The current study explores the impacts of peer support programs on recently resettled refugees to Canada. This research uses qualitative data that was collected from service users as part of a broader formative evaluation of a regional mental health initiative; the Promise of Partnership. This initiative arose from a need to proactively address the resettlement issues experienced by refugees in the Region of Waterloo. The analysis focusses specifically on the impacts to refugees involved in Arabic-speaking peer support groups as understood through the theoretical framework of the ecological model. Findings from the analysis locate key benefits to participants across the interpersonal, organizational, and community levels of the model, revealing the interwoven and impactful nature of peer support amongst participants and their broader community. Given the unprecedented influx of Syrian refugees to Canada, we argue for the continued implementation of peer support groups as a source of mental wellness promotion, empowerment, and a broadened sense of community.
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Introduction
Canada has a relatively recent history of supporting the mental health of refugees (Canadian Task Force on Mental Health Issues Affecting Immigrants and Refugees & Beiser, 1988). In light of the on-going resettlement of refugees from Syria (Canada, 2015), the Mental Health Commission of Canada has called for refugee supports that focus on promoting social integration while simultaneously preventing future mental health problems (Agic, McKenzie, Tuck, & Antwi, 2016). The current research pertains to an investigation of group support programs for Arabic-speaking refugees developed as part of an inter-organizational regional mental health initiative, the Promise of Partnership. Although similar peer support programs for refugees exist in Canada, research on participant experience is limited. This research seeks to determine the impacts of refugee peer support groups on its participants and identify the broader implications of the program among refugees in the Waterloo Region and in Canada. A review of current literature on peer support programs, in addition to other modalities of group-based programs for refugees is first discussed. An organizational overview then introduces the main service provider of the peer support programs and its community partners, and is followed by a description of the project’s rationale, its socio-political context, and the guiding research question. Second, the authors position themselves within the context of the organization and the current research, identifying tensions in evaluator research and exposing potential conflicts of interest. The methods used to conduct the evaluation are then articulated. Finally, the key findings of the research are presented; the implications of which are discussed in terms of the peer support program’s capacity for social intervention and its limitations.
The Peer Support Model
The implementation of peer support groups is increasingly common in the fields of social work, health care, and counseling (Cohen & Graybeal, 2007; Mead & MacNeil, 2006). According to Mead, Hilton, and Curtis (2001), peer support programs are used to create a new cultural context for healing and recovery. Members of these groups, often having been faced with social and cultural ostracism, are capacitated through a shared understanding of the impact of their experiences in order to engender personal, relational, and social change. Peer support has therefore tended to engage a broader understanding of mental health and recovery; eschewing the medical model that has dominated mental health care policies (Harp, 1987, p. 20-21). For the purposes of the current research the definition of peer support by Mead et al. (2001) is adopted:
Peer support is a system of giving and receiving help founded on key principles of respect, shared responsibility, and mutual agreement of what is helpful. Peer support is not based on psychiatric models and diagnostic criteria. It is about understanding another's situation empathically through the shared experience of emotional and psychological pain. (p. 135)
The peer support model accordingly promotes the holistic well-being of participants; focusing on their ability rather than illness or their disability; aspects which are instead resonant of the medical model (Adame & Leitner, 2008). Peer support programs have furthermore been characterized in the mental health care field by a desire for social justice and the promotion of an understanding of social and environmental factors that contribute to participants’ distress (Mead et al., 2001).
The peer support model has been implemented in various settings and with disparate groups. Peer support programs have for example; been adapted to caregivers of stroke patients, HIV-infected adolescents (Funck-Brentano et al., 2005), cancer patients (Ussher, Kirsten, Butow, & Sandoval, 2006), breast-feeding mothers (Dennis, Hodnett, Gallop & Chalmers, 2002), and geriatric staff (Davison et al., 2007). However, peer support groups and even more broadly group-based supports for refugees remain largely elusive.
Peer Support and Refugees
A review of the literature concerning peer support reveals that refugees have only exceptionally been implicated in research involving group-based programs. Using databases such as JSTOR, SAGE Publications, McGill University Library’s World Catalogue, and Google Scholar, journal articles were identified using combinations of the search terms “refugee” and either “group support”, “peer support”, or “mutual aid.” The resulting search yielded a dearth of literature relevant to the current research, suggesting that research is lacking in the area pertaining to refugee peer support.
The review of the literature revealed that research has predominantly examined the refugee experience using therapeutic models focusing primarily on the psychopathologies of participants, for instance with regard to post-traumatic stress disorder and psychiatric harm[1] (see Kira, Ahmed, Mahmoud, & Wasim, 2009; Crumlish & O’Rourke, 2010; Drož?ek & Bolwerk, 2010). Furthermore; existing research on refugee group-based programs in the literature has neither explored peer support nor the challenges associated with resettlement through group-based modalities. Group therapy programs for example, are common among refugee youth; especially through arts-based techniques (Rousseau et al., 2007; Schwartz & Melzak, 2005; Tyrer & Fazel, 2014). On the other hand; researchers and practitioners acknowledge the emerging importance of community and broader social context in group-based therapy, advocating for an ecological dimension in contemporary refugee mental health programs (Kira, Ahmed, Wasim, Mahmoud, Colrain, & Rai, 2012). By contrast with the literature reviewed; the program explored in this research utilizes a peer support model and is motivated primarily by issues related to resettlement and mental health promotion rather than psychiatric illness.
Research on group-based supports explicitly for refugee resettlement or mental health promotion is even sparser. Among this limited body of research Breton (2000) explored a Hispanic Women’s Support Group for refugee and immigrant women in Toronto, providing a qualitative analysis of the structural issues facing these women such as employment barriers and inadequate access to social services for domestic abuse. Nevertheless, these support groups focused on “mutual aid” and the support women derived in assisting each other; for example in obtaining counsel from government-funded legal aid programs. Behnia (2003) also explored group support through a twelve-person sample of refugees in Ottawa belonging to various “community peer groups”, such as sewing and bible-reading groups. These participants were enthusiastic about their participation in peer groups and recommended the continued formation of groups exclusively for survivors of war. Thomas, Clarke, and Krolizak (2008) also explored peer-based interventions for HIV-positive Caribbean immigrants as means of promoting healthy sexual behavior.[2]
Meanwhile, group work with refugees has been encouraged as a modality for offering social services by the United Nations High Commission on Refugees ([UNHCR] in Glassman & Skolnik, 1984, p. 47). The UNHCR suggested group support offers the capacity to create an informal learning environment, promote a mutually-supportive atmosphere, and act as a substitute for refugees’ home communities.[3] Yet Glassman & Skolnik (1984) found that the implementation of any such group support programs and the realization of their potential have been underwhelming in the field of refugee resettlement, a predicament that has been echoed more recently (McBrien, 2014, p. 214; Young & Chan, 2014, p. 42). In addition, Behnia (2003) cites gaps in knowledge around social support systems for refugees with specific reference to the rudimentary research available on peer support groups.
Despite the lacuna of research on group-based program for refugees, group programs themselves and specifically peer support models have been employed in practice with newcomer communities. For example, British Columbia Immigrant Settlement Services created Women’s Peer Support Groups focused on developing support networks, gathering information and resources, and dispelling refugees’ sense of isolation.[4] The Metropolitan Community Church of Toronto offers a monthly one-hour peer support program with the aim of building refugees’ social networks while addressing issues related to social services and financial needs.[5] Similarly, a peer support program for LGBTQ refugees focusses on supporting community networks among refugees; offering topical information sessions on issues such as employment and healthcare.[6] The Inter-Agency Network for Education in Emergencies has also implemented peer support programs for refugees in Guinea.[7] Overall, the review of the literature exposes not only a general lack of research on peer support programs with refugees nationally and internationally, but moreover, calls from community leaders and academics to more readily implement such programs.
