Background

Refugees commonly experience trauma, such as social conflicts and violence, witnessing tragic deaths, torture, forced confinement, and numerous human rights violations [1,2,3], which likely increases risk for various mental health issues and disorders [3, 4]. In fact, more than one in four refugees who have been exposed to mass conflict report posttraumatic stress disorder (PTSD), and more than one in four report symptoms of major depressive disorder [5]. In a recent review [6], asylum seekers and refugees reported high rates of depression, anxiety, and PTSD (all up to 40%), despite variation across settings (e.g., displacement or resettlement, high- or low-income countries). In addition, psychiatric disorders are notable when assessment includes mental illness beyond common mental disorders. In a German study with refugees from Syria, Iraq, and Afghanistan, 27% of those receiving neurological emergency services reported a non-epileptic seizure or psychiatric disorder, which is much higher than the 15% prevalence in native Germans [7].

Although mental health issues are more prevalent among refugees, mental health care for refugees resettled in the U.S. is sometimes neglected due to multiple challenges in service provision [8]. The concept of mental health care and psychotherapy are foreign in many refugee communities [9, 10], and mental health is a stigmatized issue in refugee communities [8,9,10,11]. In addition, service providers face challenges related to lack of capacity for culturally-responsive and -relevant services in many refugee-serving agencies. Service providers in human and social services, as well as medical settings, often lack an understanding of refugees’ cultural background and unique mental health challenges and needs [12,13,14]. Additionally, linguistic and cultural barriers keep refugees from accessing mental health services [15]. Refugee mental health interventions are the most effective when they are culturally- and linguistically-sensitive and specific to refugee groups [16]. However, even refugee resettlement agencies, who may be equipped with better cultural and linguistic competency than most social or mental health services, struggle to recognize and respond to refugee mental health needs.

Despite these barriers to care, there are few training modules or opportunities that are directly relevant to refugee mental health needs. Two well-known training programs available to refugee-serving professionals are training on the refugee health screener (RHS-15) [17] and mental health first aid training (MHFA) [18]. RHS-15 training is provided to refugee nurses who conduct refugee medical screening and to some refugee resettlement staff for referral purposes. Although this training can help with early detection of common mental disorders (CMDs), the contents are limited to basic screening and do not sufficiently prepare providers to understand and respond to refugee mental health needs. MHFA training has been delivered to refugee community leaders [19] but has limitations in addressing mental health stigma and building hands-on competencies for service providers in the community because it was developed as psychoeducation for those with mental disorders and their caregivers [18]. The curriculum is also not tailored to a refugee population, making it irrelevant or even culturally insensitive when it comes to meeting urgent issues of access to care and stigma. Additionally, many structured training programs including MHFA are costly and dependent on the availability of culturally-competent trainers who understand refugee contexts or acculturative challenges. Sustainable options are needed to ensure that mental health training is affordable and available to refugee service providers in various settings. Given such gaps, the authors developed a tailored training program that helps refugee service providers build competencies related to trauma-informed care in cross-cultural settings and community partnerships for referrals and coordination of care. The current study aims to identify refugee service providers’ mental health training needs and to evaluate the training program in building competencies and providing tools and resources to refugee-serving professionals and refugee community leaders.

Conceptual Framework

In order to address the gap in culturally-competent trauma-informed care in refugee resettlement services, the first author developed an interactive training curriculum based on Herman’s trauma recovery model [20] and Substance Abuse and Mental Health Services (SAMHSA)’s core principles of trauma-informed care [21]. The training curriculum is comprised of two pillars: (1) trauma-informed care and (2) culture-informed care. The trauma-informed pillar is based on the idea that trauma can affect entire refugee communities, and interventions must address this trauma across all types of services and care in the community. The culture-informed pillar is based on the idea that culture influences refugees’ trauma experiences and help-seeking; thus, to provide appropriate mental health care, providers must apply or embed culturally-sensitive supports to their services. Together, these pillars form the cross-cultural trauma-informed approach to refugee mental health and wellness, which aims to guide stratified interventions and services for refugees and to build healing partnership among refugee-serving providers.

