Ethiopian diaspora London.pdf

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A content analysis of oral narratives exploring factors which impact on, and contribute to, the mental ill health of the Ethiopian diaspora in London, UK David Palmer

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SSPSSR, University of Kent Published online: 19 Feb 2011.

To cite this article: David Palmer (2011) A content analysis of oral narratives exploring factors which impact on, and contribute to, the mental ill health of the Ethiopian diaspora in London, UK, African Identities, 9:01, 49-66, DOI: 10.1080/14725843.2011.530445 To link to this article: http://dx.doi.org/10.1080/14725843.2011.530445

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African Identities Vol. 9, No. 1, February 2011, 49–66

RESEARCH ARTICLE A content analysis of oral narratives exploring factors which impact on, and contribute to, the mental ill health of the Ethiopian diaspora in London, UK David Palmer*

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PhD student, SSPSSR, University of Kent (Received 5 February 2010; final version received 21 May 2010) This paper reports on a content analysis undertaken on oral history narratives with Ethiopian forced migrants residing in London. The study adopted a grounded theory approach to examine factors which impacted on, and contributed to, mental ill health for those forced migrants who participated. This research suggests that the issues and impact of deprivation, combined with the complex interaction of social and psychosocial factors, are crucial in impacting on mental ill health. It is apparent for those participants that economic deprivation, poor housing conditions and the immigration asylum process can exacerbate existing, as well as creating new, psychological stressors and in many cases has acted as a barrier to integration. This analysis identified themes and concepts and developed an integrated approach which acknowledged the multitude of social, political and administration factors which can significantly improve quality of life for Ethiopian forced migrants. Keywords: Ethiopian; forced migrants; mental health; oral history; grounded theory; content analysis

Introduction: the context and study development A review of the limited literature available revealed that the psychological health of Ethiopian forced migrants1 seems to be negatively affected by the migration and settlement process and this group is particularly disadvantaged in relation to accessing and engaging with Western service provision. Danso (2002) in his important research in Canada purports that Ethiopians encounter considerable difficulties when attempting to resettle. This research concludes that they face social exclusion and multiple forms of disadvantages including high unemployment, underemployment, and overcrowding, as well as frustrations and despair that sometimes result in suicidal behaviours, particularly among the young males (Danso 2002). Similar findings have been documented by Beyene (2000) and McSpadden (1987) in her study of Ethiopians in Washington. Fenta et al. (2004) in ‘Determinants of depression among Ethiopian immigrants and refugees in Toronto’ reported that the prevalence of depression amongst Ethiopian migrants is significantly higher among respondents who experienced pre-migration trauma, refugee

*Email: [email protected] ISSN 1472-5843 print/ISSN 1472-5851 online q 2011 Taylor & Francis DOI: 10.1080/14725843.2011.530445 http://www.informaworld.com


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camp internment, and reported higher frequency of post-migration stressful life events, and higher racial discrimination scores. Evidence available from the limited research in the UK suggests that poor access and engagement with health care provision is a major problem for the Ethiopian community (Papadopoulos et al. 2004). In the same study, Papadopoulos also indicates that this group have problems with the process of acculturation in their new society which is also linked to higher prevalence of mental ill health (Papadopoulos et al. 2004). Providing mental health care provisions for refugees is challenging. This can be for many reasons, most notably language and cultural barriers as different cultures may have different views about recovery and mental illness (Duke 1996, Harris and Maxwell 2000). Western training programmes for mental health professionals rely on biomedical models and Western diagnostic categories which focus on disease, treatment and biological reductionism and do not fully take into consideration cultural differences and psychosocial factors which may impact on accessing and engaging with services (Littlewood and Lipsedge 1997, Fernando 2002). This study adopted a grounded theory approach to examine factors which according to participants impacted on, and contributed to, mental ill health. The primary aim of this study presented here is to explore some of the difficulties and challenges experienced by the participants in their attempts to settle in the UK and to expand understanding of the impact that psycho-social factors have on mental health experience and contribute to the limited literature on the Ethiopian diaspora. The findings present some suggestions for general practice. My own interest in the subject of migration has developed through my professional experience of researching, working and engaging with forced migrants and Ethiopian London-based refugee community groups in particular. This pre-existing knowledge and experience could potentially conflict with a grounded theory approach, it is however a common misassumption that grounded theory ‘requires a researcher to enter the field without any knowledge of prior research’ (Suddaby 2006, p. 634). Glaser (1978) discusses the issues of existing theory and previous knowledge with regards to grounded theory and argues that pre-existing knowledge and data should in fact be used to ask questions in the interview that will create links. Glaser (1978) argues that existing theories should be used as if they were another informant, as without this, studies would be superficial. Without prior knowledge research would result in a ‘mass of descriptive material waiting for a theory’ (Coase 1988, p. 230). I have tried to work within this approach, and acknowledge that the reality of grounded theory research is always one of trying to achieve a practical middle ground between a theory-laden view of the world and an unfettered empiricism. This study is both explorative and interpretative and is primarily structured around the analysis of oral narratives, a further aim is to add to the very limited knowledge base on oral history and data analysis. The work of Jennifer Clary-Lemon (2010) highlights the need to expand the theory and discourse in terms of oral history and data analysis noting that there is very little scholarship that ‘links discourse analysis and oral history data’ (p. 6). Interviews were undertaken during 2007 and 2009 as part of an oral history PhD study on forced migration and Ethiopian settlement and adaptation experiences in the UK. The data analysis adopted for this research was a content analysis based on grounded theory which enables themes to evolve and develop and offers insights into settlement experiences and mental wellbeing for those who participated in the project. It is important to note that there is no systematic attempt to produce a generalisable sample from this study as the sample of interviews undertaken was small and interpretations are only related to this study (Glaser 1978). Although interviews were in-depth and the exploration