Organizational Overview and Community Partners
The Promise of Partnership (POP) is composed of several service-providers, but is primarily supported by the non-profit registered charity Carizon Family and Community Services. Carizon is a multi-service community organization committed to improving the future of individuals and families through supportive, therapeutic, and preventative programs.[8] The Promise of Partnership began in April 2011[9] as a partnership between Carizon and Reception House Waterloo Region[10], in Kitchener, Ontario, arising from a need to better address the mental health concerns and settlement issues of refugees in the Region of Waterloo. It builds upon a working relationship between the two organizations that had existed for numerous years. Throughout the denouement of the project, several other service providers have also become involved both as direct participants in the project’s initiatives and as stakeholders in the project’s outcomes in the refugee community.[11] These organizations include: Family and Children Services[12], Waterloo Region District School Board[13], The Kitchener-Waterloo Multicultural Centre[14], Focus for Ethnic Women[15], Canadian Mental Health Association[16], and the Waterloo Regional Police Service[17]. These affiliated organizations both refer clients to, and receive referrals from, mental health workers and counsellors associated with the Promise of Partnership at Carizon. Upon referral to the Promise of Partnership, clients are seen by a mental health worker for an intake appointment and can then be entered into a peer support group.
The Peer Support Programs
The peer support programs at Carizon focus on supporting participants’ resettlement process and promoting their mental well-being. Consistent with the literature on peer support programs (Mead et al., 2001), and specifically their implementation with refugee groups (Berger, 1999), the current program is well within the parameters of similar groups offered for newcomers in terms of their setting, duration, and content. The program is twelve weeks in duration; participants meet once a week at Carizon’s downtown location.[18] Two to three cycles of the program are offered each year depending on funding; typically including between 8 to 14 men or women between groups. Each session runs for two and a half hours, although sessions would commonly last up to three hours. Similarly, peer support programs deliberately occur in not-for-profit settings such as community centers, schools, and churches; occasionally a professional is invited to talk about particular issues (Berger, 1999; Behnia, 2003; Mead and MacNeil, 2006). Peer support programs in the literature reviewed were between ten and twelve weeks in duration, for an hour or two per session; although some occurred on a continual or walk-in basis[19].
Consistent with the objectives of peer support programs; the programs are discussion-based and encourage the active listening and sharing of lived experiences while a facilitator moderates discussions, and introduces topics or guests speakers from the aforementioned partnering service providers (Mead et al., 2001). The program creates opportunities for participants to build their social support networks, share their stories, learn about community services available to them, and address issues related to acculturation. In accordance with recommendations for implementing group support programs with newcomers, the program is facilitated by a native Arabic-speaker and further provides separate groups for women and men (Berger, 1999, p. 145-46). Sessions focus on a variety of topics such as discussing cultural norms, learning about the role of various service providers in the region, and building emotional strength through the group’s understanding of trauma and exchange of coping strategies. Sessions are intentionally informal as a perceived distrust of professionals is prevalent among refugee service users, including those in group programs[20] (Mead & MacNeil, 2006; Behnia, 2003; Berger, 1999). The facilitators in the current program also attend to the stigma attached to mental health issues with respect to the newcomer community. In this context, building not only a trusting a relationship between clients and facilitators, but bonds between groups members was imperative to ensuring participants could feel comfortable discussing mental health.
Rationale
An overview of the refugee[21] population is presented for both Canada and the Waterloo Region[22]. Historically, refugees have represented a disproportionally higher number of the newcomers in the Region of Waterloo compared to the national average (Region of Waterloo, 2009). Between 1996 and 2008, 7,105 refugees settled in the Region of Waterloo (Region of Waterloo Public Health, 2009), making up 22.6% of the region’s newcomer population intake during that period; while refugees[23] represented less than 11% of newcomers for national intake in the same period (Canada, 2008). The current Syrian refugee crisis has further led to an unprecedented increase in Arabic-speaking refugees both nationally and internationally.
In Canada, 40, 081 Syrians refugees arrived between November 4 2015 and January 29 2017 (Canada, 2017a). They are composed of a combination of privately sponsored and government-assisted refugees all of whom acquire permanent residency status in Canada upon arrival. Locally, as one of six Ontario Reception Centres, the Waterloo Region is a hub for the resettlement of government-assisted refugees. During the same time period, 1495 Syrian refugees were admitted in the Waterloo Region (Canada, 2017b[24]). This intake of refugees is a significant increase in view of archival data on refugee claimants in Canada and the Waterloo Region. Between 2003 and 2012, the national annual intake of refugees peaked at 36,768 claimants in 2008 and steadily declined to 20,461 refugees in 2012 (Canada, 2012). The Waterloo Region experienced corresponding annual fluctuations receiving a maximum of 344 refugee claimants in 2004 and declining numbers in more recent years; representing 0.2-1.4% of the national intake of refugees (Canada, 2012). However, in the most recent data collected by Immigration, Refugees and Citizenship Canada (IRCC, formerly Citizenship and Immigration Canada), the number of refugees settled in the Waterloo Region between January 2015 and March 2017 represented the fifth largest intake among Census Metropolitan Areas in the province of Ontario (Canada, 2017c[25]). During this period, the Waterloo Region received 1,700 of the 14,345 government-sponsored refugees resettled provincially.
Moreover, the distress experienced by refugees in Canada associated with their resettlement is well-documented. Refugees experience settlement challenges stemming from factors such as mental health issues and systemic discrimination (Beiser & Hou, 2006), in addition to institutional barriers such as lack of access to essential health and social services (Beiser, 2005; McKeary & Newbold, 2010), challenges in the education system (Kanu, 2008), and difficulty obtaining employment and housing (Carter & Osborne, 2009). Given the large increase of refugees in the Waterloo Region, appropriate and effective settlement services and access to them are especially critical to manage and prevent the settlement challenges common to the Canadian refugee experience. Yet, research on community-based supports for resettlement and group-based mental health promotion among refugees is scarce rendering the potential impacts of such initiatives on these communities uncertain.
In view of the continued Syrian conflict and consequent influx of Arabic-speaking refugees, culturally-relevant support programs are increasingly necessary to promote refugee wellness and prevent mental health issues. Given the Mental Health Commission of Canada’s recent emphasis on wellness promotion among refugee communities (Agic, McKenzie, Tuck, & Antwi, 2016), peer support groups offer a promising and timely approach to supporting refugee resettlement. This research addresses the paucity of evidence supporting peer support programs and thus aims to explore the impacts of peer support on Arabic-speaking refugees in the Waterloo Region. The guiding research question is therefore framed as follows: What are the impacts of peer support groups on the mental well-being and general resettlement experiences of refugees? The framework used to guide this research further interprets this question along four dimensions— the individual, interpersonal, organizational, and community levels—the analysis of which is discussed in the following section.
Methods
Positionality
Program evaluation is generally used in social intervention programs to measure the extent to which programs or their initiatives achieve their intended purpose and to guide recommendations for further actions within the program (Milstein & Wetterhall, 2000). However in making such assessments there exist inherent issues and conflicts of interests related to who conducts the evaluation and how it is conducted. The authors seek to explicate the potential issues confronted in the evaluation that yielded the current data by locating themselves in the context of the research and by shedding light on the decision-making in the evaluation and their personal motives.
As Carizon’s Research and Evaluation Coordinator, the first author has a vested interest in ensuring the project runs smoothly and likewise, the freedom to choose an appropriate assessment method. However, in the context of evaluation, this prerogative may intentionally or unintentionally cause interpretation biases on various levels of the project. For example, data collection methods may be selected that highlight only the positive outcomes of the project while neglecting the negative outcomes of the project. Findings from qualitative analyses may also be presented more favourably because of the researcher’s latent determination for the project to achieve its purpose. However, this research strives for transparency in the data collection methods by taking precautionary steps throughout the analysis, for example by engaging in member-checks following focus groups and interviews, and by iteratively reviewing the findings with the two co-authors; themselves former peer group facilitators. Although it is impossible to mitigate all biases, taking steps to acknowledge them allows the reader to critically understand the research and deduce their own interpretation. The authors acknowledge the importance of cultural-sensitivity in the broader evaluation and research methods employed, especially as the first author is not a newcomer to Canada (although the second and third authors are newcomers to Canada – a refugee and an immigrant, respectively). Despite the first author’s superficial distance from the issues being explored by this research, the research is motivated by a desire to both improve the provision of mental health services to refugees in the Region of Waterloo and promote equal opportunity for those who have been, or continue to be, marginalized in Canadian society. Additionally, all authors have a vested interest in generating knowledge not only to build on the project’s strengths but also to provide a critical lens to the programs and suggest areas for improvement. Finally, while the two co-authors are motivated by their lived experiences of resettlement in Canada, the first author acknowledges his privilege of not having been displaced and instead is motivated by the personal friendships with newcomers and refugees in the community. All authors, by the very nature of working with displaced peoples, have found that their experiences further encourage their belief that, as a pluralistic society, every person in Canada has the right to accessible and culturally-attentive social and mental health services.
