Abstract
Purpose
This study investigated if Rohingya refugee people resettled in camps in rural Bangladesh and urban locations in Malaysia had different levels of trauma, mental health and everyday functioning. The study also examined if direct and indirect exposure to traumatic events could predict PTSD, depression, generalized anxiety, and everyday functioning in the two groups separately. An attempt was also made to see if the relations between trauma and mental health were different across the two settings.
Methods
This was a cross-sectional study, for which we conveniently recruited 100 adult Rohingyas, 50 from each country; the majority was males. Rohingyas in Bangladesh fled Myanmar’s Rakhine State following a major military crackdown in 2017, whereas Rohingyas in Malaysia fled Rakhine gradually over the last three decades because of recurrent violence and military operations. We assessed trauma (cumulative trauma, direct trauma, and indirect trauma), PTSD, depression, generalized anxiety, and everyday functioning of the participants using traumatic event questionnaire, PTSD-8, PHQ-9, GAD-7, and WHODAS-2.0.
Results
The Bangladeshi cohort experienced more types of traumatic events (i.e., cumulative trauma) than did the Malaysian cohort (d = 0.58). Although the two cohorts did not differ in terms of indirect exposure to traumatic incidents (i.e., indirect trauma), the Malaysian cohort had direct exposure to traumatic events (i.e., direct trauma) more frequently than did the Bangladeshi cohort (d = 1.22). The Bangladeshi cohort showed higher PTSD (d = 1.67), depression (d = 0.81), generalized anxiety (d = 1.49), and functional impairment (d = 2.51) than those in Malaysia. Hierarchical linear regression analyses showed that after controlling for demographic variables, both direct and indirect trauma significantly predicted PTSD, depression, and functional impairment among Rohingyas in Bangladesh, with direct trauma being the stronger predictor. However, similar analyses showed that only indirect trauma predicted PTSD among Rohingyas in Malaysia, while all other effects were nonsignificant. The results also showed that the predictive relationship between direct trauma and PTSD was different across the two countries. With the same level of direct trauma, a participant from Malaysia would score 0.256 points lower in PTSD than a participant from Bangladesh.
Conclusion
The recently experienced direct and indirect trauma have impaired mental health and everyday functioning among the Bangladeshi cohort. However, only indirect trauma was active to cause PTSD in the Malaysian cohort as direct trauma was weakening due to the time elapsed since migration. We discuss the results in the context of the current theories of trauma and mental health and suggest therapeutic interventions for the refugee population.
Similar content being viewed by others
Availability of data and materials
As it is an ongoing PhD research project of the first author, data is not publicly available. However, it could be accessed upon request from the authors.
References
Mollica RF, Sarajlić N, Chernoff M, Lavelle J, Vuković IS, Massagli MP (2001) Longitudinal study of psychiatric symptoms, disability, mortality, and emigration among Bosnian refugees. J Am Med Assoc 286(5):546–554
Steel Z, Chey T, Silove D, Marnane C, Bryant RA, Van Ommeren M (2009) Association of torture and other potentially traumatic events with mental health outcomes among populations exposed to mass conflict and displacement: a systematic review and meta-analysis. J Am Med Assoc 302(5):537–549. https://doi.org/10.1001/jama.2009.1132
Morina N, Akhtar A, Barth J, Schnyder U (2018) Psychiatric disorders in refugees and internally displaced persons after forced displacement: a systematic review. Front Psychiatry. https://doi.org/10.3389/fpsyt.2018.00433
