to tertiary education for refugee youth in Australia; however, barriers to secondary schooling for age-eligible adolescents have not been previously reported.22 23 The Australian Human Rights Commission has reported detrimental effects from lack of schooling among those in immigration detention.24 Lack of educational access for those on Bridging visas requires urgent attention.
Academic difficulties were reported in 15% of adolescents enrolled in school. Current practice in WA involves provision of language and academic support for adolescent refugees within intensive English schools for the first 6–24 months of resettlement.25 Academic difficulties are predicted to arise during subsequent transition into mainstream education due to ongoing limited academic English language proficiency, highlighting the need for longitudinal data to demonstrate educational outcomes. Approximately one-quarter of the study cohort reported experiencing bullying/discrimination. This incidence is similar to that reported among other refugee and non-refugee students in Australia; however, targeted interventions are required to ameliorate these concerns.26 27
Transition from a traditional to a Western diet, previous food insecurities and poor health literacy can result in obesity or undernutrition in refugee children and adults from specific ethnicities.28 A greater risk of eating disorders has been suggested in immigrant youth, including refugees.29 In the current study, 20% reported body image concerns and change in appetite. Despite the majority having family meals (86%), family members were often unaware of this. Postarrival health assessments for refugees commonly include screening for nutritional disorders. These study data indicate the need to incorporate an evaluation of eating behaviours and body image perceptions into these assessments.3
Narratives from refugee youth describe the absence of extended family networks and close-knit living communities, unfamiliar social practices, difficulties navigating public spaces and language barriers as factors that affect their sense of belonging in the host country.18 Data from this study suggest that most resettling refugees in this early period are socially isolated with few friends, limited social activities and sedentary lifestyles. Subjective reports of increased screen time requiring counselling in approximately 20% highlight the importance of asking young people about use of digital media.30 Benefits of digital media among adolescent refugees include social contact with family/friends overseas. Reported negative influences including sleep disruption and depression need consideration.31
The reported prevalence of drug and substance misuse varies greatly among forced migrants, depending on the study population, including origin country and cultural norms.32 In the current study, drug and alcohol use was reported only among males and the overall frequency was low compared with other non-refugee adolescent groups, including those who have experienced abuse/neglect.15 There is however a suggestion regarding increasing rates of drug and alcohol use with prolonged periods of resettlement, reflecting the need for ongoing longitudinal assessment.32
The low levels of sexual and reproductive health knowledge among resettling adolescent refugees are concerning. This has previously been described among young adult refugees in Australia, suggesting broader health education gaps.33 The core aspect of sexual health education is provided during the middle years of Australian secondary education.34 Interrupted education and reintegration into final years of secondary school may contribute to adolescents missing this curriculum. Cultural values, whereby sexual relationships outside marriage are discouraged along with stigma associated with sexual health issues, may explain the low rates of reported risky sexual behaviours. Health professionals and policy makers have suggested using the HEADSS framework to conduct opportunistic assessments of sexual well-being in culturally diverse youth.35 The current study reflects the feasibility of achieving this among refugees.
Prevalence rates of mental health disorders among refugees vary based on personal, demographic and societal factors, including adverse experiences.7 36 Comprehensive resettlement population data are limited. A third of study participants reported witnessing trauma and 9% experienced direct trauma. Almost a third required referral to mental health services, higher than previously found among a child and adolescent cohort, highlighting the benefit of targeted adolescent assessment.10 Evidence suggests that refugees subjected to detention have higher rates of mental health issues including risk of suicide and self-harm.37 The number of detainees was small in this cohort, limiting analysis. Inability of the majority of adolescents to express their emotions to family members may be influenced by cultural stigma towards mental health issues. Our findings highlight the need to increase cultural awareness regarding mental health problems among refugee families.
Implications for clinical practice
These data provide an insight into the burden of health risk behaviours for resettling adolescent refugees. In our own unit, this has led to changes in service provision. Introduction of routine psychosocial health assessments for adolescent refugees aligns with best practice guidelines.38 This practice enables better identification and targeted intervention of health risk behaviours, with the aim of reducing morbidity and mortality. This study has identified gaps in clinical service delivery, such as in the areas of sexual and reproductive health education. This should guide resource allocation and intersectoral collaboration.
Strengths and limitations
A strength of this study was the ability to capture data from the majority of adolescent refugees resettling in WA during the study period, given the centralisation of the RHS. Previous studies have grouped adolescents into broader paediatric and adult cohorts or limited their focus to specific ethnicities. The current study has generated adolescent-specific, comprehensive population data for WA.
Family participation was universal. All guardians provided consent and every adolescent was agreeable to being seen alone. Advocates of youth health highlight the need to provide confidential healthcare to adolescents, irrespective of underlying family values.39 The utility of the HEADSS framework to conduct psychosocial assessments with young people has been established in various settings.14 15 This study demonstrates the acceptability and feasibility of the questionnaire in a culturally and linguistically diverse population with a background of trauma.
This study has limitations. Several aspects of the data relied on participants recalling past events, which may result in recall bias. Some adolescents originated from the same family. This may introduce bias particularly within the sociodemographic data due to similar background characteristics. However, considering the ethnic variability of the participants and the large proportion of adolescents who had been separated from family members, this bias is likely to be minimal.
Participants with LEP required the presence of a professional interpreter. This study makes no comparison of health risk behaviours identified in adolescents seen with and without an interpreter. Best practice recommendations describe the importance of using professional interpreters to communicate with refugee families during consultations.40 Whether the presence of an interpreter has an impact on the disclosure of sensitive information requires further research.
Conclusion and recommendations
Adolescent refugees resettling in WA report complex psychosocial health issues on a background of trauma, placing them at risk of current and future health difficulties. Multidisciplinary intervention services are required to mitigate these risks and promote resilience.
While this study is reflective of adolescent refugees resettling in Australia, concerns exist among those resettling in other high-income countries.3 4 There is a need to focus on improving the psychosocial health of this vulnerable population at a broader level. Based on current data, suggestions for healthcare services are highlighted in box 1. Longitudinal, intersectoral data collection will help to identify areas of unmet need and to implement strategies to optimise the future health trajectories for adolescent refugees.
Suggested recommendations for healthcare services to address psychosocial healthcare needs of resettling adolescent refugees
Implement the routine use of standardised psychosocial assessments during health consultations to identify health risk behaviours
Foster adolescent-friendly youth consultations that are culturally appropriate; this includes seeing adolescents alone during consultations, discussing confidentiality and utilising professional interpreters
Establish formal routes of intersectoral collaboration between various services to provide multidisciplinary healthcare to resettling adolescent refugees (eg, medical, sexual and reproductive health, mental health, allied health, educational agencies, social services, governmental bodies)
Collect adolescent-specific research data to identify and address knowledge and resource gaps in this field
Contributors KH conceptualised and designed the study, recruited subjects, collected data, conducted statistical analyses, drafted the initial manuscript, and reviewed and revised the manuscript. DNP, SC and RM conceptualised and designed the study, supervised data collection, and critically reviewed and revised the manuscript.
Funding All phases of this study were supported by a Princess Margaret Hospital Foundation seeding grant (ID number: 9546). KH is also the recipient of a 2016/2017 Princess Margaret Hospital Foundation Fellowship.
Competing interests None declared.
Ethics approval PMH Human Research Ethics Committee (2014052EP) and the University of WA Ethics Committee (RA/4/1/7370).
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement All the data for this study are presented in the manuscript.
If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.