Methods

Cross-Cultural Trauma-Informed Care (CC-TIC) Training

The Cross-Cultural Trauma-Informed Care (CC-TIC) training was developed based on the first author’s psychoeducation manual on trauma and culturally-specific, as well as general, mental health topics in the context of refugee resettlement [22]. The training, which was delivered over two consecutive days, consists of eight 1.5-h-long sessions, followed by a one-hour reflection and discussion session. The contents involve knowledge building (e.g., mental health terms, refugee trauma and its sequelae, refugee mental health issues, and cultural expressions of distress) and skill building (e.g., psychoeducation, listening skills, systems of care and multi-tiered intervention, community-based interventions, grounding and mindfulness, and self-care). The training contents were slightly modified for each site to meet unique as well as common needs in each locality. For example, a session on integrated care was included when many healthcare providers attended, while more contents on complex trauma were added when the community recruited providers in school settings and family services. The training was delivered by the first author at five sites in two states, over a two-year period, and was hosted by national agencies responsible for state-wide refugee health promotion programs. One site offered the training twice, once in 2018 and again in 2019 with slightly different topics. Table 1 shows the comprehensive list of training topics per locality. Of note, each locality has different resettlement patterns. When providing the training, the authors aimed to focus on the major refugee ethnic and cultural groups that each site has resettled. Most of the sites have many refugee groups in common, which include Afghan, Bhutanese, Congolese and Karen/Karenni.

Table 1 List of training topics per locality
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Data Collection

After each CC-TIC training, participants were asked to reflect on the training experience and assess their competencies retrospectively. Retrospective study refers to data collected about interventions or programs that happened in the past [23]. While retrospective designs may introduce bias based on participant recall [24, 25], they can allow for longer observation periods [26], greater generalizability [27], and more cost-efficient data collection [27, 28]. Studies have found that retrospective designs produce adequately valid and reliable results [29,30,31] and provide information that may be less objectively true but still important [32]. We adopted this methodology as it can allow participants to conscientiously evaluate their baseline knowledge and competencies, especially related to new subject matters, by decreasing the possibility of overestimating baseline understanding [23, 33].

As such, we used retrospective study to assess participants’ pre- and post-test knowledge related to refugee mental health and psychosocial support. We embedded this retrospective pre-and post-training evaluation (RPPE) into a mixed-methods design. First, we had participants free list three training needs to explore gaps in capacity for refugee mental health care. Then, we used RPPE to assess participants’ knowledge and skills in refugee mental health before and after the CC-TIC training. We included seven items measuring core competencies at every site (e.g., refugee trauma and mental health and trauma-informed and culture-informed care) along with four to five additional topics that were tailored to each training site. Along with the structured RPPE items, we added four open-ended questions, related to the most helpful topical areas, remaining gaps, applicability of the training, and suggestions for future training. The study was exempted from IRB review by the authors’ institution as the training evaluation was conducted by the hosting agencies for the purpose of program evaluation and no identifiable information was obtained for the assessment.

Participants

The CC-TIC training aims to improve mental health competencies for not only mental health professionals (e.g., clinical psychologists/social workers and mental health nurse practitioners/counselors) but also non-mental health care providers, including refugee resettlement staff, public health nurses, school liaisons/coordinators, caseworkers, community health workers, and refugee community leaders, volunteers, and interpreters. Participants self-reported their profession. They were given 12 response options which were then grouped into three categories: (1) mental health provider, (2) refugee resettlement worker, and (3) other [collapsed from the remaining 10 options: healthcare provider (nurse practitioners, physicians, etc.), social services, interpretation, medical liaison/community health worker/medical case manager, teacher/school social worker/provider in school settings, university researcher, refugee program supervisor (government, state coordinator, etc.), refugee community leader/volunteer, community-based organization, or other]. A total of 175 people registered to attend the training (Locality A: 79 registered; Locality B: 42 registered; Locality C: 16 registered; Locality D: 18 registered; Locality E: 20 registered). While a few individuals who registered for the training did not attend, our estimated number of across-site training attendees is 175. A total of 140 participants completed the free listing exercise (estimated response rate of 80%), and 128 participants took the survey (estimated response rate of 73.14%), with 120 participants providing complete survey answers (estimated response rate of 68.57%). Descriptive statistics are provided in Table 2.

Table 2 Descriptive analysis of evaluation data, across six sites
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Data Analysis

The free listing data and open-ended questions were analyzed using conventional content analysis [34]. Participants’ responses were grouped into themes and categories, which were compiled to broader domains across the six training localities. For the RPPE data, we ran descriptive statistics including demographic variables and frequencies of evaluation items, followed by a series of t tests, correlations and ANOVAs to determine the average change in pre- and post-test scores according to different professions and former training experiences. All the quantitative analysis was performed in SPSS Win Ver. 24.

