A Cross-National Study of the Role of Neighbourhood Context in the Mental Health of Refugees

We are in the middle of a global refugee crisis with the number of people forced to flee their country of origin as a result of war or persecution increasing at a faster rate than ever before. This is also a mental health crisis with nearly 1 in 10 refugees reported to be suffering post-traumatic stress disorder. Refugees are also more likely to suffer long term severe mental illness, with rates of disorders such as schizophrenia up three times that of the general population. We already know that migrants in general are at a greater risk of mental disorder, and this has been described by some health experts as a public health tragedy. Refugees are at even greater risk although we know much less about what affects their mental health once they arrive than we do for other types of migrant.
However, we do know that the circumstances in which refugees find themselves living can make a difference to their mental health. This is particularly important because, while we cannot alter the traumatic events that caused refugees to flee their home country, we can influence their present circumstances. This does, however, depend on our having a good understanding of what matters for refugee mental health and this is the motivation for the present study.
The research will concentrate on the kind of areas in which refugees live and how neighbourhood characteristics might be important for their mental health. This matters because refugees often have little or no control over where they live and, from what we know based on research looking at migrants in general, living in certain types of neighbourhood affects their mental health. A large number of studies have shown that migrants in areas where there are fewer people from their own ethnic background show higher rates of mental disorder. We also know, from studies of the general population, that certain types of neighbourhood; typically, those that are more urban, more deprived and less stable; are associated with poorer mental health. These are often exactly the type of area that refugees find themselves living in. However, no studies until now have looked at how refugees might be affected by the place where they live.
The proposed research will investigate this in a number of ways. The first part of the study will use health records collected for all refugees arriving in Denmark as children over roughly a 30-year period. This will be linked to a range of data sources allowing us to build up a picture of how the neighbourhoods in which they are living might influence their mental health. I have chosen Denmark because this is one of the few countries with available data about refugee mental health collected on a large scale over a long time period and previous studies show the effect of neighbourhood on mental health to be similar in Denmark and the UK. Denmark also has a refugee dispersal policy that means refugees are sent to live in a wide variety of different neighbourhoods, as in the UK, the effect of which can then be compared.
The second part of the study will look at refugees in the UK, concentrating on one refugee group (from Somalia) in one specific area (Lambeth, South East London). Somalis are one of the largest refugee groups in the UK and this part of the study will examine their experiences looking at the same questions as the Danish study but using much more detailed local data. We will use GP records for all patients in the borough that have also been linked to psychiatric records and census data telling us about the type of area where they live. Health records are limited in what they can tell us about the underlying reasons why where people live effects their mental health. Therefore a third component of the research will involve interviewing Lambeth Somali residents to find out more about how they view their neighbourhood and what they think is important about neighbourhoods for mental health and wellbeing.

This will comprise three main study components:
Study 1. Danish Natural Experiment
I will use whole population cohort data in Denmark to take advantage of the random allocation of refugee housing - in effect creating a natural experiment. This will allow me to examine the effect of the following neighbourhood characteristics:
1) ethnic density, 2) urbanicity, 3) deprivation and 4) social cohesion
on the incidence of the following mental disorders among refugees:
1) psychosis, 2) depression/anxiety, 3) PTSD
I have chosen Danish register data as this covers the entire population (including records for 18,000 refugees over up to 27 years), refugee status can be accurately identified and studies have shown comparable neighbourhood effects in Denmark and the UK.
I will then examine the overall effects of a dispersal policy on refugee mental health using the Danish data.
Study 2. Somali refugees in Lambeth, South East London
I will also examine whether relations between the same neighbourhood factors and mental health outcomes in study 1 similarly to Somali refugees in a local UK context.
This study will use a dataset comprising GP and psychiatric records linked to census data at LSOA level covering the London borough of Lambeth. Comprehensive recording of country of birth means that this can be used to accurately identify Somali refugees (N=3,200).
Study 3. UK local qualitative study
I will also conduct a qualitative study investigating the same Lambeth Somali population to:
1) investigate underlying processes that mediate between neighbourhood risk factors and mental health outcomes through qualitative research with a refugee population in a UK context
2) investigate other neighbourhood risk factors not accounted for in the previous analyses
and 3) generate further hypotheses to be tested with quantitative data.
The results of the UK local qualitative study will therefore inform further analysis of the data collected in study 1 and 2.

The proposed research will provide evidence for the role the neighbourhood environment plays in the mental health of refugees - a group already shown to be at greater risk of psychiatric morbidity compared to the general population and also other migrants. Migrant studies have shown the neighbourhood environment to be a relevant and important factor for long term mental health although little is known about how this might apply to refugees. This project will have a significant impact for two reasons: firstly, it will provide information about mental health risk factors for refugees, a group that is typically hard to access on a large scale using routine clinical and survey data; and, secondly, it will provide information about the importance of the neighbourhood in which refugees live, an area of research that has received very little attention to date. The study findings from the proposed project will therefore have an impact on refugees, clinicians and policy makers, as follows:
1) Refugees - an improved understanding of modifiable risk factors for this group will ultimately contribute to better treatments, provision of care and ultimately better outcomes, particularly over the long term. Furthermore, better mental health is associated with better economic outcomes and better opportunities for integration.
2) Clinicians and health service providers - firstly, the study will provide novel sources of information on the prevalence and incidence of different mental disorders for refugees and information about relevant risk factors. It will add to the existing evidence base using a novel resource, GP records which, to date, have not been used to identify a refugee population. Secondly, the study will provide useful information on geographical variation in the rates of disorder among refugees which is relevant for service provision. For example, at a local level, this will involve mapping rates of mental health problems among the Somali community in Lambeth. Thirdly, by providing a better understanding of the relevance of neighbourhood risk factors the study results can inform decisions regarding accommodation where clinicians have some input.
3) Policy makers - the proposed study will, for the first time, provide comprehensive information about the effect of dispersal policies on the mental health of refugees which will have direct relevance for policy makers concerned with refugees and asylum seekers. Dispersal policies are commonly implemented across Europe (Andersson 2003) therefore the project will have international relevance for policy makers. The project will also provide information about the relative contribution of different neighbourhood factors to the mental health of refugees which can help guide housing policy for this group.
4) Voluntary sector organisations / local authorities providing housing and social care for refugees - a better understanding of the role of neighbourhood factors would better inform the work of these organisations both in terms of where to allocate housing and also how to ameliorate environmental risk factors for those already housed. For example, if isolation appears to be a factor for groups identified in study 2 and 3 then this could inform the work of local organisations concerned with the welfare of the Somali population in both South East London and elsewhere in the UK. For example, the location of a befriending service or other social support interventions could be informed by the present study results.
5) Wider public -the welfare of refugees is a topic of general concern and this study will contribute to an improved understanding of how best to accommodate this group into our society.