The Ecological Model
The findings from this research are understood through the ecological model; which positions the individual within successively nested layers of their social environment (Bronfenbrenner, 1977). The individual is understood through the interwoven mosaic of their interpersonal relations within their immediate community (microsystem), the interrelations among the organizations and people in the individual’s microsystem (mesosystem), and the community and social structures—formal or informal—which affect the individual but do not necessarily encompass them such as government agencies or informal social networks (exosystem). The final layer of the ecological model consists of the overarching political, cultural, and economic systems (macrosystem).
The ecological theory is often applied as a framework for community health promotion and to promote a nuanced understanding of the social determinants of individuals’ well-being (Stokols, 1996; Nelson & Prilleltensky, 2011, p. 79). This contextual approach is consistent with the Mental Health Commission of Canada’s recommendations for an integrated response to refugees’ mental health. The Commission asserts that Canada’s refugee mental health initiatives must prioritize addressing the social and institutional challenges of settlement thereby preventing future mental health issues (Agic et al., 2016, p. 6).
An ecological approach to understanding the peer support groups is appropriate for very reason that the ecological model positions the individual at the confluence of many interacting “socio-physical” factors; thereby acknowledging the joint influence of intrapersonal and environmental factors on their well-being (Stokols, 1996). Indeed, practitioners have encouraged an ecological understanding of the impacts of group-based programs on refugee participants rather than focusing solely on individual psychopathologies (Kira et al., 2012). Accordingly, the ecological model promotes the necessary theoretical understanding of the social and environmental factors contributing to the refugees’ aforementioned resettlement challenges. The congruence of the contextual approach of the peer support model (Mead et al., 2001) and this program’s multi-dimensional approach to resettlement issues justify the adoption of the ecological model. The structure of the ecological model therefore informs the organization of the findings by locating the impacts of peer support through the multiple levels of participants’ social ecology.
Data Collection and Sources
A definition of program evaluation is first provided to contextualize how the data collected is understood. Program evaluation has been defined as: “The use of social research methods to systematically investigate the effectiveness of social intervention programs in ways that are adapted to their political and organizational environments and are designed to inform social action to improve social conditions” (Rossi, Lipsey, & Freeman, 2003). Accordingly, this evaluation employs a systematic collection and methodical analysis of data procured from the program’s refugee clients and collaborators through focus groups and interviews.
Focus groups were conducted to collect qualitative data on refugees’ experiences with peer support programs in 2014. As a new program, data had not yet been collected on refugees’ experiences with the programs and focus groups provided an open-ended format from which to critically understand their experiences. The use of focus groups is further supported by the fact that qualitative data can help inform areas for quantitative assessment and future evaluation (Creswell, 2013). Focus groups were chosen in lieu of interviews with the refugee participants because the group format puts less pressure on the individual to participate, and may potentially avert the participant’s discomfort from being in a one-on-one setting which could compromise the counselor-client relationship they have with Carizon. Given that peer support is predicated on group discussion, a focus group is opportune for data collection because focus groups locate the “interaction in a group discussion as the source of the data” (p. 130, Morgan, 1996). Focus groups also give a “voice” to, and empower marginalized groups giving participants greater control over when they would like to speak (Magill, 1993; Nichols-Casebolt & Spakes, 1995). In contrast, interviews were collected with individual service providers. Interviews in this instance were advantageous both practically because service providers are at different locations across the Region, and methodologically because service providers attend separate peer support sessions and provide services or information distinct from other agencies. The experience of service providers was thus connected neither to their participation in the peer support group, nor to their work with other agencies, rendering a focus group between service providers inefficacious.
Focus groups
A convenience sample was used for the focus groups. Facilitators from both the men and women’s support groups asked participants attending their session to participate in a focus group after their session the following week. The facilitators of both the men and women’s groups were further instructed to ensure that the six participants selected for the focus groups’ were generally representative of the service users who attended the program and capable of participating in a focus group. Many of the participants of the peer support programs expressed interest; however, each focus group was limited to six participants due to limitations within the evaluation’s human resources and scheduling constraints. The facilitators hence provided the evaluator with the contact information (i.e. telephone numbers) for six participants who they felt would provide a broad range of perspectives from the program. Additional participants’ contact information was provided in the event that the proposed participants were not available. The guidelines for selecting participants at the facilitator’s convenience is an approach that “reflects the range of participants and sites that make up the population so that others outside the sample might have a chance to connect to the experiences of those in it” (Seidman, 2006, p.55). Convenience sampling was justifiably used to give voice to the diversity of refugee peer support participants and even those who are not participants to the program. Remarkably, several of the focus group participants shared that they had been personally asked by other peer group members to convey to the evaluator the experiences of those peers who were non-participants to the focus group. In addition, a convenience sample was proposed by the facilitators given that they were in a position to determine whether a participant would be emotionally prepared to share their experience independently without potentially causing further distress to the participant.
Although it remains an obvious possibility that the programs’ facilitators would be able to deduce who had attended the focus groups, the evaluator ensured that participants were aware that their conversation would remain confidential and that only the evaluator would have access to the data collected from focus group. Participants were reminded by the interpreter that their participation had no bearing on their relationship with any service provider. Their participation and responses would remain anonymous and their names would not be used in the transcription of the documents. Participants were provided with a copy of the consent form and the contact information for the evaluator and Carizon counselling services in case they required immediate attention or support with regard to their participation in the focus group.
The focus groups were conducted with the help of an experienced Arabic-speaking interpreter, who was hired for the purposes of the focus groups from the Kitchener-Waterloo Multicultural Centre. The interpreter was provided with a copy of the focus group protocol several days prior to the focus group and both provided feedback and requested clarification on the content of the questions for the purposes of the clarity of their translation. For the focus groups, the interpreter and evaluator met with the participants at Carizon’s main location in a private room. Participants, the evaluator, and the interpreter were seated around a large square table providing a comfortable distance between participants. Refreshments were also provided and accessible to participants throughout the focus groups. Immediately prior to the focus groups, informed consent statements written in English were read aloud in English by the evaluator and translated verbally into Arabic by the interpreter. Following any clarifications requested by the participants, they each signed a consent form. The interpreter provided translation services for both focus groups, during which the evaluator posed questions in English in accordance with the focus group protocol and asked further probing questions as necessary throughout the group’s discussion. The interpreter relayed the evaluator’s questions in Arabic to the participants and translated back to the evaluator, in English, what participants had said one-by-one, asking participants to pause when necessary in order to accurately articulate what they had said. Participants responded primarily in Arabic although some chose to occasionally respond in English. Focus groups were audio recorded with two audio-recording devices positioned at opposite ends of the table to enhance the overall collection of data, serving to later remind the evaluator of the group dynamics and aural cues suggesting agreement among the group or the tone of the conversation.
The focus groups generally concentrated on participants’ experiences with the peer support programs, their needs, and their settlement experiences so far in Canada. For example, a question in the focus group protocol is “Overall, what do you think the refugee community gets out of the group support programs offered through the Promise of Partnership?” An additional question was asked in the women’s focus group, “In what ways have group support programs supported or not supported your mental well-being as a woman?
Men’s focus group
Five refugee men participated in the focus group.[26] Participants’ were between the ages of 21 and 65, among whom three participants reported their age to be between the ages of 36 to 45.[27] All participants reported having a high school education while three participants reported having either a university or college education. Four participants had at least one child, and four participants indicated their marital status as “married” while one participant was “single.” Participants had been settled in Canada for between one and three years and had attended a mean of 11.4 sessions. The duration of the focus group was roughly two hours.