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thorough, the analysis did cease when the meanings, experiences and categories felt saturated (Guest et al. 2006). It is apparent for the participants in this research that economic deprivation, poor housing conditions and the immigration asylum process can exacerbate existing, as well as creating new, psychological stressors and in many cases have acted as a barrier to integration. The methodological approach adopted for this research identified concepts and developed an integrated approach which takes into account the multitude of social, political and administration factors, which could significantly improve quality of life for Ethiopian forced migrants residing in the UK.


The Ethiopian diaspora: demographic, political and social context Ethiopia is the second most populous country in sub-Saharan Africa, with a population growth rate that is amongst the highest in the world (Alene and Worku 2009). Technically diverse, there are more than 80 cultural and linguistic groups that live together in Ethiopia. The major ethnic groups include Amhara, Oromo, Tigrean, Sidama, Shankilla, Gurage, Somali, and Afar. The dominant religions are Christianity (mainly Ethiopian Orthodox) and Islam. Located on the Horn of (East) Africa at the Red Sea, Ethiopia shares borders with Sudan, Somalia, Djibouti, and Kenya. Over the past half century, the Horn of Africa has played host to some of the world’s deadliest conflicts. During the last 25 years more than a million Ethiopians have been displaced within the country and an estimated 1.25 million have fled to neighbouring countries (McSpadden and Moussa 1993). Before the 1973 military coup there were very few Ethiopians living in Western countries. It is estimated that there are now 25,000 – 30,000 Ethiopian refugees in the UK, most residing in inner London boroughs (Papadopoulos et al. 2004). The specific and complex experience of refugees, as different from other migrants, requires a more precise conceptual framework in which their specific transnational social relations can be described. This research found that the Ethiopian community matched the criteria for a diaspora presented by William Safran (1991) as discussed by Wahlbeck (2002) in the following ways: . They have been dispersed to foreign regions. . They retain a collective memory about their original homeland reflecting a complex level of attachment to their homeland. . They feel partly alienated and insulated from the host society emphasising the wider context of disadvantage and hardship with an overall sense that the ‘community’ feels itself at the margins of UK society. . They regarded their homeland as an ideal with a clear intention of returning when conditions were appropriate. The formation of the Ethiopian community as referred to in this paper represents the Ethiopian diaspora and refers to all those who have come to the UK via Ethiopia. The concept of ‘community’ is not in itself unproblematic. Anderson (1983) refers to transnational and disaporic communities as ‘imagined communities’, a concept coined which states that a national community is socially constructed, which is to say imagined by the people who perceive themselves as part of that group (Anderson 1983, pp. 6 – 7). The Ethiopian ‘community’ is therefore imagined as a homogeneous entity, relating to an imagined existence; however, it is important to acknowledge that in reality the community is hugely divided in terms of ethnic groupings and religion. This paper still refers to an Ethiopian ‘community’ as this is the primary term used by participants in the research to

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identify themselves. All the participants in this study, despite differences in ethnicity or religion, identified themselves foremost as ‘Ethiopian’.


