Mental health risks and stressors faced by urban refugees: Perceived impacts of war and community adversities among Somali refugees in Nairobi

Abstract

Background:

There is a gap in understanding of refugee mental health risks unique to urban areas of low-income countries.

Material:

A qualitative rapid appraisal using focus group interviews with community stakeholders explored main stressors pervasive by Somali refugees in Nairobi, Kenya.

Discussion:

This study identified the intersection of war trauma and daily stressors that affect both functional and structural challenges and risk of mental health issues among Somali urban refugees.

Conclusion:

Findings underscore the importance of understanding mental health in the broader context of community adversities, suggesting development of contextually informed interventions responsive to complex needs of urban refugees.

Keywords

Urban refugee Somali refugee mental health trauma community adversity

Introduction

According to United Nations High Commissioner for Refugees (UNHCR) (2016), 86% of refugees are displaced in low- and middle-income countries (LMICs) and more than half of them are settled in urban settings. Refugee camps often generate meager conditions and constraints of living, urging the influx of refugees to urban areas in effort to increase stability, autonomy and security (Crisp, Morris, & Refstie, 2012; Grabasky, 2006). Facing numerous adversities, from war trauma to daily stressors during migration, urban refugees in low-resource settings are likely to develop health and mental health issues, such as major depressive disorder, posttraumatic stress disorder, somatic symptoms, substance use disorders and many others (Berthold, 2000; Reed, Fazel, Jones, Panter-Brick, & Stein, 2011). Such mental health burdens are affected by the inauspicious conditions of the host country that create additional difficulties in stability and psychosocial care, furthering the risks of poor health and mental health status of refugees (Lindert, von Ehrenstein, Priebe, Mielck, & Brahler, 2009; Pumariega, Rothe, & Pumariego, 2005). Urban refugees, mostly self-settled in overcrowded settings, live in fear of detainment, encampment or deportation, increasing invisibility of this population. UNHCR and other international aid agencies face complex challenges in identifying and approaching refugee populations, making assessment and services to urban refugees more difficult (Amara & Aljunid, 2014). Despite the prevalent needs to address mental health symptoms and stressors, urban refugee populations face chronic paucity of interventional strategies that detect the needs and mobilize resources due to legal, cultural and language obstacles and thus remain in the state of perpetual vulnerability (Pumariga et al., 2005).

Somali refugees in Kenya

Somali refugees including asylees have settled in Kenya since the early 1990s following the Somali humanitarian crisis. According to UNHCR (2014), there are a total of 427,550 registered refugees in Kenya, but this number is an underestimate as Somali refugees often do not formally register and strive to blend in among local populations (Hammond, 2014). Prolonged refugee status results in a state of limbo where social, political, legal and economic solutions are unforeseeable (Purkey, 2013). Somali refugees, therefore, either leave or bypass the camps for urban areas, such as Nairobi, where they can find economic independence and educational opportunities (Pavanello, Elhawary, & Pantuliano, 2010). In leaving camps, urban refuges often forgo the support, assistance and attention the camp can provide (UNHCR, 2009). Despite seemingly considerable resources and opportunities in urban areas, Somali refugees in Kenya contend with restricted rights and rely upon limited private charity or international benevolence and goodwill (Harrell-Bond, 2002). Even urban refugees with government documentation are often subject to harassment, threats of detention and demands for bribery by the local community. Although the Kenyan Refugee Act of 2006 created a legal framework for refugees who wanted to leave the camps, poor implementation resulted in a confusing array of documentation that at best is not accepted and at worst is considered fraudulent (Pavanello et al., 2010). In the fear of detainment and further harassment, urban Somali refugees in Kenya face risk of victimization by criminals or by police with no legal resources or proper protection (Harrell-Bond, 2002; Human Rights Watch, 2013).