Women’s focus group
Six refugee women participated in the focus group. Three participants were between the ages of 26 and 35, two participants were between the ages of 36 and 45, and one participant was between the age of 46 and 55. Four participants reported having a high school education and two participants reported having a university or college education. Two participants each reported either being married, single, or single with children. Participants had, on average, two children. Participants had been in Canada for between one and three years and had attended a mean of 10.5 sessions at Carizon. The duration of the focus group was slightly more than two and half hours.
Interviews
Interviews were conducted with representatives from agencies partnering with Carizon through the Promise of Partnership (POP). The agencies represented five service providers[28] in the Region of Waterloo that provide services directly to refugee and newcomer communities. Similar to the convenience sampling technique described above, the POP coordinator provided the contact information of the service provider representatives who were directly involved with the program. The selection of participants to reflect this particular criteria is reflective of a snowball process wherein the researcher’s social and professional networks are employed in providing a sample that meets the required professional profile (Warren, 2001). Eight interviews were initially requested via emails to these representatives. All interview requests were accepted with the exception of one representative who declined because of their change in position within the organization and consequent disengagement from the POP. Interviews were conducted by the evaluator in-person and in English at the location of the service provider. The interviews primarily explored aspects of service coordination through the POP however, for the purposes of this research, only data from responses to three pertinent questions were analyzed from a section of the interview related to resettlement and mental health programs. For example, a question asked was, “What impacts have the group support programs had on participating refugee clients?” Interviews were conducted in English and audio-recorded, and generally endured between forty and ninety minutes.
Analysis
A qualitative grounded theory paradigm was adopted in the analysis of each unit of data followed by a general inductive analysis in conducting a thematic analysis. Qualitative research assumes that the researcher plays a direct role in social inquiry, ascribing meaning to their collection of data from people in particular settings (Cresswell, 2013, p.44). Grounded theory explicitly recognizes the researcher as the interpreter of the data gathered, building a theory around a socially constructed reality and providing a “meaningful guide to action” (Corbin & Strauss, 1998, p. 12).
The initial units of data – two focus groups and seven interviews – were first transcribed onto a computer word processor. For each unit of analysis, a preliminary three-stage analysis process of line-by-line open-coding of the transcripts was performed. The open-coding was conducted in order to break down and reduce the data. During open coding, “data are broken down into discrete parts, closely examined, and compared for similarities and differences. Events, happenings, objects, and actions/interactions that are found to be conceptually similar in nature or related in meaning are grouped under more abstract concepts termed ‘categories’” (Strauss & Corbin, 1998, p. 102). Open-coding was concluded when there was an exhaustion of sources, a saturation of categories, or the emergence of regularities in the data. Second, axial coding was used to identify the interconnected categories of codes “whereby data are put back together in new ways after open coding, by making connections between categories” (Strauss & Corbin 1990, p. 96). Third, a thematic analysis of the categories was performed to identify emergent themes across the focus groups and interviews.[29]
A general inductive approach was used to categorize themes according to the levels of the ecological model. An inductive approach “primarily uses detailed readings of raw data to derive concepts, themes, or a model through interpretations made from the raw data by an evaluator or researcher” (Thomas, 2006, p. 238). Furthermore, a general inductive approach is used in evaluation research where data analysis is guided by evaluation objectives, yet the establishment of transparent links between these objectives and qualitative findings is necessary.
Key Findings
Individual-level impacts
Impacts of the support groups on the individual-level (i.e., direct impacts to participants) are presented in relation to three themes that emerged for both men and women. These three over-arching individual themes are relational impacts, social impacts, and the development of a resilient mindset; although an additional theme reflective of uniquely the women’s focus group is also included.
Relational impact
The participating men and women discussed the relational impacts of peer support, emphasizing their sense of relief from negative emotions stemming from past trauma and subsequent resettlement. The refugee men in particular derived comfort from feeling like they could relate to, or empathize with, one another through a group setting. A participant, Derek[30], shared, “It was very beneficial for myself […] hearing about others’ experience that remind us of maybe family members face the same thing or witness it, or some other individual, so it was a good experience. It touches us really deeply. That’s why it was very beneficial and improving; healing someone from inside especially.”
Similarly, the refugee women discussed the impact of participating in the group support programs in terms of relational support arising from building community and empathy. For example, the women discussed past experiences and current challenges through which they could emotionally relate to and support one another. As Joanne disclosed:
With this sessions, I feel that they are my family, I can talk to them if I feel sad or sick, and so they are keeping the community and the socialization. As well, they [peer support sessions] make us more closer even with the community so many people we didn’t know before but now because we are suffering from the same problem we feel us as a family.
The women also talked about a feeling of “stress relief” associated with peer support, Alice explains “You can’t even imagine what the relief we have when we are here, how we are really very comfortable; it’s a stress relief for us; it’s kind of like we are feeling very positive energy.”
Some participants related the impact of peer support to alternative forms of community support available in their home country insofar as helping them through emotional difficulties. For example, Matthew compared his experiences with the group to spiritual or religious supports he previously frequented, “Everybody needs the emotional support, it might come at any stage like emotion drops suddenly in anybody’s life so it’s really important because before it was through churches, through mosques, this kind of support.”
Social impact
Participants relayed the impacts of group support in terms of progressing in their settlement and regaining a sense of sociability. The men explained that given the amount of time spent in group sessions every week, their core social foundation changed drastically because they could rely on seeing each other at regular intervals and develop a network of peers. The women likewise reflected on the importance of regular meetings and were impacted by the sense of community they gained from peer support groups, despite the challenges they were facing through settlement and with their past trauma. For example, participants discussed exchanging organizational skills that assisted their settlement and general mental well-being in addition to knowledge about citizenship or administrative issues and Canadian customs.
Men and women also expressed that the self-confidence they built through group support programs reassured them of their capacity to contribute in their community. The interpreter explained a participant’s point of view, “Joanne used the Arabic expression, ‘If you don’t have something, you cannot give any’, so if you don’t have the care, or somebody taking care of you, you cannot give back. When I am at the group sessions, I found those kinds of things, so that’s why now we can give back even more and in a better way.” Hence, both men and women experienced social impacts as a result of their participation in peer support groups.
Development of a resilient mindset
Participants expressed the development of a “resilient mindset.” Through the peer support programs men and women began thinking positively about their future and developing coping strategies for settlement-related stressors such as anger. Participating men expressed resilience both through the belief they can “deal with failure and learn from it” and by “not giving up.” Participants further felt that they emerged more hopeful about their settlement despite their circumstances. The development of positive-thinking is reflected by Matthew, “Again about failure […] when you come to Canada like it’s kind of a spirit’s coming flying with lots of energy and suddenly facing those problems which is not expected, it’s kind of feeling down, from up to down, so the group was helping me to focus on how to get up, like, especially how to get up again.”
Women found that the group support sessions fostered their mental well-being through strategies related to positive-thinking; in addition to anger management. For example, the women cited benefits from learning strategies such as breathing techniques and remaining calm in order to diffuse their anger. Farah clarified, “they teach us how to be calm and how to understand that person in front of you; they will do some exercise with us, like physically or breathing, the way how to breathe and to relax.” Participants also developed positive-thinking about their future and framing their experiences dialectically, for example by viewing personal failures as opportunities to learn. Mallory, expressed this hope as, “We felt that it’s true like, it’s not the end of the world, but we have a lot coming, we can create something better than what we have.”
Affirmation of gendered identity
Finally, the women’s focus group discussed the impacts of group support unique to their experiences as refugee women. Participants found the support groups empowered them to reclaim their identities and aspects of their lives as women that they felt had been previously neglected. Participants elaborated that, because of their past trauma and recent resettlement, they had forgotten about feminine aspects of their lives. In Veronique’s words:
Unfortunately, we forget even about our identity because of the challenges especially as single moms; we have all of the responsibilities on us, but back home I felt that I was strong, but then coming here facing everything by myself, I found myself weak— so now we say even with the challenges, the responsibilities, we have forgotten even about the feminine.
Participants appreciated discussions centered on their unique challenges as refugee women and found the group’s focus on self-care reinforced their sense of collective and individual self-worth. A participant described how the emphasis on them as women in the group programs served as a reminder of their gendered identity[31]. Deda explained on behalf of the group, “The group programs; they are focusing on us, but they’re not at all forgetting at the back; we are single moms with these sorts of challenges. The sessions are getting at the whole package.” The findings from the women’s support group highlight the empowerment experienced by refugee women, an impact that resonated particularly among single parents.