The goodness of fit: researching forced migrants – why and how oral history can inform our understanding This study incorporated an oral history approach which enables each complex, individual story to be told, as remembered by the interviewee in his or her own voice. Although the oral cultural traditions within Ethiopia would not be deemed ‘oral history’ in the strictest sense, it is important to consider these oral traditions as this reinforces the validity and suitability of an oral history methodology for this research. The Horn of Africa region is home to robust and living oral cultures. Oral narratives play a very important role in Ethiopian culture and have done so for thousands of years. Ethiopian society places great worth in the oral tradition as a primary means of transmitting knowledge and human experience, and of conveying and continuing cultural traditions and customs, and as a mode of transmitting beliefs, feelings, and attitudes (Levine 1972). Scholars of African oral literature, among them, Finnegan (1970) has pointed out that the special role of oral poetry in most African rural communities is worth considering as a historical source, especially during times of social and political change. Researching complex health issues cross-culturally can be difficult. Classically positive depressive, anxiety and psychotic symptoms are identified by a process of medical cross-examination, whereby the definition of the symptoms is matched by someone’s experience (Fernando 2002). Medical diagnostic interviews about mental health are however impractical for those from non-western cultures as understandings and expectations are often completely different (Fernando 2002). Oral history/narratives and narrative techniques are therefore considered to be more appropriate because of the complex and detailed nature of the research, the nature of the research situation and the characteristics of the respondents (Slim and Thompson 1993). Oral narratives have been increasingly recognised as enabling marginalised and excluded individuals to ‘become agents and not just objects’ (Slim and Thompson 1993, p. 19) through valuing the process of remembering and interpreting the past (Thompson 1999). Thompson in ‘Moving stories: oral history and migration stories’ (1999) found oral history to be an indispensable tool in understanding the human dimension of the migration processes. This method of inquiry is particularly useful in understanding the significance of, and impact of, forced migration on individual lives, and exploring ‘both personal trauma as viewed within a social context and society as reflected in an individual’s life’ (Ben-Ezer 1999, p. 30). Mental health and forced migration: Studies suggest that mental health issues reflect the complex relationship between premigration and social difficulties experienced in post-migration. Van der Veer (1998), states that the stresses and challenges at different stages of the migration process can lead to psychological distress and physical ailments. Bhugra (2004) has indicated that among the potential predisposing factors for mental health issues in forced migrants are: separation from family and friends (particularly the intense suffering when separated from children), language difficulties, obtaining accommodation, a hostile host community, unemployment, suffering prior to exile, and unknown cultural traditions. Literature also suggests that exile-related stressors may be as powerful as events prior to flight and

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therefore impact hugely on health (Watters 2001, Summerfield 2001, 2003). Refugees may also continue to have strong emotional ties with their native country and as a result may not possess sufficient motivation to acculturate (David 1970). This situation is further compounded by different practice and ongoing debates on how to work with established mental health needs, with some rejecting aspects of ‘western’ models of mental illness whilst others continue to use this model. This body of research is expanding and offers valuable insight into the plight of forced migrants, however, as highlighted elsewhere; few studies actually explore the perspective from Ethiopians in exile.


The research: methodology – emergence of themes This study is concerned with the development of themes rather than testing established models and is based on the premise of ‘grounded theory’ (Glaser and Srauss 1967). Although Glaser’s and Strauss’s collaborative work led to the introduction of grounded theory, their later works show epistemological differences with Glaser advocating a more rigorous positive perspective towards qualitative analysis (Glaser 1978, 1992, Strauss 1987, Strauss and Corbin 1990). This study adheres more to the grounded theory approach as highlighted by Glaser (1978) with regards to prior knowledge and external validity. Grounded theory is an established research approach for qualitative analysis in social research (Glaser and Strauss 1967, Glaser 1978, Strauss 1987, Strauss and Corbin 1990, 1998). It is a ‘theory discovery’ or development tool, ‘grounded’ by observational or empirical data regarding the particular topic or phenomenon being investigated (Glaser and Strauss 1967, p. 6). Strauss and Corbin (1990) permit the researcher to predetermine the area of enquiry before undertaking research and coding is then orientated around these issues. Unlike traditional methodological approaches where the hypothesis is set and tested, data analysis involves searching out the concepts behind the actualities by looking for codes, then concepts and finally categories (Allan 2003). Grounded theory therefore has as its goal the development of a theory through inductive approaches. The theory is ‘grounded’ in the data; it ‘must fit the situation being researched . . . by fit we mean that the categories must be readily (not forcibly) applicable to and indicated by the data under study; by this we mean it must be relevant to and be able to explain the behaviours under study’ (Glaser and Strauss 1967, p. 3). The theory evolves from the research, the general to the specific not the other way round. Working from rich sets of data (full-length audio interviews) three hierarchical steps of coding were used: open coding, axial coding and selective coding, which using the constant comparison method form the basis for theory construction. The sample For this study, non-probability sampling was undertaken which refers to situations where the research cannot or does not sample the whole population and therefore cannot claim representativeness (Jeffri 2004, Denzin and Lincoln 1994). A snowballing technique was used to locate respondents and some existing contacts at community organisations in London; Voluntary Action Camden, Brent Refugee Forum, the Migrant and Refugee Communities Forum and the Ethiopian Health Support Association and the Ethiopian Women’s Empowerment Group were approached as key initial informants. This technique, in which informal informants nominate others for interview until a chain has been selected (Burgess 1984), has been noted for its suitability for dealing with small and ‘difficult to find’ groups or populations such as forced migrants (Bernard 1995, p. 97). Wahlbeck (1999) has also noted the necessity of using networks and communities to