Previous studies show a high prevalence rate of post-traumatic stress disorder (PTSD), depression, anxiety and psychosis among Somali populations (Fazel, Wheeler, & Danesh, 2005; Kroll, Yusuf, & Fujiwara, 2011; Porter & Haslam, 2005). Such mental health burdens are further impacted by various types of migration challenges, including chronic poverty (Onyut et al., 2009), discrimination (Ellis, MacDonald, Lincoln, & Cabral, 2008), family disruption (Warfa et al., 2006) and pre-migration traumas such as risk to life, ethnic cleansing and famine (Bhui et al., 2003). Daily stressors, such as economic hardship, discrimination, little social support, legal issues around employment and mobility and family separation or conflicts, can compound migration-related mental health and impede coping ability (Crisp et al., 2012; Miller & Rasmussen, 2010). The predominant literatures on refugee challenges and their role in mental health, however, are from refugees resettled in high-income countries or in refugee camp settings, leaving gaps in understanding of refugee experiences unique to urban areas of low-income countries, where the majority of the refugee population is located.

Despite the heightened needs, Somali refugees in Nairobi face a lack of psychosocial assistance coupled with discrimination and xenophobia by residents and law enforcement (Campbell, 2006). Appropriate interventions to refugees remain especially challenging due to cultural and language barriers, misunderstanding of cultural norms, legal issues, failure to recognize the impact of daily stressors and structural barriers (Crumlish & O’Rourke, 2010). This study aims to explore and identify major stressors that increase a risk of mental health and psychosocial issues impacted by accumulative refugee trauma and adversities faced by urban Somali refugees in Nairobi, Kenya.

Methods

This study adopted a qualitative method to explore and identify the impacts of urban refugee adversities on mental health and psychosocial issues perceived by various community stakeholders in Nairobi, Kenya. As previous research pointed out (e.g. Bolton, Surkan, Gray, & Desmousseaux, 2012; Familiar et al., 2013), qualitative approaches are both effective and necessary to explore the complexity of post-conflict impacts on people at multiple levels by enhancing understanding of the context and scope of experiences involved (De Jong & Van Ommeren, 2002). A modified rapid appraisal process was employed because this method allows exploring community health needs in a relatively short time period while triangulating information sources and gathering insights from various key informants (Rowa-Dewar et al., 2008). This study focused on eliciting community context and embracing refugee community’s understanding of current issues pervasive in local settings. As part of the Eastleigh Youth Project supported by the Kenya Transitional Initiative (KTI) of USAID–Kenya, this study utilized community profiles and internal reports developed by KTI to identify the first wave of key stakeholders, particularly community leaders, who turned into a community advisory board to provide ongoing consultation and share information between the community and the project team.

Sampling and participants

Participants of this study were identified and recruited through a combined method of convenience and snow-ball sampling. Initially, the project team organized a group of key community stakeholders in the Somali community, including two medical doctors, three psychosocial counselors and three community leaders. Through multiple consultation meetings, this advisory group helped identify and suggested 10 categories for focus group interviews: community leaders, religious leaders, teachers, parents, traditional healers, health and mental health providers and Kenyan civic service providers including law enforcement, youth leaders, at-risk youth and local community-based organization (CBO) staff. Considering gender differences and group dynamics, at-risk youth and mental health/health provider groups were divided into two: male at-risk youth, female-at-risk youth, health providers from clinics and pharmacists. Total 12 groups were formed and each group, except for Kenyan civic service providers group, consisted of 10 Somali refugees who settled in Nairobi after the Somali civil war in 1991. Any identifiable information, including clan membership, was not collected as per the suggestion of the community advisory board. The civic service group included officers from District Office, Office of County Services and Officer Commanding Police Division and three Kenyan local district representatives surrounding Eastleigh area, where most Somali refugees reside.

Data collection and analysis

Focus group interviews were co-facilitated by the first author (H.I.) and two Somali community leaders who are fluent in both Somali and English. Focus groups with civic service and mental health providers from clinics were conducted in English, while the rest were performed in both English and Somali, as preferred by participants. A set of questions were developed and modified by the authors and the advisory board. The semi-structured interview involved two parts with multiple follow-up questions: (1) common challenges and stressors that affect mental health and psychosocial problems in Somali refugees in Eastleigh and (2) impacts of such challenges and stressors on mental health and health. All interviews were audio-recorded for transcription after participant agreement and then transcribed verbatim in English by three bilingual counselors. H.I. shared the transcripts with the advisory board to validate the contents and crosscheck for accuracy and completeness. To analyze the interview data, a thematic analysis was adopted since this method allows the researchers to fully reveal the meaning emerging from the data while conceptualizing narrative reports as per significant information units (Ritchie & Lewis, 2003). The first two authors extracted themes after in vivo coding, which were arrayed in either level of challenges after multiple meeting for thematic reconciliation.