Microsystem: Familial and interpersonal impacts
Two themes emerged related to the impact of peer support on participants’ interpersonal relations or their microsystem.
Impact on families’ well-being
Men and women cited that their participation in peer support positively impacted their children and partners. Participants specifically discussed their sense of ableness to provide for, and support, their family through settlement, while the positive changes participants observed in their own mental wellness were reflected in the well-being of their children. Some participants shared parenting strategies they developed to cope with family stressors unique to refugees’ circumstances. For instance, mothers in the women’s focus group discussed the difficulties associated in raising a child alone, and expressed that the support groups not only helped them respond to their child’s needs but also provided them with time to focus on their personal mental well-being. The stress of supporting a child was conveyed by Mallory as follows:
(Interpreter providing pretext: And it’s not only for her, even for her daughter, because she is a single mom and she said that it’s [the group support program] reflecting even if her 13 year old has a problem she can even solve it now.) If I have like something personally, I have a family with kids if they are facing even something wrong with school and with the kids, I can deal with it now.
The impact on familial well-being was echoed by service providers who had interacted with participants as well. A service provider remarked that the group support programs fostered a sense of community that resonated in their relationships at home. Natasha surmised, “I think one of the impacts is that it creates a family situation, so, in this neighbourhood you have a lot of single parents particularly moms, so what we’ve noticed […] when you are positively engaging in group support, I think that plays out at home.” Both participants and service providers observed direct impacts to refugees’ well-being on a familial level as a result of group support programs, with particular benefits experienced by single-parent families.
Demystification of community services
Hearing other participants discuss their interpersonal experiences with community services had a positive impact on peer support group members. Service providers discussed the notion of “demystification” as the ability to create an understanding among refugees about the purpose of various services available to them in the region. According to service providers; refugees’ understanding of some service providers were justifiably burdened by past experiences and traumas, however inter-service provider communication and collaboration in the group support programs helped mitigate some of the misunderstandings present in the refugee community. A service provider discussed the importance of demystifying services in relation to difficulty navigating various systems as a newcomer:
[Resettlement] creates obviously a great deal of anxiety for anyone, but in particular, for individuals who may not be familiar with the nature of the systems that they’re involved with […] it is confusing for anyone, let alone for somebody who may not speak the language. So that’s what I mean by demystifying, it is a very complicated web of systems. (James)
The clarification of the purpose of service providers through partnerships in the group support programs helped reduce some anxiety associated with services offered, for example, by Family and Children Services and Waterloo Regional Police Services. Participants likewise described that the groups helped them feel more comfortable approaching other services providers by hearing from each other’s experiences and making personal connections with guests of particular group support sessions. Thus, the peer support program demonstrated impacts related to the interpersonal relations developed by other refugees and community partners through the clarification or demystification of regional services. Participants’ “microsystem” further intersects with the impacts occurring at the various additional levels of the ecological model such as the meso- and exosystem.
Mesosystem: The interface of peer support and impacts in the immediate community
Impacts from peer support groups emerged at the level of the mesosystem, through the various interactions of the elements comprising individual participants’ microsystems such as their family and immediate community. These impacts were evidenced, broadly through three themes: 1) parasocial support 2) the development of employment capacity, and 3) contributions to local community development.
Parasocial support
Participants were impacted by the indirect effects of peer support on their immediate community. Participants discussed how the group support programs impacted their family and friends through the sharing of the participants’ knowledge and insight about mental well-being that they had gained in peer support programs. The impacts on people other than the direct recipient thereby provide additional, “parasocial”, benefits to non-participating refugees. Consider the experience of Derek:
What keeps us coming is the very strong benefit, improvement in ourselves as well as for me, you can see strongly even when I share it outside [the program] with the family, they can share it with friends who cannot reach the services, but they can even share it so it’s impacting other people as well, so this good benefit it’s reflecting other people through us.
Participants also expanded on the parasocial impacts of group support to their children. For example, learning about strategies for coping with failure enabled Clarence, a refugee father, to support his children through their own experiences with social barriers in their daily lives. He described his experience as follows:
After the fact [i.e. a particular group session], I went home and talked to my son, like, about this failure course and how to deal with it, how to pass through it, so it’s reflecting this way… even, I was saying, that it’s reflecting in the way we talk to the kids because it’s giving us ways to, of how to, go through and discuss with our kids even.
Several participants also found that their distant relatives (i.e. family who are not living in Canada or remain in their home country) observed positive changes in participants’ attitudes and behaviors; an observation communicated to them through conversations with their family back home. Moreover, participants’ relatives felt comforted by the improvement participants noticed in their own mental health since joining the group program and the positivity they relayed about their experience with group support. These participants also described that their families, despite being removed from any direct participation, nonetheless felt reassured by the group support program and its impact on the refugee participants, as one participant added, their family knew that “she was going to be okay.” Taken together, the impacts on participants’ immediate family and peers supports the program’s ability to extend its benefits to the mesosystem, or the interpersonal relations of other refugees in the community, and even abroad.
Building community employment capacity
Participants discussed the impact of the peer support in terms of gaining employment-related skills and knowledge. They viewed these skills as valuable to building their prospects for future employment and helping them cope with their personal stressors once in the workplace. Several specifically expressed that the knowledge they gained at the sessions helped them understand how to seek employment. For example, participants found that the group helped facilitate discussions about gaining skills and experience relevant for obtaining employment and addressed the cultural nuances, and myths, surrounding employment in the region. Participants also expressed a sense of self-agency in their ability to gain education and were motivated to pursue their career aspirations.
An interview with a service provider from Employment Ontario’s Focus for Ethnic Women found that the program helped initiate participants’ interest in their employment options and prepared them mentally and emotionally for the workplace. Cassandra explained, “They [the peer support programs] meet with clients, they get together, they talk about different issues in their daily life and from that, if there’s a need for employment, to see a counsellor, or have a health problem or a housing problem or any other issues, they work with them, different agencies, to see where they can get help.” Peer support can therefore prepare participants with the necessary “soft” skills for employment while identifying and coordinating support services in the mesosystem to optimize refugees’ success at obtaining and retaining employment.
Contributions to local community development
Participants disclosed that the peer support programs encouraged them to contribute to the local community through volunteering, and finding employment. A refugee woman, Veronique, explained: “So when you treat the inside, it reflects all sorts of you. The more we connect with people, we will know more about the community, so we will be more knowledgeable with the community so we can even help out in the future time. This can treat as much as the country gives us, we would like to give back.” Participants also relayed that the self-esteem they gained from group support helped them feel more confident in their cultural competency and ability to navigate the local job market. As Alice explained, “Even giving us confidence in ourselves to even be open to work, for example volunteering, to have the strength to do it, to take this step, to look for a job even sometimes they give us resources, so we can start.” Indeed, some of the participants reported they were already volunteering at schools and libraries; refugee men also framed their desire to work in terms of being able to “give back” and contribute to the Canadian economy. In addition, a service provider from the Waterloo Region Police Services found that the groups opened dialogues with critical services to the community by building “outreach capacity” which fosters transparency and trust between refugee communities and service providers via members of the group support programs. Group support therefore contributes to the development of local communities in which refugees live and also bridges refugee communities with services providers in the region.
Exosystem: Impacts to institutional relations between service providers and their provision of services to refugees
Impacts to the exosystem, or the broader social structures which affect participants, are demonstrated by peer groups’ impacts on institutional levels such as service providers’ relations to refugees and changes to service provision patterns. First of all, participants of the group support programs developed an informal community network through the personal connections they developed with one another, which decreased their self-reliance on formal mental health supports. This community network was described as a source of peer support and resource-sharing that participants felt had the capacity to assist them in their settlement process beyond the program’s duration. Specifically, participants discussed that the mental well-being support groups fostered a sense of community and trust amongst themselves, thereby diminishing their reliance on formal mental health supports such as medical doctors, counsellors, and psychologists. In addition, a few participants suggested that they were able to discontinue using medication for depression. Joanne offered the following explanation for her new found ability to self-care, “The support groups helped me find a better way to care for myself. As a single mother, I felt for me like here I have no family […] but with this sessions I feel that they are my family, I can I can talk to them if I feel sad, if I’m sick, so they are keeping the community and the socialization.” From the perspective of local agencies, one service provider further explained that the awareness of various service providers engendered among refugees and discussions about their services helped optimize service coordination while ensuring refugees understood their purpose—
Because it’s a program where they’re supporting involvement with other community partners, […] that opens the door to get to know the Family and Children Services, and know that the services exist to families in case something happens, you know, they can get support from other community partners too.