Silove D, Ventevogel P, Rees S (2017) The contemporary refugee crisis: an overview of mental health challenges. World Psychiatry 16(2):130–139. https://doi.org/10.1002/wps.20438
Tay AK, Rees S, Miah MA, Khan S, Badrudduza M, Morgan K, Azim DF, Balasundaram S, Silove D (2019) Functional impairment as a proxy measure indicating high rates of trauma exposure, post-migration living difficulties, common mental disorders, and poor health amongst Rohingya refugees in Malaysia. Transl Psychiatry 9(1):213. https://doi.org/10.1038/s41398-019-0537-z
Strauss K, Dapp U, Anders J, von Renteln-Kruse W, Schmidt S (2011) Range and specificity of war-related trauma to posttraumatic stress; depression and general health perception: displaced former World War II children in late life. J Affect Disord 128(3):267–276. https://doi.org/10.1016/j.jad.2010.07.009
Lindencrona F, Ekblad S, Hauff E (2008) Mental health of recently resettled refugees from the Middle East in Sweden: the impact of pre-resettlement trauma, resettlement stress and capacity to handle stress. Soc Psychiatry Psychiatr Epidemiol 43(2):121–131. https://doi.org/10.1007/s00127-007-0280-2
American Psychiatric Association (2013) Diagnostic and statistical manual of mental disorders: DSM-5, 5th edn. American Psychiatric Association, Arlington
Zimering R, Gulliver SB, Knight J, Munroe J, Keane TM (2006) Posttraumatic stress disorder in disaster relief workers following direct and indirect trauma exposure to Ground Zero. J Trauma Stress 19(4):553–557
Lee CY, Furnham A, Merritt C (2017) Effect of directness of exposure and trauma type on Mental Health Literacy of PTSD. J Ment Health 26(3):257–263. https://doi.org/10.1080/09638237.2016.1276531
May CL, Wisco BE (2016) Defining trauma: how level of exposure and proximity affect risk for posttraumatic stress disorder. Psychol Trauma Theory Res Pract Policy 8(2):233–240. https://doi.org/10.1037/tra0000077
Abu Suhaiban H, Grasser LR, Javanbakht A (2019) Mental health of refugees and torture survivors: a critical review of prevalence, predictors, and integrated care. Int J Environ Res Public Health 16(13):2309
Getnet B, Medhin G, Alem A (2019) Symptoms of posttraumatic stress disorder and depression among Eritrean refugees in Ethiopia: identifying direct, meditating and moderating predictors from path analysis. BMJ Open 9(1)
Kaya E, Kiliç C, Karadaǧ Çaman Ö, Üner S (2019) Posttraumatic stress and depression among Syrian refugees living in Turkey: findings from an urban sample. J Nerv Ment Dis 207(12):995–1000
Shannon PJ, Vinson GA, Wieling E, Cook T, Letts J (2015) War trauma, and mental health symptoms of newly arrived Karen refugees. J Loss Trauma 20(6):577–590
Borho A, Viazminsky A, Morawa E, Schmitt GM, Georgiadou E, Erim Y (2020) The prevalence and risk factors for mental distress among Syrian refugees in Germany: a register-based follow-up study. BMC Psychiatry 20(1)
Crea TM, Calvo R, Loughry M (2015) Refugee health and wellbeing: differences between urban and camp-based environments in Sub-Saharan Africa. J Refug Stud 28(3):319–330
Miller KE, Rasmussen A (2010) War exposure, daily stressors, and mental health in conflict and post-conflict settings: bridging the divide between trauma-focused and psychosocial frameworks. Soc Sci Med 70(1):7–16
Follette VM, Polusny MA, Bechtle AE, Naugle AE (1996) Cumulative trauma: the impact of child sexual abuse, adult sexual assault, and spouse abuse. J Trauma Stress 9(1):25–35
Neuner F, Schauer M, Karunakara U, Klaschik C, Robert C, Elbert T (2004) Psychological trauma and evidence for enhanced vulnerability for posttraumatic stress disorder through previous trauma among West Nile refugees. BMC Psychiatry 4(1):34. https://doi.org/10.1186/1471-244X-4-34