Results

Common stressors among urban Somali refugees

Community stakeholders reported a wide scope of challenges that contribute to a high risk of psychological distress and mental health burdens in the urban Somali refugee community in Nairobi. Identified stressors were assorted into two levels: (1) individual and interpersonal challenges that obstruct individual social functioning and (2) collective and societal issues that create structural barriers to the refugee community as a whole (see Table 1). This categorization allowed the authors to discern between functional problems directly affecting mental health issues and structural problems that dictate community resources and support systems that often cause various coping issues.

Table 1.

Perceived adversities and stressors affecting mental health in urban refugee community: themes and codes.

	Community stakeholders (community/religious leaders, teachers, parents, traditional healers, healthcare providers, civic service providers and youth at risk – boys and girls, youth leaders and CBO staff)
	Theme	Code
Functional challenges (individual /social level)	Lack of livelihood and financial resources	Unemployment, financial instability, lack of resources, financial strain, unmet basic needs, food insecurity
	Lack of education	School dropout, lack of access to education, poor education (low quality), parents’ financial constraint for educational support, illiteracy, no value of education
	Lack of discipline and guidance	No parental guidance, parents bailing delinquent children out of jail, parent’s negligence of children’s education, children sent from abroad under no guidance, bad peer influence, peer pressure for gang membership or drug use
	Lack of awareness or information	Lack of knowledge (in general), lack of information, disconnection between teachers and parents, lack of community education regarding hygiene and mental illness and substance abuse
	Substance abuse	Drug/substance abuse
	Domestic violence and family conflicts	Domestic violence, prostitution, forced marriage, divorce without family support, child labor (especially girls), child/wife abuse, gender-based violence within family
	Lack of support	Lack of financial support, lack of emotional support, no support of any kind
	Health concerns	Poor hygiene, lack of health care services (e.g. no rehabilitation center in Eastleigh), lack of qualified healthcare providers
	Sexual or gender-based violence	Prostitution, domestic violence toward women, rape, forced marriages, male prostitution, mistreatment of girls and women
	Demoralization	Idleness, wasting time, loss of hope, feelings of frustration, dissatisfaction with life, wanting more from life, feeling as if one has no options, feeling discrimination against due to gender, inability to achieve goals, loss of unity in community, feeling insulted and disrespected
	Violence	Fights, gang involvement, robbery, stealing
Structural challenges (collective/societal level)	Insecurity and community violence	Community violence, insecurity, terrorism, robbery, gang groups, fear of gang violence, violent mistreatment of community members by police, gang activity due to need for drugs, community member mistreatment–especially girls, organized crime, lack of peace in the community, youth violence, feeling physically or psychosocially insecure in community, community based crime, fear of mistreatment by police/government
	Lack of community resources	Poor infrastructure, poorly maintained roads (flood issue), congested living condition, lack of clean environment, no way to provide for community members’ needs, unavailability of public or social amenities, community’s poverty, lack of community leadership
	Lack of community services	Lack of healthcare, lack of financial assistance for medical needs, lack of treatment facilities for mental health issues, no rehabilitation center for youth involved in substance abuse
	Lack of opportunity for refugees	Limited employment options, limited educational opportunities for Somalis, perceived shortcomings of teachers, no means for livelihood
	Lack of legal protection	Police harassment and exploitation, police bribery, police blaming community members, discrimination by police, political/government creating division in community, being made to feel like community is living in Kenya illegally, no valid documents, no identification, no government representation, lack of civil rights
	Community breakdown	Broken sense of belonging or connectivity, community blaming, community difficulty due to community violence, lack of communication, community discrimination. Lack of connection with community perceived norms and values, communication breakdown between generations, lack of unity, lack of communication within the community, misunderstanding among community, lack of respect, corruption, community discontent, community discrimination and segregation of youth, feelings of being devalued or unduly influenced by other members of the community, loss of community values
	Cultural issues	Loss of traditional way of conflict resolution, language barrier, perceived loss of community morals, lack of support for girls, gender inequity, imposing masculinity (that fuels violence), tribalism/clannism, imposed gender role that obstructs girl’s education
	Social discrimination	Use of language that refugees cannot understand, being considered a foreigner, being accused of terrorism, no sense of belonging, being exploited, social labeling of Somali youth and Somali community, xenophobia

CBO: community-based organization.