Another service provider from CMHA suggested that the support groups focused clients and agencies on the services available to them in the region and build support systems that are local to them:
Instead of going to Toronto or somewhere else, it kind of brings us back, okay, there are also valuable people in the region and there is valuable knowledge in the region being recognized and exchanged […] they bring the attention to what we already have here.
Peer support programs therefore demonstrate community-level, or exosystem impacts through changes to service provision patterns and the reduction of strain on formal health services engendered by informal community networks.
Discussion
The discussion first highlights evidence supporting the project’s impacts in terms of ameliorative and transformative changes, then situates the findings from the peer support programs through community-oriented outcomes, and finally proposes recommendations for subsequent research while providing insights for other service providers both regionally, and nationally.
First, the authors must address the obvious limitation of the analysis of peers support among refugees. The sources of data used do not and potentially cannot address the impacts to the macrosystem of the ecological model. The highest level of the model, the macrosystem encompasses the economic, cultural, and political systems in which individuals are embedded (Bronfenbrenner, 1977). Peer support groups are inherently limited in their capacity to effect such broad, and perhaps aspirational changes. First, peer support groups as demonstrated by the findings affect primarily refugees, their peers, families (i.e. the microsystem), the relations within their community (i.e. the mesosystem), and the relationships between community service providers (i.e. the exosystem). These connections preclude the broader Canadian population whose engagement could be influential in generating broader social or political change, for example through advocacy or critical consciousness-raising (Dittmer & Riemer, 2012). With respect to wellness promotion, critical community psychology focuses on aspects of mental health beyond psychosocial processes[32], paying attention instead to the political and social structures underlying community health (Campbell and Murray, 2004). Particularly among marginalized communities lacking in political power and resources (Campbell and Murray, 2004) underline that changes to policy necessitate alliances and partnership with “powerful actors and agencies.” (p. 11) For example; consider the aforementioned systemic issues facing refugees such as housing discrimination, racism, poverty, and employment barriers (Beiser & Hou, 2006; McKeary & Newbold, 2010; Carter & Osborne, 2009). These issues remain concerns that necessarily implicate a broader group of stakeholders than solely participants and service providers involved in peer support programs in order to effectuate political and social change. The ecological framework was therefore inherently limited in providing impacts to the macrosystem level, an area that future programs and research alike could address.
Ameliorative and transformative group support
The multi-level impacts of group support programs reflect outcomes to refugee mental wellness that are potentially both ameliorative and transformative. Ameliorative change represents outcomes that are beneficial to individuals in the short-term but that do not necessarily cultivate systematic changes on political and institutional levels required for sustained social change (Nelson & Prilleltensky, 2010, pp. 156-59). Transformative change represents a societal shift in attitudes that can manifest itself through societal and institutional levels, for example through changes in public policy. Both aspects are important and even complementary in the field of mental health and prevention (Nelson & Prilleltensky, 2010, pp. 208-09). First, ameliorative changes are discussed before examining transformative changes.
Ameliorative changes from the group support programs were evidenced through the social and relational impacts individually experienced by program participants. Participants were also supported by the interpersonal connections and empathy they developed from hearing others’ lived experiences. These processes are documented in psychiatric settings wherein peer support has been found to engender participants’ empathy through the feeling of a common experience. This understanding is conveyed through the “universality” of meaning that participants develop through their shared group interactions (Yalom & Leszcz, 2005, p. 6). Participants further disconfirm the belief that they are alone in their suffering, developing a mutual sense of trust and support (Beiling, McCabe, & Antony, 2006, p. 14). This finding is consistent with the little research available on group-based supports for refugees. For example, Behnia (2003) found that community peer groups addressed participants’ isolation by helping them realize they were not alone in coping with their problems; enabling them to identify with others. In the context of refugees’ secondary migration (i.e. migration to other communities within their host country), Simich, Beiser, and Mawani (2003) found that affirmation of shared experience also led to refugees seeking social supports in other regions.
The refugees in the current peer support program share the validation experienced by other peer support groups and also had their sense of isolation mitigated by refugees in their sense of belonging (Mead et al., 2001). describe that “peer groups specifically create a ‘milieu’ for participants who experienced social isolation and an inability to share their experience to meet others with similar experiences, generating a sense of belonging.” This sense of shared identity and belonging is a concept resonant of psychological sense of community. Psychological sense of community infers the perceived connection of an individual to their community and has been defined as “a feeling that members have of belonging, a feeling that members matter to one another and to the group, and a shared faith that members' needs will be met through their commitment to be together” (McMillan & Chavis, 1986). Participants of the focus groups relayed that their shared histories and social challenges allowed them to feel connected to one another. Glassman and Skolnik (1984) have similarly identified the need for regaining a sense of belonging in order to foster community among South-East Asian refugees. Moreover, sense of belonging as a key component of Citizenship and Immigration Canada’s mandate and data collection with immigrants (Painter, 2013; Statistics Canada, 2015). Refugees’ sense of belonging could be a key indicator of well-being for future program evaluation because it has been linked to civic and social participation, and life satisfaction (Chavis, Lee, & Acosta, 2008).
The development of a resilient mindset further solidifies the positive, albeit ameliorative impact of peer support. Resilience in psychology typically refers to the ability to “bounce back” from adverse emotional or social circumstances (Tugade & Fredrickson, 2004). Although the literature on resilience as a protective factor is much too large to adequately discuss here, the cognitive and behavioral changes evidenced through peer support are demonstrative of participants’ resilience to social adversity. For example, the perception of being able to both better manage distress and adapt to personal failures are illustrative of participants’ resilient mindset. The development of this mindset further reflects “community resilience” – the ability of individuals and their families to “fit” with their environment (Van Breda, 2001, p. 159-60), a concept itself resonant of the ecological model and moreover, community psychology theory (Nelson and Prilleltensky, 2011, p. 79). Martin-Breen and Anderies (2011) identified that programs bolstering resilience “foster existing relationships, in families and communities, rather than ‘come to the rescue’ when acute adversity strikes.” Communities and families are resilient systems; policy that respects them, rather than tries to control them, can significantly affect positive outcomes” (p. 35).The current program leveraged the refugee and service provider communities, demonstrating correspondingly positive impacts to participants’ resiliency. For example, the findings also indicated impacts not only on the individual level, but in the interpersonal and community relations of participants’ microsystems. Finally, resilience has been connected to the growing body of literature surrounding post-traumatic growth and the capacity for trauma to bring about positive changes to cognitions (Tedeschi & Calhoun, 2004; Weiss & Berger, 2008). The participating refugees similarly demonstrated positive cognitive changes through the resilient mindset they engaged as a result of the peer support program.
Individual level impacts also resonate with previous research on the acculturation of refugees in group-based programs. For example, participants gained an understanding of norms and social skills needed to integrate in their new culture, generate hope, and self-confidence; processes which Glassman and Skolnik (1984) have found to be empowering to the individual. Berger (1999) has perhaps politically-incorrectly labelled this process the “all-in-the-same-boat” phenomenon; finding that participants shared experience in acculturation alleviates their feelings of pain, helplessness, guilt, anger, and frustration, and also helps them regain a sense of identity (p. 143). The psychosocial impacts of peer support are equally resonant of group therapy whereby the opportunity to belong to an informal social network diminished participants’ isolation, and validated their feelings of confusions, shame, and anger (Shulman, 1993; Leader, 1991). Despite the sense of community and shared psychosocial impacts fostered through peer support, these outcomes represent ameliorative and not transformative change because they reflect changes to individual well-being rather than changes to structural levels of society.
