Community-Based Approaches to Understanding Refugee Resettlement and Mental Health:
Philadelphia Refugee Photovoice Project
Ellen J Plumb*, Melissa Fogg**, Anna Escuder*, Christie Mulholland*, Michael Cafarchio*, James D
Plumb*, Rickie Brawer*
Thomas Jefferson University Hospital, Department of Family and Community Medicine, Center for Urban Health
**Lutheran Children and Family Service
INTRODUCTION
Refugees are a population at high risk for mental health issues due to premigration, migration, and post-migration stressors. The Philadelphia Mental
Health Collaborative is a citywide coalition aimed at identifying and developing
refugee mental health services in Philadelphia. Through this innovative
Collaborative, Philadelphia area refugee resettlement agencies, communitybased arts organizations, and refugee clinical care providers have partnered to
develop culturally and socially appropriate mental health programming for
disparate refugee populations that address and reflect the complexity of the
resettlement process.
OBJECTIVES
The purpose of this study is to conduct a community-based assessment of
mental health needs in Iraqi, Burmese, and Bhutanese refugee resettlement
communities in Philadelphia using the Photovoice methodology in order to;
1.Identify migration and resettlement stresses that affect mental health and
identify social, environmental, and cultural determinants of and concepts of
mental health in Bhutanese, Burmese, and Iraqi refugee families
Opportunity
RESULTS
Recruitment
Camera Training
Small Group
Discussion
ENVISIONING HOME: EXHIBIT CATEGORIES
1. enable people to record and reflect on their community’s strengths and
concerns
Multi-Step Process: training with camera, taking photographs, choosing
photographs, large and small group discussions (focus groups), creating
a narrative, telling a story
Recruitment: through referrals from resettlement agencies and providers
I like the woman in this mural.
She describes life here. She
has to carry heavy things.
There are a lot of hard things
in our life here but if we try
hard we can make it. We must
be insistent to carry our
burdens, have patience, and
think of our future.
DISCUSSION
Face in Shadows
Cemetery
This woman’s mother died. She is
sitting alone in the darkness
mourning her death. No-one is
allowed to touch her during the 13
days of mourning.
This is a cemetery. Cemeteries are very
different here. They are like heaven,
like a garden. Death is not a terrible
thing here. In Iraq, everyone is scared
of death. The cemeteries are very large
and almost full. So many people have
been killed.
Ceremonial Feast
When a new baby is born in our culture, we
celebrate. After 11 days, we have a baby
naming ceremony, Nuran. We invite friends
and family for food. Here we are free to
have these ceremonies.
Family
Father at Home
Mother in Law
My father is new here. I came
here two or three months
before he came here. My
father is old, so he doesn’t
have a job. Being old, he
cannot walk around the
street so he is at home. He is
isck, so he cannot do any
work.
This is my mother in law. For
the first 10 days that she was
here,
she
was
feeling
depressed. She feels like there
is no life here, like no-one is
related to each other and
everyone is busy. She wasnts to
go home. She feels strange
here.
2. promote critical dialogue about important issues through large and small
group discussion of photographs
3.to reach policymakers.
Mural of a Statue
Culture
The main goal of CBPR is to develop community health programs that
address and recognize differences in culture, health beliefs, and disease
presentations.
Photovoice, a community based research methodology, is a process by which
people can identify, represent, and enhance their community through a specific
photographic technique, and it has three main goals:
I thought when I came to the U.S.
that I would have a better job and
better salary. While it was not
comfortable to live in the refugee
camps in Malaysia, we did not have
to pay bills there. In Philadelphia,
there are so many bills to pay. I
keep them in this jar.
This is the welfare office, where
many refugees go to receive
support for healthcare and other
services. It is very difficult to get
our benefits, especially when we
do not speak English well.
Refugees who are fluent in
English often accompany other
refugees. It can take 2-3 hours
per trip and many refugees are
not aware of their benefits.
Honoring Our Roots-Culture: The traditions that are distinctive of the individual's native
country. These aspects include clothing, food, religion, art, and history.
Where the Heart Is-Family: The relationships, activities, and stresses of daily life.
Between Earth and Sky-Environment: How individuals perceive and engage with the world
around them.
Building Futures-Opportunity: The opportunities and struggles experienced in the pursuit of
growth and prosperity for individuals and families.
RESEARCH APPROACH
RESEARCH METHODS
This represents my brother
and I fleeing through the
jungle from Malaysia. We
followed an uncle from our
village to the refugee camp.
We were only 14 and 15
years old and we were very
scared.
Welfare Building
3.Develop socially and culturally appropriate mental health services for
refugee populations in Philadelphia
characterized by the equitable involvement of researchers and community
members in the research process.
Panda Jar
Sharing Stories
2.Gain a greater understanding of community development among refugee
communities resettling in Philadelphia.
Community Based Participatory Research (CBPR) Approach is
Jungle Fingers
Environment
Trash
There is a lot of garbage
thrown on my block and in
my neighborhood. We do not
understand
why
people
throw
garbage
on
the
ground-we thought America
was a clean, beautiful place.
Sneakers
When I moved here, I noticed
the shoes hanging on the
telephone wires. I can’t believe
how wasteful that is! Shoes are
expensive.
We
did
not
understand that this was a
symbol for a drug corner. This
is outside of an elementary
school.
Although still in progress, this Photovoice project is providing important information about
the resettlement experiences of Philadelphia-area refugees and guiding efforts to provide
quality mental health care and services for disparate populations in transition in a clinical
environment characterized by limited socio-cultural knowledge, communication
challenges, insurance issues, and systems-level inefficiencies. The data collected is
allowing us to address these quality of and access to care issues and answer important
clinical questions, such as:
When is the best time to screen for mental health in refugees? Who is the best provider
for mental health in this population? Where is the best place to provide mental healthcare
for these communities? What is a good model for mental healthcare for disparate refugee
populations in Philadelphia.
.
This Photovoice project has also provided a foundation for innovative academiccommunity partnerships between Philadelphia area social service agencies, arts-based
organizations, and clinical care providers. Through these partnerships, there has been a
movement towards more culturally appropriate and community-focused mental health
initiatives, including implementation of a refugee mural arts project by the City of
Philadelphia Mural Arts Program and the development of a new community center with
programming focused on community empowerment, preservation of cultural heritage, and
economic development. Most importantly, the photographs and stories created by refugee
participants as part of this Photovoice project will continue to be used to generate
awareness of mental health and resettlement stress among refugees and advocate for
policy-level changes aimed at improving access to mental health services for these
populations.
Acknowledgments
Lutheran Children and Family Services, Philadelphia Mental Health Collaborative,
Jefferson Family Medicine Residency Program, Magic Gardens Philadelphia, City of
Philadelphia Mural Arts Program, BuildaBridge, First Person Arts