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negotiate access to other participants and to help establish ‘trust’ in the community. Indeed this approach was adopted as a practical response to difficulties in trying to access a narrow subgroup of the general population for which adequate sampling frames and statistical data and characteristics are not available. The participants were not a truly representative sample of the Ethiopian refugee population, as demographic variables such as age, gender, level of education, profession etc. were not considered. In total, 13 interviews were undertaken. Interviews varied in duration but lasted, on average, for one hour. A guide included the following broad and overlapping issues: . Demographic characteristics . Experience in exile . Issues identified (if any) which impact on mental health and improvements to health outcomes. All interviewees reported some form of mental health difficulties. The most common complaints were sleeping problems and anger, depression, and stress. Nine of those interviewed were accessing talking therapies at the time of being interviewed whilst four had previously accessed primary or secondary counselling/support in respect of their mental health. Ethical issues The ethical aspects of implementing respectful informed consent procedures, ensuring confidentiality and anonymity required much consideration when researching complicated and sensitive issues with forced migrants. Informed consent from all respondents was vital and was duly obtained. Respondents who agreed to participate were able to determine when and where interviews would take place. Permission to record interviews was sought from all respondents. Interviews were restricted, due to time constraints, to those who understood and were fluent in English; however, it is important to acknowledge that such a sample is unrepresentative of Ethiopian forced migrants in general (Temple and Moran 2006, Papadopoulos et al. 2004). Characteristics of study All demographic characteristics of the sample were coded at the initial stage (Table 1). A total of 13 (n ¼ 13) Ethiopian forced migrants participated in this research. In terms of gender, 46.1% per cent (n ¼ 6) were female and 53.9% (n ¼ 7) were male. The ages ranged from 18 years to 67 years, with a mean age of 43.6 years. All participants lived in London. The years of residence in the UK ranged from 9 months to 12 years with a mean of 5 years. Six (n ¼ 6) 46.01% lived alone whilst the remainder lived with their spouse and or other family members. All participants were unemployed and one (n ¼ 1) 7.7% was without any form of see National Asylum Support Service (NASS)2 or subsistence support and was destitute. Seven (n ¼ 7) had full refugee status. English language ability was good and none required an interpreter for this study. All participants (n ¼ 13) were first Ethiopian generation forced migrants. Analysis: data coding As highlighted previously an inductive analysis of empirical data was conducted for the creation of a theory (Strauss and Corbin 1990). Strauss and Corbin (1998) suggest coding

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Table 1. Characteristics of the study population (n ¼ 13).


Variable Gender Male Female Age . 30 31 – 40 41 – 50 50 – 60 60 þ Immigration status Asylum-seeker Refugee Other Time resident in UK Up to 3 years 3 – 6 years 7 – 10 years More than 10 years Borough of residence Brent Islington Southwark Haringey Camden Kensington and Chelsea Tower Hamlets Wandsworth Lambeth

Number of respondents

%

6 7

46.1 53.9

1 5 4 1 2

7.7 38.5 30.8 7.7 15.4

4 7 2

30.8 53.9 15.4

3 7 2 1

23.1 53.9 15.4 7.7

1 1 1 2 4 1 1 1 1

7.7 7.7 7.7 15.4 30.8 7.7 7.7 7.7 7.7

by ‘microanalysis which consists of analysing data word-by-word’ and ‘coding the meaning found in words or groups of words’ (pp. 65– 68). A microanalysis from the interview text was therefore undertaken on a quote from each interview (n ¼ 13) which was ‘belonging to, representing, or being an example of some more general phenomenon’ in the study (Spiggle 1994, p. 493). This coding frame was the primary focus of the analysis. The following section will describe the processes and phases used to code the data. Open coding: the process of finding the quote The process of data analysis begins during the data collection (interview) process, the stream of narrative provides much of interest and significance and the researcher, by nature of the intimacy and personal dynamic of the oral history interview, is immersed in the story and context. The interview process facilitates discussion, clarification and in-depth understanding, which is followed by careful listening to the interviews, reading transcriptions and generating data, the research process therefore progresses from the minutiae of full narrative transcripts to individual keywords, phrases and quotes and finally to the development of categories and themes. Coding is a method of ‘conceptualising research data and classifying them into meaningful and relevant categories for the participants in the study’ (units of analysis) (Bowling and Ebrahim 2005, p. 296). Coding defined by Strauss and Corbin (1998) is an analytic process through which ‘data are