Lalande KM, Bonanno GA (2011) Retrospective memory bias for the frequency of potentially traumatic events: a prospective study. Psychol Trauma Theory Res Pract Policy 3(2):165–170. https://doi.org/10.1037/a0020847
Wilker S, Pfeiffer A, Kolassa S, Koslowski D, Elbert T, Kolassa IT (2015) How to quantify exposure to traumatic stress? Reliability and predictive validity of measures for cumulative trauma exposure in a post-conflict population. Eur J Psychotraumatol 6(1):28306. https://doi.org/10.3402/ejpt.v6.28306
Tay AK, Rees S, Chen J, Kareth M, Lahe S, Kitau R, David K, Sonoling J, Silove D (2015) Associations of conflict-related trauma and ongoing stressors with the mental health and functioning of West Papuan refugees in Port Moresby, Papua New Guinea (PNG). PLoS ONE. https://doi.org/10.13171/journal.pone.0125178
Slewa-Younan S, Yaser A, Guajardo MGU, Mannan H, Smith CA, Mond JM (2017) The mental health and help-seeking behaviour of resettled Afghan refugees in Australia. Int J Ment Health Syst 11(1):49. https://doi.org/10.1186/s13033-017-0157-z
Jørgensen SF, Auning-Hansen MA, Elklit A (2017) Can disability predict treatment outcome among traumatized refugees? Torture J 27(2):12–26
Sedano-Capdevila A, Barrigón ML, Delgado-Gomez D, Barahona I, Aroca F, Peñuelas-Calvo I, Miguelez-Fernandez C, Rodríguez-Jover A, Amodeo-Escribano S, González-Granado M, Baca-García E (2018) WHODAS 2.0 as a measure of severity of illness: results of a FLDA analysis. Comput Math Methods Med. https://doi.org/10.1155/2018/7353624
Robinson IG, Rahman IS (2012) The unknown fate of the stateless Rohingya. Ox Monit Forced Migr 2(2):16–20
Tay AK, Riley A, Islam R, Welton-Mitchell C, Duchesne B, Waters V, Varner A, Moussa B, Alam AM, Elshazly MA, Silove D (2019) The culture, mental health and psychosocial wellbeing of Rohingya refugees: a systematic review. Epidemiol Psychiatr Sci 28(5):489–494. https://doi.org/10.1017/S2045796019000192
Lee R (2014) A politician, not an icon: Aung San Suu Kyi's silence on Myanmar's Muslim Rohingya. Islam Christ Muslim Relat 25(3):321–333
Mathieson D (2009) Perilous plight: Burma's Rohingya take to the seas. Human Rights Watch, New York
Thom G (2016) The May 2015 boat crisis: the Rohingya in Aceh. Cosmop Civil Soc Interdiscip J 8(2):43–62. https://doi.org/10.5130/ccs.v8i2.4816
Kiragu E, Rosi AL, Morris T (2011) States of Denial–a review of UNHCR's response to the protracted situation of stateless Rohingya refugees in Bangladesh. Policy Development and Evaluation Service, UNHCR. https://www.unhcr.org/4ee754c19.pdf. Accessed 10 Dec 2019
Khan NZ, Shilpi AB, Sultana R, Sarker S, Razia S, Roy B, Arif A, Ahmed MU, Saha SC, McConachie H (2019) Displaced Rohingya children at high risk for mental health problems: findings from refugee camps within Bangladesh. Child Care Health Dev 45(1):28–35. https://doi.org/10.1111/cch.12623
Riley A, Varner A, Ventevogel P, Taimur Hasan MM, Welton-Mitchell C (2017) Daily stressors, trauma exposure, and mental health among stateless Rohingya refugees in Bangladesh. Transcult Psychiatry 54(3):304–331. https://doi.org/10.1177/1363461517705571
World Health Organization (2016) mhGAP intervention guide for mental, neurological and substance use disorders in non-specialized health settings: mental health Gap Action Programme (mhGAP), version 2.0. World Health Organization. https://apps.who.int/iris/handle/10665/250239. Accessed 23 Nov 2019
Keynejad RC, Dua T, Barbui C, Thornicroft G (2018) WHO Mental Health Gap Action Programme (mhGAP) Intervention Guide: a systematic review of evidence from low and middle-income countries. Evid Based Ment Health 21(1):30–34
Mollica RF, Caspi-Yavin Y, Bollini P, Truong T, Tor S, Lavelle J (1992) The Harvard Trauma Questionnaire: validating a cross-cultural instrument for measuring torture, trauma, and posttraumatic stress disorder in Indochinese refugees. J Nerv Ment Dis 180(2):111–116