Individual and interpersonal level: functional challenges

The Somali refugee community unanimously pointed out unfulfilled basic needs, such as education, livelihood, security, healthcare, legal protection and support systems, as the primary mental health risk. A traditional healer stated,

People lack financial support. This [Kenya] is not their country. They have no food, no milk, no meat, and no place to sleep. It is like they are locked up and there is no space to breath. They end up hating themselves. They need to have a stable and calm mind and they will if they find financial support.

Across focus groups, participants reported unbridgeable gaps between a wide range of needs and the ability to acquire needed resources. Such gaps often led to demoralization related to lack of awareness, information and social morale. Dearth of financial support or means for livelihood created further desperation and precariousness as described by a madrasa teacher. ‘There is lack of financial support and some families may eat just once a day and do not meet all their basic needs. This leads to insecurity’. He continued with an example, ‘Girls that do not have financial support are at risk. They might go into prostitutions and into gang groups so that they can get some money’. Lack of education and awareness was noted as a primary concern that exacerbates social dysfunction of Somali refugees. A religious leader said, ‘Majority of our people are illiterate. They do not have knowledge and most of the time are not fully informed’.

In addition, Somali clan conflicts, allegiances to kinship groups over others, have divided the country and prolonged hardships, which resulted in vicious consequences, such as mistrust among people, daily struggles with limited support system, dissatisfaction with life and dejectedness. Community members also noted how war trauma from parents and lack of parental guidance led young generations toward violence and gang involvement. A community elder sated, ‘There is no proper guidance from their parents and these leads the youth to take part in gang activities to get a sense of belonging’. Parent focus group agreed and said, ‘Some [boys] do not have parents who can discipline them properly. For those with parents they are neglected. No one cares what they do or do not do’.

Refugee traumas occur and recur in various forms of daily violence, some of which are normalized in the name of culture or religious rules. Consequences of such a vicious cycle of trauma and violence mostly affect the vulnerable among the vulnerable. Children and girls, in particular, are the most susceptible to physical and emotional harms caused by community issues. As a community leader pointed out,

The girl child is mistreated in our community and the problems she faces are domestic conflict, violence, prostitution. Child labor and some of the girls these days run to drugs due to the trauma they experienced. On the other hand, boys also have their own issues like gang involvement and drug abuse.

Multiple issues are left unaddressed due to chronic gaps in resources and systematic impairment of community functions and support. These functional problems are extended to collective and structural challenges at the societal level and vice versa.

Community and societal level: structural challenges

Participants identified a myriad of structural issues caused by war that incubate problems of individual functioning and mental health. Among others, insecurity at community level was reported as the foremost obstacle across all focus groups. As a community elder indicated, ‘All these problems are caused by insecurity and just by being Somalis’. Another community leader espoused the formidable threats of insecurity and said,

Our people are blamed for every explosion in the area. The police, instead of protecting the civilians, kill them and torture them every day. The painful part is that all other communities in the area are not discriminated as much as the Somalis are discriminated.

Structural obstacles, such as restriction in mobility, livelihood and community services, resulted in distress and trouble simply due to Somali refugee status. Somali community stakeholders unanimously viewed lack of legal protection as a major burden to families and individuals. A leader pointed out,

If someone is locked up, no one is there to help them. No one stands up for us. We do not have a government to represent us. Our families are the only ones who suffer for us in all the ways.

In the broader context, community challenges coincide with social discrimination and negative societal atmosphere against refugees and Somalis in particular. The host community often viewed the Somali refugee community as provoking violence and causing insecurity, labeling Somalis as terrorist sympathizers or potential adversaries, which is also aligned with amplified opposition and tensions between two religions (i.e. Somali Muslims vs Kenyan Christians).

Internally, multidecade-long clan conflicts have fractured community connections and solidarity of Somali people devastating lives of Somali refugees. Community breakdown due to clannism was described by a madrasa teacher. ‘There is a lot of misunderstanding between the Somalis. Misunderstanding between the teachers and parents. No connection between the parents and their children. There is no connection among all the Somalis’. Another religious leader strongly agreed and said, ‘Ever since we were young, we were taught about the clans and now clannism is tattooed in our veins’.