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fractured, conceptualised, and integrated to form theory’ (Strauss and Corbin 1998, p. 3); it involves ‘breaking down, examining, comparing, conceptualizing, and categorizing data’ (Strauss and Corbin 1990, p. 61). A combination of data collection methods in grounded theory has been well documented (Strauss and Corbin 1990); however for this study only recorded interview data was used to create a theory. All interviews (n ¼ 13) were recorded using a Merantz digital recorder. Some keyword notes, descriptive or short phrases (memos) were taken during the interviews, which helped identify open codes. Open codes are the substantive codes and tend to be the words of the research participants (Munhall and Boyd 1993). This open coding process is fundamentally interpretive and ‘includes the perspectives and voices of the people’ involved in the study (Strauss and Corbin 1994, p. 274). All interviews were listened to several times at different stages and throughout the study so that I could familiarise myself with the data and the general patterns that could be identified at this stage in the data. This enabled me to develop and utilise ‘open or unfocused codes’ based on re-occurring words, phrases and themes. As discussed previously grounded theory recommends that all interview data is analysed line by line; however time constraints meant that this was not feasible and consequently, for the purpose of this explorative study, a micro-analysis of quotes which underlined codes previously identified during the initial open coding stage was undertaken. These quotes were then broken down into distinct units of meaning or categories (Glaser 1978) – categories defined as an abstract conceptual label which summarises the key characteristics of a passage. The initial general coding approach generated 98 codes in total, all of which have potential meaning and relevance. During this course of coding, more than one code came out from the text; so, for example, taking the coding related to housing issues (Table 2), a variety of keywords/codes were identified in the interviews, which provided the basis for subsequent analysis and groupings. Another example of the open coding, the breaking-up of the data into small pieces (Munhall and Boyd 1993), is the words used by respondents in relation to self-reported mental health symptoms and feelings (Table 3). Once again these codes provided the basis for subsequent analysis and groupings. During this process the researcher is open to creating new themes and to changing these initial codes in subsequent analysis. In short, open coding brings themes to the surface from deep inside the data (Neuman 1997).

Table 2. Open code frame: housing. 1 2 3 4 5 6 7 8 9 10 11 12

Accommodation Housing difficulties Living on the streets Sleeping on floors Privately rented Destitute Nowhere to live Council flat Living with friends Moving from place to place No housing Homeless

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Table 3. Coding frame: self reported mental health symptoms. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

Stress Anxiety Depressed Sad Tearful Easily upset Nervous Panicky Sleep problems Nightmares Anger Big temper Low mood Losing hope Feeling too low Remembering all the time

17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32

Fear Scared Crying much No motivation Fed up Unable to sleep Can’t concentrate Not able to focus Suicide Suicidal Too much thinking Problems Crazy Worry Headaches Mad

Axial coding The next stage of the analysis, axial coding, involved refining the core codes by deleting or combining some categories, followed by making connections between the categories and thus generating a central category – that is, between categories and subcategories, which thus serves to deepen the theoretical framework. At this stage indexing comprises sifting and managing the data, highlighting quotes and making comparisons both within and between interviews. Data is reduced, which is achieved by comparing, contrasting and analysing data in order to see the relationship between the keywords and categories. In grounded theory research, the researcher gathers data, undertakes complex coding and sorts it into categories whilst comparing merging categories. Glaser and Strauss described this method of continually comparing concepts with each other as their constant comparative method (Glaser and Strauss 1967, p. 115). Constant comparative method is a fundamental feature of grounded theory: Comparison explores differences and similarities across incidents within the data currently collected and provides guidelines for collecting additional data. Analysis explicitly compares each incident in the data with other incidents appearing to belong to the same category, exploring their similarities and differences. (Spiggle 1994, p. 493)

By comparing similar incidents, the properties of a basic category are developed and defined: ‘An in depth examination is likely to yield a dense theory that also accounts for behavioural variation’ and eventually categories emerge (Munhall and Boyd 1993, p. 201). The data obtained was subsumed into a core category which is ‘the central phenomenon around which all the other categories are related’ (Strauss and Corbin 1990, p. 116) and is the foundation for the creation of the theory. Strauss and Corbin (1998) give the following criteria, which was adhered to for choosing a central category: . It must be central to other major categories. . It must appear frequently in the data. This means that within all or almost all cases, there are indicators pointing to that concept. . The explanation that evolves is logical and consistent and there is no forcing of data. . The name or phrase used to describe the central category should be sufficiently abstract leading to the development of a more general theory.

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D. Palmer . As the concept is refined analytically through the integration with other concepts, the theory grows in depth and explanatory power. . The concept is able to explain variation as well as the main point made by the data; that is, when conditions vary, the explanations still hold, although the way in which a phenomenon is expressed might look somewhat different. One also should be able to explain contradictory or alternative cases in terms of that central idea. (Strauss and Corbin 1998, p. 147)


Pair coding: collaborative analysis I worked collaboratively with a fellow PhD student who had an interest in the data and was keen to learn about grounded theory during the axial coding stage. Although such ‘pair coding’ is mainly used to increase software quality, I used this method due to the large amounts of data and my inexperience of undertaking grounded theory coding. The cocoder worked with me at the axial coding stage only. Excel software was used to assist with the coding. The advantage of pair programming is its gripping immediacy; it is impossible to ignore suggestions/ideas when the coder is working with you. Each half of the coding pair has to understand the code immediately, as it is being written. This pairing also forced a level of communication and understanding of the data that may not be otherwise achieved. Much work was undertaken fitting and refitting codes and there was much discussion relating the concepts to each other; in finality this pair coding resulted in an agreement over the coding. Axial coding and paired coding: results A matrix was produced which highlighted the coding undertaken by both coders at this stage of the process in relation to the quote selected from the interview. The quote selected from each interview was read and re-read several times and scrutinised line by line and through this process axial and selective coding were identified in the text. Quotes were identified and moved from the original context and keywords were re-arranged and grouped under the newly-developed thematic context as highlighted in Table 4. The matrix coding relating to the axial codes from the text was then grouped to show relationships between the codes.