Results

Free Listing of Training Needs

The free listing data is shown in Table 3. We identified six overarching themes in the training priorities listed by the study participants: (1) refugee interventions and programs, (2) refugee trauma, (3) refugee service resources, (4) refugee resettlement challenges and needs, (5) provider networking, and (6) other. Of the 140 participants, most (83.6%) listed refugee interventions and programs as one of their top three training priorities. Most participants (56.4%) also reported learning about refugee resettlement challenges and needs as a training priority. Table 3 also shows subthemes within each of the six themes.

Table 3 Topics of training needs for refugee mental health care and services (N = 140)
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RPPE Data

The total and individual-item means for the evaluation data are shown in Table 4, along with the t test results and average change in pre- and post-test score. All t tests were significant at the pre-determined cutoff point of 0.05. For the seven core competency items included in the survey for all six localities, the average change in total core competency score was 8.35 (t[119] = 15.078, p < 0.001). The pre-test to post-test change in individual core competency score ranged from 0.80 (basic mental health terms) to 1.71 (multi-tiered model for refugee mental health and psychosocial support. Table 4 also shows four of the tailored competencies, each of which was included in at least three localities.

Table 4 Items and mean scores for pre- and post-tests, across sites and competency domains
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Open-Ended Responses

Analysis of the four open-ended survey questions revealed a set of themes. The most common theme regarding the most helpful contents (N = 128) was refugee trauma and trauma-informed care (n = 56, 43.8%), followed by cultural competency and cultural idioms of distress (n = 40, 31.3%), and partnership building (n = 35, 27.3%). Others reported mental health symptoms and clinical skills (n = 19, 14.8%), self-care (n = 10, 7.8%), and the multi-tiered intervention model (n = 5, 3.9%) as the most beneficial topics. Regarding remaining gaps (N = 128), most participants skipped a response or reported that all topics were clear (n = 17, 13.3%). Participants requested extended training on community partnership building (n = 25, 19.5%), trauma recovery (n = 12, 9.38%), techniques of mental health assessment and interventions (n = 11, 8.6%), the multi-tiered programs (n = 7, 5.5%), and self-care (n = 2, 1.6%). Analysis of the applicable topics and future training needs are detailed in Table 5.

Table 5 Analysis of open-ended questions on applicable topics and future training (N = 128)
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A series of t tests comparing the average change in pre- and post-test scores by prior mental health training (yes = 101, no = 23) revealed a greater change in total common competency scores (t[115] = 3.070, p = 0.003) for those without prior mental health training (M = 11.55, SD = 6.30) than for those with prior mental health training (M = 7.35, SD = 5.66). The areas of competencies showing the most improvement among those without prior training included: mental health term knowledge (t[118] = 2.917, p = 0.004), refugee CMD knowledge (t[119] = 2.055, p = 0.042), psychoeducation knowledge (t[119] = 4.438, p < 0.001), tiered model knowledge (t[118] = 2.556, p = 0.012), and trauma-informed knowledge (t[119] = 2.577, p = 0.011.). There was no significant difference in change in refugee trauma knowledge (t[119] = 1.498, p = 0.137) or cultural influence knowledge (t[27.10] = 1.669, p = 0.107) based on prior mental health training. We also did not find meaningful differences in competency scores across localities except for: (1) site B (M = 22.90, SD = 3.76), which had a significantly higher total common competency score at pre-test (F[5,115] = 2.626, p = 0.027) compared to Sites C (M = 16.07, SD = 5.32) and D (M = 15.11, SD = 4.65) and (2) Site A time 1 (M = 26.22, SD = 3.39), which had a significantly higher total common competency score at post-test (F[5,114] = 3.127, p = 0.011) compared to Site A time 2 (M = 23.81, SD = 3.48).

Table 6 shows the results of a series of ANOVAs comparing the average change in pre- and post-test scores by profession. These results indicated that the mean change in score was significantly different for mental health providers when compared to refugee resettlement workers and other professions for all core competency items except for refugee trauma knowledge.