Hansen M, Andersen TE, Armour C, Elklit A, Palic S, Mackrill T (2010) PTSD-8: a short PTSD inventory. Clin Pract Epidemiol Ment Health 6:101–108. https://doi.org/10.2174/1745017901006010101
Mahmuda M, Miah MAA, Elshazly M, Khan S, Tay AK, Ventevogel P (2019) Contextual adaptation and piloting of Group Integrative Adapt Therapy (IAT-G) amongst Rohingya refugees living in Bangladesh. Intervention 17(2):149–159. https://doi.org/10.4103/INTV.INTV_48_19
Kroenke K, Spitzer RL, Williams JB (2001) The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med 16(9):606–613. https://doi.org/10.1046/j.1525-1497.2001.016009606.x
Spitzer RL, Kroenke K, Williams JB, Löwe B (2006) A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med 166(10):1092–1097. https://doi.org/10.1001/archinte.166.10.1092
Üstün TB, Kostanjsek N, Chatterji S, Rehm J (2010) Measuring health and disability: Manual for WHO disability assessment schedule WHODAS 2.0. World Health Organization, Geneva
Faul F, Erdfelder E, Buchner A, Lang A-G (2009) Statistical power analyses using G*Power 31: tests for correlation and regression analyses. Behav Res Methods 41(4):1149–1160
Field A (2017) Discovering statistics using IBM SPSS statistics: North American edition. Sage
UN News (2017) UN human rights chief points to textbook example of ethnic cleansing in Myanmar. https://news.un.org/en/story/2017/09/564622-un-human-rights-chief-points-textbook-example-ethnic-cleansing-myanmar. Accessed 27 July 2019
Tazreiter C, Pickering S, Powell R (2017) Rohingya women in Malaysia: decision making and information sharing in the course of irregular migration. Robert Schuman Centre for Advanced Studies Research Paper No. RSCAS, 55. https://doi.org/10.2139/ssrn.3079644
Menon P, Marshell ARC (2015) Malaysian police reveal grim secrets of jungle trafficking camps. Reuters. https://www.reuters.com/article/us-asia-migrants/malaysian-police-reveal-grim-secrets-of-jungle-trafficking-camps-idUSKBN0OB09E20150526. Accessed 10 Dec 2019
The Guardian (2017) ‘They drowned before our eyes’- dozens die as Rohingya refugee boat capsizes. https://www.theguardian.com/world/2017/sep/29/boat-carrying-fleeing-rohingya-muslims-capsizes-myanmar. Accessed 10 Dec 2019
International Organization for Migration Report (2019) Mediterranean migrant arrivals reach 36,670 in 2019; Deaths reach 686. https://www.iom.int/news/mediterranean-migrant-arrivals-reach-36670-2019-deaths-reach-686. Accessed 10 Dec 2019
Wahab AA, Khairi A (2019) Moving onward: Transnationalism and factors influencing rohingyas’ migration from Bangladesh to Malaysia. J Nusantara Stud 4(1):49–68. https://doi.org/10.24200/jonus.vol4iss1pp49-68
Hobfoll SE (1989) Conservation of resources: a new attempt at conceptualizing stress. Am Psychol 44(3):513–524. https://doi.org/10.1037//0003-066x.44.3.513
Silove D (1999) The psychosocial effects of torture, mass human rights violations, and refugee trauma: toward an integrated conceptual framework. J Nerv Ment Dis 187(4):200–207
Karunakara UK, Neuner F, Schauer M, Singh K, Hill K, Elbert T, Burnham G (2004) Traumatic events and symptoms of posttraumatic stress disorder amongst Sudanese nationals, refugees and Ugandans in the West Nile. Afr Health Sci 4(2):83–93
Mollica RF, McInnes K, Pham T, Fawzi MCS, Murphy E, Lin L (1998) The dose–effect relationships between torture and psychiatric symptoms in Vietnamese ex-political detainees and a comparison group. J Nerv Ment Dis 186(9):543–553. https://doi.org/10.1097/00005053-199809000-00005
Mollica RF, McInnes K, Pool C, Tor S (1998) Dose–effect relationships of trauma to symptoms of depression and posttraumatic stress disorder among Cambodian survivors of mass violence. Br J Psychiatry 173(6):482–488. https://doi.org/10.1192/bjp.173.6.482