Somali refugees search for safety and peace in urban areas as camps turned from a sanctuary into a breeding ground of physical threats and insecurity. However, urban Somali refugees often fall into social margins of urban life, constantly exposed to dual sources of violence: clan and gang violence within the refugee community and law enforcement and local criminals from the host community. As a consequence, community members endure chaos created by layers of violence. A community elder noted,

Politicians and the government [of Kenya] … are inciting divisions. They are able to do something about these problems but they choose to sit back, relax and watch it. Insecurity is skyrocketing. In Eastleigh it is like everyone is just out there to cause harm. Before the start of youth gang groups we have had Kenyan thieves who were terrorizing us and are still doing so. […] Every finger is pointed at our youth but the fact is that parents neglected these children until they turned out to be criminals killing their own kind.

Both functional and structural adversities were closely interwoven and inseparable in many responses. The consequences of social conflicts and war in Somalia deeply affect each and every corner of life from mental disorders to family conflicts and to widespread community malfunctioning. A religious leader said, ‘all these problems are due to the ongoing war in Somalia. Everything that you see happening here has something to do with war in Somalia’. The community stakeholders all noted that a vicious cycle of exposure to trauma and violence plagues the community exacerbating vulnerability and thus mental health of urban Somali refugees.

Impacts of functional and structural stressors

The impact of functional and structural adversities on mental health and psychosocial issues is multifaceted and widespread in the Eastleigh Somali community. Mental health issues were openly discussed as a primary concern among community stakeholders, particularly community leaders and health providers. Common somatic symptoms and issues seen by pharmacists, such as insomnia, headache and muscle tensions, are often attributed to psychosocial struggle. A pharmacist stated, ‘To me, I think it is because of the daily stress people go through’. Another said,

For men, I think it is caused due to financial instability since they try so hard to provide for their family and pay school fees. For many women, it is family conflicts because their husbands tend to marry second wife or so.

Forced migration and family separation further deteriorate emotional health and social functioning. A pharmacist stated, ‘Most of them [my patients] are people who left their homes, their families and belongings in order to find a better life [here]. So, they are having doubled the stress than people who are with their families here’.

As a consequence of unprocessed and unhealed trauma of the community, self-destructive coping mechanisms became prevalent. Substance abuse, among others, was one of the most rampant responses as a threat to mental health issues in the Somali community. The unbearable predicament drives youth, in particular, to become involved in substance abuse to cope with distress while adopting violence to leash their frustration and anger. A community leader said, ‘Every youth in Eastleigh is at risk because majority of these children are traumatized and angry inside. Even the girls are joining gang groups and abusing drugs these days. This is an indication of how severe the problem is’. A traditional healer described how frustrated dream for resettlement can lead to substance abuse and other health concerns:

We are all traumatized. Everybody wants to go to outside countries like America and Europe. They [Somali refugees] would sell their land, their properties, and use all their wealth just to go to these countries, so they leave nothing behind in their country, nothing at all. If they don’t go [to other countries] they are forced to go back to their homes. Now they start using khat [local substance] to forget their problems, they stay awake all night chewing khat and chatting with ‘khat friends’, and they forget their responsibilities and families.

Trauma further impacted by the community’s powerlessness to affect change and resource deficiency led many refugees to utilize substances and gang activity to cope. Intersection of war experiences, stressors of daily living and mental health symptoms were seen in the multitude of functional difficulties within this urban Somali refugee community.

Discussion

Findings of this study revealed multifaceted threats to mental health and constant stressors experienced by urban Somali refugees displaced in Kenya. This study provided a framework of two layered adversities, individual functioning issues and community structural problems, interwoven in the lives of Somali refugees in urban settlement. This study confirmed the strong links between mental health risks and various refugee challenges, such as post-migration stress, discrimination, family disruption and various daily stressors living in social margins as refugee (Ellis et al., 2008; Warfa et al., 2006). The findings show that daily stressors particularly impeded mental health and psychosocial outcomes of the Somali community, while destructive consequences of war linger in the community over generations. Daily struggles with unmet basic needs directly impact not only individual coping and daily functioning but also unity and morals of the community, which invigorates gang membership that replaces clan protection among youth in particular and intensifies community violence (Im, Caudill, & Ferguson, 2016; Roberts, Damundu, Lomoro, & Sondorp, 2009). Profound lack of resources and opportunities creates further physical, mental and behavioral health problems, including substance use and somatic pains (Karunakara et al., 2004). Adverse legal conditions, including restraints of employment and mobility, are also found to impair both mental health and coping mechanism as discussed in many other studies (Araya, Chotai, Joop, & de Jong, 2007). In addition, chronic exposure to community violence is a primary harm to mental health and social functioning in the Somali refugee community in Eastleigh (Roberts et al., 2009). This indicates the importance of approaching mental health in the broader context of community adversities beyond individual and family levels.