Table 6 Items and mean scores by profession, across sites
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Discussion

The aim of this study was twofold: (1) evaluation of the effectiveness of refugee mental health training for refugee service providers and (2) exploration of needs and challenges in building competencies for refugee mental health. First, the retrospective self-assessment shows how two-day intensive training can build competencies to help understand and respond to refugee mental health needs. Though mental health professionals reported significantly higher competencies in overall topics prior to the training, the reflective post-training scores showed marginal differences across professions, and non-mental health professionals attained a good level of understanding in mental health topics and foundational skills that are crucial to trauma-informed services. It is also notable that mental health providers often do not receive professional training on trauma-related topics [35, 36], let alone specifically on refugee mental health. T In fact, mental health professionals reported the low baseline scores on refugee CMDs, cultural influences on trauma and mental health outcomes, multi-tiered interventions, and trauma-informed care in this study. Although most participants (79%) reported previous mental health training, there was no significant difference in preexisting knowledge of how trauma and culture intertwine to shape mental health and refugee CMDs. The amount of previous experience (i.e., time) working with refugees also did not affect training outcomes in core competencies except for self-assessed general confidence prior to the training, which corroborated that work experiences alone do not build competencies in how to respond to refugee mental health needs. This implies significant gaps in currently-available training for refugee-serving professionals and a lack of culturally-responsive and -sensitive mental health training not only for those without mental health backgrounds but also for mental health professionals with formal training and direct practice experience.

This study also sheds light on current needs and challenges in refugee mental health training and proposes future suggestions and strategies for building capacity for trauma-informed care for refugees in various service settings. Knowledge and hands-on skills for refugees with mental health needs were of the highest demand, followed by resettlement-related mental health needs and cultural knowledge to provide culturally-responsive and contextually-relevant programs. Reportedly, mental health professionals showed higher competencies in overall mental health knowledge and skills and less understanding of culture-specific needs and resettlement contexts, while refugee resettlement staff and community leaders presented the opposite patterns. Though mental health professionals take a critical role in community capacity for trauma-informed care and refugee mental health services [37, 38], the findings of this study also emphasize the importance of collaborative and coordinated care. Participating in the training with a heterogeneous group provided insight into refugee mental health supports and situated individual programs in a broader system of care beyond segmented interventions, also helping to overcome pathologization of normal grieving processes and acculturation distress in the refugee community.

Participants highly valued mutual learning and networking opportunities throughout the CC-TIC training, which corroborates the synergic effects suggested by previous training models to promote interprofessional learning [39] and mutual empowerment through intercultural communication and advocacy [40, 41] in community settings. This format promotes a public health approach and the principles of trauma-informed care, which underscores awareness of trauma impacts not only in the refugee community but also among caregivers and service providers and emphasizes collaborative care and partnership building across service sectors to overcome challenges in mental health stigma, cultural and linguistic barriers to services, and other psychosocial issues that obstruct mental health care (e.g., transportation, insurance and eligibility, literacy, etc.) [42]. As previous research points out [43, 44] training alone may not suffice to build collaborative care across agencies and service settings. This study shows that capacity-building efforts allow an open platform to discuss common challenges across communities of practice and to reorient gaps in knowledge and skills on an individual level to advocacy and partnership at organizational- and community-levels. Regardless of localities, participants were enthusiastic about the idea of providers’ networks or partnership meetings to regularly discuss refugee mental health issues despite such challenges as lacking buy-in or internal supports from leadership, few resources for community-wide action, and limited inter-agency accountability.

As a naturalistic evaluation study, this research has some limitations to consider. The study was conducted as part of program evaluation by two state-wide refugee health programs and turned into a case study of five resettlement sites with no comparison groups. Follow-up to track how participants retain and utilize training competencies would be beneficial and is the next step of this study. Retrospective measures were efficient in this study due to limited self-awareness on unknown topics (e.g., cultural humility); however, future research may consider adopting a conventional pre- and post-test design to assure improvement in competencies over time. Also, an in-depth study on how partnerships can be built across mental health fields and psychosocial programs would help design an effective community partnership or coalition model addressing common refugee mental health challenges beyond services working in silo.

New Contribution to the Literature

This study contributes to the field by addressing gaps in knowledge related to mental health training and capacity building in the context of refugee resettlement services. We developed and implemented training on refugee mental health that is culturally sensitive and contextually relevant to service environments, which fills gaps in the field related to lack of appropriate trainings for refugee-serving staff. We have also proposed an innovative training approach that emphasizes mutual learning and partnership building opportunities. The culturally-responsive trauma-informed approach helps bridge gaps between mental health care and psychosocial services in current refugee resettlement program, which can promote exchanges of knowledge and expertise to build collaborative care and community partnership.