On the other hand, transformative change was evidenced through community capacity-building. Community capacity-building refers to “the identification, strengthening, and linking of your community's tangible resources such as: local service groups, and intangible resources like community spirit” (Ontario Healthy Communities Coalition, n.d.). Community capacity-building is a transformative outcome of peer support that was supported by refugee participants’ sense of empowerment, their development of resilience to adversity, and their feelings of self-agency. For example, the refugee women expanded their community networks through peer support, and learning to navigate settlement issues themselves while turning to each other for emotional support. Furthermore, participants were motivated to gain employment and pursue post-secondary education, having been linked to various educational and leadership programs that promoted their sense of ownership of their careers while teaching them to set goals and encouraging them to explore their career and personal aspirations. The implications of community capacity-building are important for sustaining refugee mental wellness beyond the duration of the peer support programs. Indeed, Mead et al. (2001) suggest:
Peer support, therefore, becomes a natural extension and expansion of community rather than modeling professionalized caretaking of people defined as defective. […] They (peers) naturally come to understand their problems in the larger social and political context from which they emerge, rather than pathologizing themselves. Peer support is a simultaneous movement towards autonomy and community building (p. 8).
The turn to social and political context is reflected in the changes participants experienced not only in their empathy with one another, but in their integration within community and institutional settings. The micro- and mesosystem impacts that were highlighted in the findings such as refugees’ participation in the community and service provider linkages may therefore translate to community capacity-building, while potentially decreasing the burden on formal health care providers. In fact, peer support programs have been suggested as means of reducing people’s dependence on professional supports (Mead et al., 2001, p. 24).
The development of community capacity-building might also be demonstrated by the relationships of trust created between refugee service users and service providers. The peer support programs fostered a sense of trust between refugee participants and regional service providers, the impact of which service providers suggested even extended to other organizations in the region. The findings exposed the development of not only participants’ local networks, but also participants’ capacity to act as community leaders for other refugees in the region. Participants engaged refugees who were non-participants to the program in their learning through the dissemination of both resettlement strategies they developed and the knowledge they gained about community service providers. Similarly, Behnia (2003) found that participants of peer support revealed that their informal networks were one of the primary pathways through which they learned about mental health services. Transformative change is demonstrated by this ripple effect of refugees’ peer support and their changing attitudes about, and relationships to, service providers in the region.
The ripple effect of peer support (i.e. parasocial support) may be an unintended benefit of peer support programs that can promote mental wellness in the community by preventing issues before they occur. Preventative intervention likewise addresses mental health issues before they occur, or reduces their severity, through health promotion, strengths-based approaches, and the development of protective factors (Mrazek & Haggerty, 1994). The prospect of refugees supporting each other instead of government-designated services is itself transformative and supports further inquiry into knowledge dissemination and mobilization strategies for the broader refugee community. Future evaluations could thus gain valuable insight from the effects of group support on non-participating refugees in the community. Overall, peer support provides evidence of ameliorative and transformational changes not only through the enduring multi-level impacts of group programs but by the momentum generated in the community’s capacity to respond to refugees’ settlement needs.
Next Steps
Community capacity-building could be further leveraged through the continued implementation of peer support programs, however with the addition of past participants as facilitators in the program. Similar “mutual help”-based programs are employed for example with Alcoholics Anonymous and psychiatric survivor programs, both of which demonstrate impacts comparable to peer support programs such as participant self-efficacy (Tonigan, Connors, & Miller, 2003) and supportive relationships (Nelson, Ochocka, Griffin & Lord, 1998), respectively. Another model for community capacity-building that merits consideration is a mentorship model such as that used by Big Brothers Big Sisters of Canada[33] or Youth Assisting Youth[34]. Already, similar programs that employ one-on-one peer mentoring exist for refugees. A peer support program in British Columbia for example, matches refugee youth with trained peer support workers.[35] In addition, Ottawa Community Immigrant Services Organization has recently begun one-on-one partnering between Syrian refugees and newcomers with Arabic-speaking volunteers.[36] The concept of peer mentorship was evoked by refugee participants themselves. Participants of both the men and women focus groups suggested that the group support sessions ought to incorporate participants from past sessions in their future programs thereby promoting sustained mental well-being for themselves and incoming refugees. Derek offered the following recommendation for the program which resonated with other participants as well:
I would like to offer a suggestion and that it would be great even from the facilitators if they can keep us as a group and use our benefit from the groups for other people, we can share our stories, our kind of before and after stage and how we benefit from these groups because really these groups have had a very big direct effect on us which is why we’d love to keep in touch not only like for a certain time but we would like to keep in touch and become even a part of it.
The interest in other forms of group support and the incorporation of past participants warrants further exploration of community capacity-building through mentorship and peer-support models. The recent reports by the Mental Health Commission of Canada and CAMH echo this need for community-centred supports (Agic, McKenzie, Tuck & Antwi, 2016; Centre for Addiction and Mental Health, 2016). Despite the ingenuity and resourcefulness of refugees, Behnia (2003) cautions that refugees are not capacitated with the resources to implement peer support groups without the support of community partners. However, the expanision of group-based mental well-being supports is evidently vital in light of the continued influx of Arabic-speaking refugees.
In summary, peer support for refugees reveals promising avenues for promoting positive settlement experiences, and preventing future mental health issues. The impacts of peer support programs are testament to the community capacity already existing among refugees resettled to Canada. In implementing similar programs, a semi-structured approach to peer support programs, as evidenced in the review of the relevant literature, is critical. Allowing the time for participants to organically create connections, but also providing targeted activities and topical information sessions, provide the necessary social environment for group bonding and mutual support. In doing so, building on partnerships with service providers is essential to creating exposure to available community supports, which can lead to for example, the demystification of services. Furthermore, practitioners should consider not only the diversity of the refugee community, but the strengths participants bring to the group. Peer support however is not a replacement for mental health services – suffice to say – as the psychosocial needs of refugees are complex and one program cannot be expected to be a panacea for all settlement issues. Continued engagement with individuals in the community, trauma-informed practice and facilitators, and checking-in with peer group participants are recommended. Insofar as the impacts of peer support in the current research demonstrate, there are innumerable practical benefits to refugee peer support. The implementation of peer support programs, although relatively informal and demanding little in the way of resources, offers immense potential to communities resettling refugees.
Acknowledgement
The authors would like to acknowledge the contribution of stakeholders in Promise of Partnership project, especially the refugee community for their trust and commitment to improving the settlement process for newcomers to Canada. Their participation in the evaluation process and the knowledge and insight that they were able to share have been invaluable to this research. The contributions from the refugee community have further enlightened these authors to the diversity and admirable strengths of the refugee community in the face of adverse pasts and current circumstances. The many wonderful staff and service providers in the region are also to thank, in particular the incredibly dedicated and supportive staff at Carizon who made the programs possible. The community relationships created through the Promise of Partnership reaffirm Carizon’s commitment to improving the accessibility of culturally-appropriate and effective mental health supports to all peoples in the Region of Waterloo.
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[1] For criticisms of this “silo” approach to refugee mental health, see for example: Marsella & Yamada, 2007; Watters, 2001; Bracken, Giller, & Summerfield, 1997.
[2] A Masters of Social Work thesis also explored informal community supports through the networks created by urban refugee youth in Quebec (Plotkin, 2014).
[3] Glassman and Skolnik (1984) further provide an account of a group program in New York City that brings together South-East Asian refugee men and women in groups of ten in settings such as schools and churches. The program integrates ESL (English as a Second Language) classes with two hour sessions focused on cultural orientation (e.g. how to use 9-1-1, and learning about Halloween) and discussions about their resettlement experiences.