Keatley E, Ashman T, Im B, Rasmussen A (2013) Self-reported head injury among refugee survivors of torture. J Head Trauma Rehabil 28(6):E8–E13. https://doi.org/10.1097/HTR.0b013e3182776a70
Hynie M (2018) The social determinants of Refugee mental health in the post-migration context: a critical review. Can J Psychiatry 63(5):297–303. https://doi.org/10.1177/0706743717746666
Liamputtong P, Kurban H (2018) Health, social integration and social support: the lived experiences of young Middle-Eastern refugees living in Melbourne, Australia. Child Youth Serv Rev 85:99–106. https://doi.org/10.1016/j.childyouth.2017.12.020
Van Dijk JA, Schoutrop MJA, Spinhoven P (2003) Testimony therapy: treatment method for traumatized victims of organized violence. Am J Psychother 57(3):361–373. https://doi.org/10.1176/appi.psychotherapy.2003.57.3.361
Esala JJ, Taing S (2017) Testimony therapy with ritual: a pilot randomized controlled trial. J Trauma Stress 30(1):94–98. https://doi.org/10.1002/jts.22163
Agger I, Raghuvanshi L, Shabana S, Polatin P, Laursen LK (2009) Testimonial therapy. A pilot project to improve psychological wellbeing among survivors of torture in India. Torture 19(3):204–217
Rothbaum BO, Davis M (2003) Applying learning principles to the treatment of Post-Trauma reactions. Ann NY Acad Sci 1008(1):112–121. https://doi.org/10.1196/annals.1301.012
Wessa M, Flor H (2007) Failure of extinction of fear responses in posttraumatic stress disorder: evidence from second-order conditioning. Am J Psychiatry 164(11):1684–1692. https://doi.org/10.1176/appi.ajp.2007.07030525
Neria Y, Sullivan GM (2011) Understanding the mental health effects of Indirect exposure to mass trauma through the media. J Am Med Assoc 306(12):1374–1375. https://doi.org/10.1001/jama.2011.1358
Johnstone L, Boyle M, Cromby J, Dillon J, Harper D, Kinderman P, Read J (2018) The power threat meaning framework. In British Psychological Society, Leicester
Azis A (2014) Urban refugees in a graduated sovereignty: the experiences of the stateless Rohingya in the Klang Valley. Citizsh Stud 18(8):839–854. https://doi.org/10.1080/13621025.2014.964546
Towadi M (2017) The application of Sharia Maqashis on the protection of the rights of minority of Muslim Rohingya in regional ASEAN (Indonesia–Malaysia). J Indones Leg Stud 2(1):43–54
Acknowledgements
The authors acknowledge the contributions of the members of the Rohingya refugee communities in Bangladesh and Malaysia, who participated in the study. They also acknowledge Tony Wainwright for giving feedback on the earlier version of the manuscript.
Funding
The authors thank Monash University Malaysia for offering a Merit Scholarship for PhD to Sanjida Khan.
Author information
Authors and Affiliations
Contributions
SH and SK conceived the research idea. SK was involved in data collection. SH and SK contributed to data analysis and equally involved in the writing of the manuscript.
Corresponding author
Ethics declarations
Conflict of interest
The authors declare no conflict of interest.
Ethical approval
Data collection commenced after ethics clearance from Monash University Human Research Ethics Committee (Project No. 12032) and the National Research Ethics Committee (NREC) under Bangladesh Medical Research Council (Registration No. 13831072018).
Consent to participate
Informed consent was taken from participants.
Consent for publication
The authors have consent for publication.
Rights and permissions
About this article
Cite this article
Khan, S., Haque, S. Trauma, mental health, and everyday functioning among Rohingya refugee people living in short- and long-term resettlements. Soc Psychiatry Psychiatr Epidemiol 56, 497–512 (2021). https://doi.org/10.1007/s00127-020-01962-1
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00127-020-01962-1