Table 4. Axial coding frame and relative frequency. 1 2 3 4 5 6 7 8 9 10 11 12 13

Accommodation/housing difficulties Financial difficulties Immigration status/fear of deportation Stress/distress Depression, negativity, hopelessness Illness/health problems Sleep problems Unemployed Language/need for interpreter Myth/public perception Lack of support networks Suicidal/suicide Other

76.90% 30.80% 76.90% 38.40% 38.40% 15.40% 15.40% 15.40% 7.70% 7.70% 7.70% 15.40% 30.80%

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The emerging theory The final stage of the data analysis is selective coding, which ultimately becomes the basis for the grounded theory. Strauss and Corbin define selective coding as ‘the process of selecting the core category, systematically relating it to other categories and validating those relationships’ (Strauss and Corbin 1990, p. 116). Figure 1 shows the relationships between the codes and the interviews. By linking the categories and investigating the connections between concepts the themes emerge. The main categories impacting on mental health were identified as housing, immigration and financial difficulties. The emergent grounded theory of the research can be summarised in the following sections. Factors influencing the mental health and social care needs of participants When we were in Ethiopia we used to live in extended families but when you come to the UK it’s very difficult because you are living by your own and with language barriers and employment barriers and immigration problem with all these sort of issues . . . it’s really difficult for you to access the problem because you feel isolated . . . loneliness and employment, housing problem, immigration problem and all these things add up to make suicide . . . . (SR, June 2009)

The coding and analysis of data indicated that social factors are significant predictors for general and mental health status. Inadequate housing, poverty, and insecurities with regards to immigration status were identified in the coding by all the participants (n ¼ 13) to be detrimental to their mental wellbeing. The most dominant categories were housing and immigration which were high and occurred in 77% (n ¼ 10) of the interviews. All interviewees reported having emotional difficulties mainly associated with the post-migratory resettlement process. Whilst the role of traumatic experience should not be overlooked when determining the psychological illness patterns of those interviewed, the psycho-social factors appear to be more of an influence on immediate, social and psychological wellbeing. Coding highlighted that housing, employment/lack of income and positive asylum applications were again, priorities for improving wellbeing.

A1 1 2 3 4

A3

A4

A5

A6

A7

Immigration status/ fear of deportation Stress/distress

6

Depression, negativity, hopelessness Illness/health problems

7

Sleep problems

8

Unemployed

9 10

Language/need for interpreter Myth/public perception

11

Lack of support networks

12

Suicidal/suicide

98

Other

5

A2

Accommodation/housing difficulties Financial difficulties

Figure 1. Matrix of relationship between codes and interviews.

A8

A9

A10

A11

A12

A13

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D. Palmer KEY THEMES RESPONSES Other Suicidal/suicide Lack of support networks KEY THEMES RESPONSES

Myth/public perception Language/need for interpreter Unemployed Sleep problems


Illness/health problems Depression, negativity, hopelessness Stress/distress Immigration status/fear of deportation Financial difficulties Accommodation/housing difficulties 0

1

2

3

4

5

6

7

8

9

10

Figure 2. Bar chart of number of responses – key themes.

In an interview with SR June 2009, the interviewee draws attention to the forced exile and subsequent difficulties faced by refugees from Ethiopia. The opening quote above highlights the effect that forced exile can have on an individual. The interviewee refers to an exile which not only places the individual ‘outside’ the public space – the community, culture and country – but also ‘outside’ the private sphere. The latter is an interesting concept, when this private sphere is seen as being the individual or mental sphere and therefore they experience being ‘outside oneself’. Such feelings and psychosocial maladjustment difficulties highlighted above have been expressed in the coding of other Ethiopians who participated in the study; uncertainty in exile was central to symptoms presented. Feeling ‘hopeless’, ‘lost’ or ‘afraid’ can be inextricably linked to postmigratory resettlement difficulties, it is therefore essential that service providers have an understanding of the migration process and its effects on mental health in order to provide and deliver appropriate care services and responses. Psychosocial factors and mental health The narratives and subsequent coding and analysis undertaken in this study suggest that mental health symptoms arise as a direct consequence of the external oppressive forces which structure marginalisation. Depressive and anxiety disorders are related to the stressors of the exile experience, which include high levels of social and economic deprivation, anxiety about immigration status, and isolation and cultural bereavement. The study provides insights on concepts of social suffering for the forced migrants who participated. For many, the suffering arises mainly from ‘cultural bereavement’, which entails the loss of country, cultural values, family, relatives and friends (Eisenbruch 1990). You know all the things they do you know the smell, the essence of food, sheep, chicken, things . . . we don’t eat frozen things back home. You have to get fresh lamb or chicken and then you all those things Happy New Year, Happy Christmas all that things I missed. I always crying, crying crying especially on that time. I can’t even talk to them. When I phone them