[4] Immigrant and Settlement Services of British Columbia [ISSBC]. Immigrant Women’s Peer Support Program. Immigration and Settlement Services of British Columbia. Retrieved May 10 2017 from https://issbc.org/programs/settlement-services/immigrant-womens-peer-support-program/
[5] Metropolitan Community Church of Toronto. Refugee Peer Support Group. Metropolitan Community Church of Toronto. Retrieved May 24, 2017 from http://www.mcctoronto.com/ministry-meetings/refugee-peer-support-group-2
[6] Self-Help Resource Centre. The 519 Church Street Community Centre – LGBTQ Refugee Support. Self-Help Resource Centre. Retrieved May 24, 2017 from http://www.selfhelp.on.ca/2014/10/the-519-church-street-community-centre-lgbtq-refugee-peer-support/
[7] Inter-Agency Network for Education in Emergencies [INNE]. Peer Groups for Refugee Adolescents. Inter-Agency Network for Education in Emergencies. Retrieved May 10 2017 from http://toolkit.ineesite.org/toolkit/INEEcms/uploads/1040/Peer_Groups_Refugee_Adolescents.PDF
[8] The organization’s mandate is to provide comprehensive and integrated approaches to the delivery of community services in the area of family support, financial counselling, and mental wellness. Carizon specializes in children's mental health, youth engagement and development, family violence services, individual and family counselling, parental support and education, credit counselling, workplace resilience, settlement support and community wellness. Some of their services include programs related to domestic violence prevention (Family Violence Project), child and youth development (Pathways to Education), and programs for newcomers and refugees (Promise of Partnership). For more information, see www.carizon.ca.
[9] The authors would like to acknowledge, and are grateful for, the project funding provided by Citizenship and Immigration Canada (under Contribution Agreement S143924013).
[10] Reception House Waterloo Region (RHW) is a community-based organization that provides temporary accommodations to newly-arrived Government-Assisted Refugees (GARs). Their programming is supported by Citizenship and Immigration Canada and centres on orienting and assisting refugees in their adjustment to living in Canadian society especially within their first month of settlement, while assisting them in finding permanent accommodations and building skills necessary for navigating the Canadian healthcare and financial institutions. RHW does not focus on refugees’ settlement needs related specifically to mental health.
[11] These community-level partnerships aim to build the community’s capacity to respond to newcomer mental health needs, particularly among refugees resettling in the Kitchener-Waterloo community. They also aim to raise community awareness about the needs of refugees while developing collaborative approaches to effective and inclusive mental health service delivery.
[12] Family and Children’s Services of the Waterloo Region (FACS) offers assistance and information for child welfare, family support, and fostering programs for family and children. Its mission is to work with the community to protect and support children, strengthen families, and develop a caring environment for children. FACS has a statutory responsibility to protect children in danger of physical and emotional harm. See https://www.facswaterloo.org/
[13] The Waterloo Region District School Board (WRDSB) represents all public elementary and secondary schools (e.g. middle schools and high schools) in the Region of Waterloo. Participating elementary schools in the school district house programming for youth participating in POP programs as well as teacher training and knowledge dissemination events for ESL teachers. See http://www.wrdsb.ca/
[14] The Kitchener-Waterloo Multicultural Centre is a non-profit organization, housed in Kitchener, offering services free of charge to newcomers in the region, providing translation services, support with financial needs, employment aid, and counselling. See http://www.kwmc.on.ca/
[15] Focus for Ethnic Women (FEW) is a not-for-profit agency housed in Employment Ontario that is committed to improving the lives of newcomer women and supporting them in achieving employment opportunities. FEW’s services are free and include services such as career counselling, skills- and customer service-training, and job search assistance. See http://www.few.on.ca/
[16] Canadian Mental Health Association (CMHA) is a national non-profit organization that supports people from diverse backgrounds who have experienced, or are experiencing, mental health issues. The Waterloo-Wellington-Dufferin branch of CMHA offers services in Kitchener, Waterloo, and Cambridge, providing full care systems for addictions, mental health, and developmental needs. See http://www.cmha.ca/
[17] The Waterloo Regional Police Service (WRPS) provides policing services to Waterloo, Kitchener, Cambridge, and the townships of North Dumfries, Wellesley, Wilmot, and Woolwich. A core value of the WRPS is community diversity and WRPS is represented by its officers at various cultural celebrations events throughout the year such as Chinese New Year and the Ertugrul Education Society Events. See http://www.wrps.on.ca/
[18] Complementary programs such as community outings and an arts-based program may have additionally brought together some of the peer support participants beyond the hours of the peer support programs themselves.
[19] These programs would allow participants to join at any time rather than delimiting the program to a prescribed number of weeks.
[20] This distrust was palpable from the primary researcher’s experience as participants at first questioned whether he was sent on behalf of the federal government and whether the groups had come under its scrutiny.
[21] According to Citizenship and Immigration Canada, a refugee is defined as someone who meets the criteria set forth in the United Nations 1951 Geneva Convention Relating to the Status of Refugees or found to be needing protection based on risk to life, risk of cruel and unusual treatment or punishment, or in danger of torture as defined in the Convention Against Torture (Citizenship and Immigration Canada, 2012, p. 120)
[22] The population of Waterloo Region (composed of the cities Cambridge, Kitchener, and Waterloo, and surrounding counties) as of the 2016 Census is 535, 154. (Statistics Canada, 2017)
[23] For years 1996-2008, 141,146 refugees were settled in Canada (United Nations High Commissioner for Refugees, n.d.).
[24] Calculated by using the total sum of GAR, PSR, and mixed visa refugees admitted across the following three listed communities “Waterloo”, “Kitchener”, and “Cambridge.”
[25] The most current data available from IRCC, updated April 13 2017, using dataset: “Canada- Admission of Resettled Refugees by Province/Territory and Census Metropolitan Area (CMA) of Intended Destination and Immigration Category”
[26] One of the anticipated participants did not attend the focus group, hence the group was composed of five men.
[27] Age is expressed in mode and range because the demographic questionnaire requested participants’ age as a categorical variable (i.e., what is your age? 19-25, 26-35, 36-45 etc.). The decision to include age as a categorical variable in the questionnaire was to minimize the identifying information asked of the participant given the necessary sensitivity to their personal circumstances.
[28] These organizations include: Family and Children Services, Canadian Mental Health Association, the City of Kitchener, Focus for Ethnic Women, and Waterloo Regional Police Services
[29] Researcher memos were also used during the preliminary analysis in order to keep track of ideas and thematic developments related to the codes and their relationships to broader themes and categories.
[30] Each participant was given a pseudonym to ensure confidentiality
[31] One participant shouted, “We are women!”
[32] Campbell & Murray (2004) assert “psycho-social changes need to be accompanied by real changes in a community’s access to power and resources. This argument goes hand in hand with community psychology’s on-going debate about the most appropriate level at which to pitch attempts to generate social change in the interests of facilitating health-enhancing community contexts” (p. 9).
[33] Big Brothers Big Sisters of Canada. http://www.bigbrothersbigsisters.ca/
[34] Youth Assisting Youth. http://www.thepeerproject.com/
[35] DiverseCity: Community Resources Society. Child and Youth Mental Health: Refugee Peer Support Program. Retrieved May 25 2017 from http://www.dcrs.ca/pdf/CYMH%20Refugee%20Peer%20Support%20Brochure%20Final.pdf
[36] Canadian Broadcasting Corporation [CBC]. (2016, December 18). Syrian refugees get help from not-so-new newcomers. Canadian Broadcasting Corporation. Retrieved May 10 2017 from http://www.cbc.ca/news/canada/ottawa/syrian-refugee-peer-support-ociso-1.3899757
Joel Badali, Santiago Grande, Keghani Mardikian
Joel John Badali is a law student at McGill University, and former Research and Evaluation Coordinator to Carizon Family and Community Services. He obtained his Master in Community Psychology from Wilfrid Laurier University in 2014.
Santiago Grande immigrated to Canada in 1988. He was born in an Indigenous community in El Salvador and his family later migrated due to the civil war. In Canada, he worked with immigrants and refugees through Mosaic Counselling and Family Services. He obtained a Master of Social Work degree from Wilfrid Laurier University. Currently he works at Renison University College in Waterloo, Canada.
Keghani Mardikian, born in Syria, immigrated to Canada from Armenia in 2006. Keghani holds a Bachelor of Arts from the State University of Yerevan, Armenia. She holds the master of Social Work degree from Wilfrid Laurier University. Currently she is a family violence treatment specialist at Family and Children’s Services of the Waterloo Region. Mardikian works with individuals and couples, mainly to address adult conflict and trauma issues related to childhood, and also delivers the Caring Dads program in partnership with John Howard Society.
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