Community-Based Approaches to Understanding Refugee Resettlement and Mental Health:

1
Community-Based Approaches to Understanding
Refugee Resettlement and Mental Health
Philadelphia Refugee Photovoice Project Ellen J
Plumb, Melissa Fogg, Anna Escuder, Christie
Mulholland, Michael Cafarchio, James D Plumb,
Rickie Brawer Thomas Jefferson University
Hospital, Department of Family and Community
Medicine, Center for Urban Health Lutheran
Children and Family Service
INTRODUCTION
RESULTS
Opportunity
Refugees are a population at high risk for mental
health issues due to pre-migration, migration,
and post-migration stressors. The Philadelphia
Mental Health Collaborative is a citywide
coalition aimed at identifying and developing
refugee mental health services in Philadelphia.
Through this innovative Collaborative,
Philadelphia area refugee resettlement agencies,
community-based arts organizations, and refugee
clinical care providers have partnered to develop
culturally and socially appropriate mental health
programming for disparate refugee populations
that address and reflect the complexity of the
resettlement process.
Panda Jar I thought when I came to the U.S. that
I would have a better job and better salary.
While it was not comfortable to live in the
refugee camps in Malaysia, we did not have to pay
bills there. In Philadelphia, there are so many
bills to pay. I keep them in this jar.
Jungle Fingers This represents my brother and I
fleeing through the jungle from Malaysia. We
followed an uncle from our village to the refugee
camp. We were only 14 and 15 years old and we
were very scared.
Recruitment
Camera Training
Small Group Discussion
Sharing Stories
Welfare Building This is the welfare office,
where many refugees go to receive support for
healthcare and other services. It is very
difficult to get our benefits, especially when we
do not speak English well. Refugees who are
fluent in English often accompany other refugees.
It can take 2-3 hours per trip and many refugees
are not aware of their benefits.
ENVISIONING HOME EXHIBIT CATEGORIES
OBJECTIVES
Mural of a Statue I like the woman in this mural.
She describes life here. She has to carry heavy
things. There are a lot of hard things in our
life here but if we try hard we can make it. We
must be insistent to carry our burdens, have
patience, and think of our future.
Honoring Our Roots-Culture  The traditions that
are distinctive of the individual's native
country. These aspects include clothing, food,
religion, art, and history. Where the Heart
Is-Family  The relationships, activities, and
stresses of daily life. Between Earth and
Sky-Environment  How individuals perceive and
engage with the world around them. Building
Futures-Opportunity  The opportunities and
struggles experienced in the pursuit of growth
and prosperity for individuals and
families.  

• The purpose of this study is to conduct a
  community-based assessment of mental health needs
  in Iraqi, Burmese, and Bhutanese refugee
  resettlement communities in Philadelphia using
  the Photovoice methodology in order to
• Identify migration and resettlement stresses that
  affect mental health and identify social,
  environmental, and cultural determinants of and
  concepts of mental health in Bhutanese, Burmese,
  and Iraqi refugee families
• Gain a greater understanding of community
  development among refugee communities resettling
  in Philadelphia.
• Develop socially and culturally appropriate
  mental health services for refugee populations in
  Philadelphia

Culture
DISCUSSION
Although still in progress, this Photovoice
project is providing important information about
the resettlement experiences of Philadelphia-area
refugees and guiding efforts to provide quality
mental health care and services for disparate
populations in transition in a clinical
environment characterized by limited
socio-cultural knowledge, communication
challenges, insurance issues, and systems-level
inefficiencies. The data collected is allowing us
to address these quality of and access to care
issues and answer important clinical questions,
such as When is the best time to screen for
mental health in refugees? Who is the best
provider for mental health in this population?
Where is the best place to provide mental
healthcare for these communities? What is a good
model for mental healthcare for disparate refugee
populations in Philadelphia. . This Photovoice
project has also provided a foundation for
innovative academic-community partnerships
between Philadelphia area social service
agencies, arts-based organizations, and clinical
care providers. Through these partnerships, there
has been a movement towards more culturally
appropriate and community-focused mental health
initiatives, including implementation of a
refugee mural arts project by the City of
Philadelphia Mural Arts Program and the
development of a new community center with
programming focused on community empowerment,
preservation of cultural heritage, and economic
development. Most importantly, the photographs
and stories created by refugee participants as
part of this Photovoice project will continue to
be used to generate awareness of mental health
and resettlement stress among refugees and
advocate for policy-level changes aimed at
improving access to mental health services for
these populations.
RESEARCH APPROACH
Cemetery This is a cemetery. Cemeteries are very
different here. They are like heaven, like a
garden. Death is not a terrible thing here. In
Iraq, everyone is scared of death. The cemeteries
are very large and almost full. So many people
have been killed.
Face in Shadows This womans mother died. She is
sitting alone in the darkness mourning her death.
No-one is allowed to touch her during the 13 days
of mourning.
Ceremonial Feast  When a new baby is born in our
culture, we celebrate. After 11 days, we have a
baby naming ceremony, Nuran. We invite friends
and family for food. Here we are free to have
these ceremonies.
Community Based Participatory Research (CBPR)
Approach is characterized by the equitable
involvement of researchers and community members
in the research process. The main goal of CBPR is
to develop community health programs that address
and recognize differences in culture, health
beliefs, and disease presentations.
Family
Mother in Law This is my mother in law. For the
first 10 days that she was here, she was feeling
depressed. She feels like there is no life here,
like no-one is related to each other and everyone
is busy. She wasnts to go home. She feels strange
here.
Father at Home My father is new here. I came here
two or three months before he came here. My
father is old, so he doesnt have a job. Being
old, he cannot walk around the street so he is at
home. He is isck, so he cannot do any work.
RESEARCH METHODS

• Photovoice, a community based research
  methodology, is a process by which people can
  identify, represent, and enhance their community
  through a specific photographic technique, and it
  has three main goals
• enable people to record and reflect on their
  communitys strengths and concerns
• promote critical dialogue about important issues
  through large and small group discussion of
  photographs
• to reach policymakers.
• Multi-Step Process training with camera, taking
  photographs, choosing photographs, large and
  small group discussions (focus groups), creating
  a narrative, telling a story
• Recruitment through referrals from resettlement
  agencies and providers

Environment
Sneakers When I moved here, I noticed the shoes
hanging on the telephone wires. I cant believe
how wasteful that is! Shoes are expensive. We did
not understand that this was a symbol for a drug
corner. This is outside of an elementary school.
Trash There is a lot of garbage thrown on my
block and in my neighborhood. We do not
understand why people throw garbage on the
ground-we thought America was a clean, beautiful
place.
Acknowledgments
Lutheran Children and Family Services,
Philadelphia Mental Health Collaborative,
Jefferson Family Medicine Residency Program,
Magic Gardens Philadelphia, City of Philadelphia
Mural Arts Program, BuildaBridge, First Person
Arts