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I always crying and my mum says to me why am I crying if you are not happy please come back . . . but I can’t. (YA, May 2009)

Participants identified a number of health concerns that they link to the everyday suffering they endure – i.e. feeling inadequate and hopeless, negative, distressed and having sleeping difficulties. I’m tired and its . . . just . . . it’s not moving forward. I can’t sleep . . . I feel alone and isolated. The problem is the immigration and I feel without hope and em . . . stress. (HA, May 2009)


In addition, the relationship between negative symptoms and exile experiences suggests that these symptoms impact on social functioning: Social suffering results from what political, economic and institutional power does to people and, reciprocally, from how these forms of power themselves influence responses to social problems. Included under the category of social suffering are conditions that are usually divided among separate fields, conditions that simultaneously involve health, welfare, legal, moral and religious issues. (Kleinman et al. 1997, p. ix)

According to Kleinman (1999) social suffering can be viewed as a category which cannot be separated from misery and he identifies suffering as a problem of society and politics, the symptoms of social suffering presented in the study could therefore be viewed as the collective consequence of social structures which have been created by human agency and which can also therefore be changed by human agency. Housing Ten (n ¼ 10) (77%) of participants reported that housing, poverty played a major role in their mental health problems. Poor housing was cited as one of the biggest difficulties and an immediate stressor. I have my difficulties, my friends do, we don’t have anybody to turn first of all I think it’s hard for Ethiopians to admit I am depressed or something. Housing, getting housing, moving place to place and not sleeping and all of that has big problem for me. I’m out of place here. (SA, March 2009)

Housing is a concrete manifestation of socio-economic status, which has an important part to play in the development of explanations of the social production of health inequalities. Consequently, poor housing and homelessness will have an effect on psychological wellbeing. The home provides more than shelter, and the ‘meaning of home’, as for example a haven of security, is an accepted psychological and social construct. This is perhaps even more significant for refugees, in that something additional is being expressed in the meaning of home, having lost both their actual home and their homeland. Housing problems, such as frequent moves, contribute to stress and in severe cases can be contributing factors in the onset of clinical depression (Brown and Harris 1978). Brown and Harris (1978) link overcrowding and cramped living accommodation, lack of privacy, inadequate facilities to mental distress. Examining the impact of poor housing on health more holistically, Ambrose (1997) lists possible indirect effects such as lowered resistance to mental and physical illness, unhealthy habits and reduced self-organisation. The immigration/asylum process Frustration at the (UK) Home Office, that’s the main problem. Every morning before you open the door you have to watch for that brown envelope. People are very worried about it in the

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community and we . . . are now sending information in white envelopes. Unemployment is high. Many are educated, unemployed and isolated. Lack of status affects everything. You can’t plan, you can’t study, and you don’t feel part of society. It affects every aspect of daily living. (TB, May 2007)

Another important factor impacting upon the mental health of those interviewed was the immigration system and the complexity and great uncertainty surrounding their legal status. This was highlighted by 77% (n ¼ 10) of the respondents. Persistent anxiety over the possibility of deportation, and the need to deal with the complex legislation and immigration decision-making process, has resulted in an increased level of mental distress and demoralisation for many of those interviewed. The challenge of dealing with the asylum and immigration system can encourage feelings of helplessness and despair due to a lack of control over the situation. It is believed that humans’ basic drive is to control their environment (Stipek 1988). In turn, if an individual has a lack of control over an aspect of their environment in one situation this will impair learning in similar situations. This lack of control can impact on self-esteem, perspective, and self-confidence and consequently individuals can be locked in an internal pattern called ‘learned helplessness’. Demoralisation is viewed by some to fit the learned helplessness paradigm rather than the medical condition of depression (Kroll and McDonald 2003). Learned helplessness is understood as a motivational issue whereby failure or lack of control over a situation or situations makes the individual believe that they are incapable of doing anything to improve their situation and consequently can have a detrimental effect on the individual’s wellbeing (Peterson et al. 1995).

Economic activity Other social issues were identified including financial difficulties – inability to find work, studying and welfare benefits issues. All respondents were unemployed, attending training and were in receipt of Income Support, Incapacity Benefit credits or NASS support. One was destitute and without any form of income. Evidence suggests that forced migrants suffer high levels of unemployment and are disadvantaged in the labour marked due to, amongst other things, language (Harris 2004). Interviewees demonstrated frustration and felt they were not able to accurately represent their capabilities, thus impacting on, and highlighting, their relative deprivation and structural disadvantage. The inability to find employment and in some cases reach their previous occupational and social status has impacted on the long-term mental wellbeing of those interviewed and resulted in many experiencing feelings of hopelessness and despair. Holistic model of health and illness The research findings reveal a much more complex picture of the causes, symptoms and perpetuating factors influencing the mental health of participants. This deeper understanding goes beyond narrow diagnostic labels and would therefore require a more relevant approach to prevention and treatment. There is an increasing conviction that the major detriments of health are based on cultural, social and economic interventions rather than medical (Dunn 2000) and this is also reflected in the coding analysis of this research. This view of health is primarily based on Engel’s Biopsychosocial (BPS) Model of Health and Illness. The model accounted for biological, psychological, and sociological interconnected spectrums, each as systems of the body and recognising that psychosocial factors greatly impact on the progression of, and recuperations of ill health (Engel 1980). The biopsychosocial model is an approach to medicine which stresses the importance of a