Due to lack of proper protection measures for this transitory settlement, Somalis in urban Kenya are deliberately exposed to dual sources of violence: within and outside the refugee community. Often viewed as temporary guests that do not have the right to settle into the community refugees have to endure hostility from local residents who believe refugees are economically advantaged due to foreign aid, which generates unrest between refugees and local residents (Ikanda, 2008). In reality, however, Somali refugees in Eastleigh are rather deprioritized or disregarded by humanitarian agencies or donors due to relatively affluent resources and seemingly lavish environments compared to refugee camps (Sommers, 2001). As the host community views refugees as an economic burden and security concern, xenophobia and discrimination is pervasive, even though evidence shows that urban refugees provide needed human resources through cheap labor and contribute to economy through rental and commercial activities (Grabasky, 2006).

Despite prevalent somatic symptoms, substance abuse, social malfunctioning and unrest, urban Somali refugees in Kenya have little choice in treatment (Polzer & Hammond, 2008) and face service fragmentation and disruption (Gong-Guy, Cravens, & Patterson, 1991). Important to note is that although this refugee population has high incidence of mental health issues, there remains a low usage of mental health resources (Bettman, Penney, Freeman, & Lecy, 2015), leading to a need to extend a focus on mental health to psychosocial support relevant to cultural, contextual and structural needs (Murray, Davidson, & Schweitzer, 2010; Scheppers, van Dongen, Dekker, Geertzen, & Dekker, 2006). This study implies the importance of interventions culturally and contextually responsive to urban refugees whose primary concerns are derived from prolonged exposures to multiple traumas, including pervasive and continued threats of security and daily stressors associated with poverty. Psychosocial interventions aimed at both functional and structural needs, rather than mental health services in silo or Western pathological models, should be placed to address such extensive needs of urban refugees. Chronic displacement with unforeseeable solutions created destitute situations causing health and mental health issues that are chronically unaddressed and untreated. Therefore, policy-level interventions based on multilateral partnerships should be critical in responding to the source of such problems. International communities, both inter-government and non-government, may also assist building local capacity to tackle the issues of vulnerability while promoting resilience of the community through cultural empowerment and durable social development.

This study has a few limitations to be noted. The sampling was based on snowball sampling although inevitable given the difficulty reaching out to this highly mobile and invisible community. Voices from females were less represented in the study findings, given the cultural context of gender disparities that affect the absolute number of available female leaders and providers in the community. The rapid appraisal allowed considerable flexibility and in-depth discussion and yet also a risk of individual biases (Rowa-Dewar et al., 2008). Also, the qualitative study findings well depicted stressors specific to urban refugees, but the extent or pervasiveness of the issues was not fully revealed by this method. For further investigation of epidemiology and situational analysis, a quantitative approach may be necessary for that reason.

To our knowledge, this is the first systematic needs assessment focusing on risks and needs of mental health and psychosocial consequences of community adversities among Somali refugees displaced in urban Kenya. This study verified the existing literatures highlighting the gap between enormous needs for mental health and psychosocial support and scant, inadequate resources systems to address accumulated stressors derived from war and daily adversities that are often indistinguishable. Such challenges, combined with protracted limbo situation of Somali refugees in Kenya, fuel the insecurity and instability of the urban refugee community. Proper attention and measures from both international and local communities are in dare need while developing and implementing contextually sensitive interventions that consider unique needs of urban refugee community.

Footnotes

Acknowledgements

This study is indebted to Somali community leaders and focus group participants in Nairobi, Kenya, as well as the staff of the Tawakal Medical Centre and African Mental Health Foundation, Kenya. We would like to thank Kenya Transitional Initiative (KTI), who provided generous support for this project.

Funding

The author(s) received no financial support for the research, authorship and/or publication of this article.

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