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holistic concept, a more complete; ‘whole-patient-as-a-person’ type approach. It considers factors outside the biological process of illness when trying to understand health and disease. In this approach, an individual’s social context and psychological wellbeing are key factors in their illness and recovery, along with their thoughts, beliefs and emotions. Dunn suggests that ‘one’s immediate social and economic environment and the way that this environment interacts with one’s psychological resources and coping skills, shapes health much more strongly that the medical model would suggest’ (Dunn 2000, p. 343). This alternative model acknowledges the social, political and culturally constructed definitions and arrangements/experiences that determine an individual’s expectations, knowledge and circumstances and aims to move away from imperialistic ethnocentric preoccupations of diagnostic labels and psychiatric models of trauma. This concept requires that the social and political inequalities of power between different groups and within systems are explored when planning appropriate services and delivering care. It therefore follows that health is a holistic concept embracing an individual’s social, physical and mental wellbeing and influenced by social, economic, political and environmental experiences. In this way the solving of mental health ‘problems’ becomes an issue beyond that of the individual, rather encompassing the challenge of working with the organisation of key aspects of social life (to include housing, employment, legal status and community access). The content analysis findings of this study reflect this complexity with many social, economic and political factors being cited as contributory factors to mental distress. Conclusion This exploratory oral history research utilised a content analysis approach to analyse key points/extracts and adopts grounded theory whereby codes and subsequent themes emerged from the interview data. In this paper I have demonstrated how themes emerged from open coding and how the core category of the theory and related concepts developed through axial and selective coding. The study also incorporated pair coding at the axial stage which proved successful in increasing reliability. This study has been a process of learning, allowing the development of oral history research and analysis techniques but, most particularly, increasing my knowledge and understanding of grounded theory, especially in terms of its time-consuming processes. It is however important to note that due to time and word constraints it is beyond the scope of this paper to provide a thorough analysis of grounded theory and the differences and conflicts that divide theorists (Kelle 2005). Due to size limitations and resource constraints, this research places the emphasis on a small number (n ¼ 13) of respondents. Although the size of the sample base is not reflective of the Ethiopian refugee community as a whole, the findings have been consistent with the limited available research on the larger refugee population. Using grounded theory, the coding and analysis which emerged from the interview data suggest that psychosocial factors play a significant role in determining the mental ill health of respondents who participated in the study. This research suggests that the issues and impact of deprivation, combined with the complex interaction of social and psychosocial factors, are crucial in impacting on mental ill health. It is apparent for those participants that economic deprivation, poor housing conditions and the asylum process can exacerbate existing, as well as creating new, psychological stresses. For those who participated in the study, poor housing and homelessness was a significant factor of distress in the resettled environment. Similarly, persistent anxiety over the possibility of deportation and having to deal with the complex immigration legislation has also resulted in an increased level of

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mental distress and demoralisation, which inevitably impacts on mental wellbeing and emotional and behavioural responses. This research indicates that all professionals and commissioners involved in the planning, delivery and funding of health and social care provision need to acknowledge the range of problems and issues experienced by those living in exile. As a result, and as this research highlights, health providers need to offer a ‘holistic’ response providing advice and advocacy, social and emotional support and access to appropriate housing, education and training. Undoubtedly further research would be more insightful and rewarding and may promote further development and modification of the themes which emerged. Notes 1.

2.

The International Association for the Study of Forced Migration defines forced migration as a general term that refers to the movements of refugees and internally displaced people (those displaced by conflicts) as well as people displaced by natural or environmental disasters, chemical or nuclear disasters, famine, or development projects. The term in this paper refers to anyone involved in the asylum process and therefore includes refugees and asylum-seekers The National Asylum Support Service (NASS) is a section of the UK Border Agency (UKBA), which is itself part of the Home Office (UK). It is responsible for supporting and accommodating people seeking asylum while their cases are being dealt with.

Notes on contributor David Palmer is, with the aid of a grant from the Economic Social Research Council, undertaking a PhD at the University of Kent, UK, which uses oral narratives to explore the significance and impact that cultural traditions, beliefs, and the ritual Buna ceremony have on the mental wellbeing of Ethiopian forced migrants in the UK (http://www.bunaandpopcorn.org.uk). His research interests include mental health and social care needs of migrants, self-help, and wellbeing initiatives, ethics, participative research methods and, in particular, user-led research in mental health.

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