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. Author manuscript; available in PMC: 2024 Jul 1.
Published in final edited form as: J Trauma Stress. 2022 Jun 21;35(5):1472–1483. doi: 10.1002/jts.22853

Geocultural variation in correlates of psychological distress among refugees resettled in the United States

Meredith A Blackwell 1, David T Lardier 2, Ryeora Choe 3, Jessica R Goodkind 3
PMCID: PMC11216627  NIHMSID: NIHMS2000083  PMID: 35729776

Abstract

Attention to cultural variability in mental health symptoms could inform intervention targets; however, this is currently a neglected area of study. In this study, we examined whether the associations between common mental health disorder (CMD) symptoms and predictors of these disorders varied cross-culturally. Participants were 290 refugees from three geocultural regions (Afghanistan, Great Lakes region of Africa, and Iraq and Syria) who recently resettled in the United States and completed assessments of CMD symptoms and predictors. Multilevel generalized linear modeling was used to examine the interactions between correlates of depressive, anxiety, and posttraumatic stress disorder (PTSD) symptoms and each of the three cultural reference groups. Relative to refugees from other geocultural regions, Iraqi and Syrian participants demonstrated stronger associations between the number of reported traumatic experiences and both depressive, B = 0.01, SE= .003, p = .003 and anxiety symptoms B = 0.01, SE= .003, p < .001; Afghan participants showed a stronger association between physical quality of life and PTSD symptoms, B = 0.02, SE = .011, p = .037; and African participants demonstrated a stronger association between gender and symptoms of all three CMDs, Bs = 0.11–.020, SEs = .04–.06, ps = .005-.008, and a weaker association between traumatic event exposure and CMD symptoms, Bs = −0.01–−0.02, SEs = .003–.006, ps = .000-.002. CMD symptoms likely present differently across cultures, with various predictors more salient depending on cultural backgrounds and differential experiences that vary based on context. These findings have implications for cross-cultural assessment research and mental health.

Due to the violent and destabilizing nature of conflict, refugees and forcibly displaced persons are at a higher risk of mental health disorders than citizens of stable nations (Fondacaro & Mazulla, 2018; Ibrahim & Hassan, 2017). Most civilians from conflict-affected areas will have experienced at least one potentially traumatic event, such as torture, sexual violence, or separation from family and imprisonment, either in conflict or during vulnerable and unprotected migration stages (Johnson & Thompson, 2008). In addition to traumatic events, refugees are also likely to experience prolonged stress, such as limited access to services, inability to work, and insecure residency status (Nickerson et al., 2015). A combination of these stressors means that compared to the 1–4% of citizens from Western nations who report posttraumatic stress disorder (PTSD; Atwoli et al., 2015), refugees resettled in Western nations present at rates of 9% (Fazel et al., 2005), and refugees who have not been resettled experience PTSD at even higher rates of 39%–100% (Chung et al., 2017; Steel et al., 2002).

Because of the link between environment and mental health, there is some debate as to whether an emphasis should be placed on empirically supported treatments (ESTs) or more concrete psychosocial aid (Alfadhli & Drury, 2016; Nickerson et al., 2011). Although there is growing support that adapted ESTs have utility (Singla et al., 2017), detractors note that psychotherapy may be a less effective, compensatory measure to address individuals’ social contexts. Miller and Rasmussen (2010) found that among war-exposed groups, chronic stress—such as concerns over living conditions and health—and prior trauma exposure played equal roles in mental health outcomes. In a recent study on unconditional cash transfers in Kenya, Haushofer (2020) not only found that cash transfers improved mental health more than a therapeutic intervention but also that individuals who received both cash and therapy did not improve more than those who received just money. However, not all cash transfer programs demonstrate effects on mental health, even if recipients report other positive impacts on general health and quality of life (Zimmerman et al., 2021). It is possible that interventions focused on psychosocial relief might effectively improve mental health in some groups, whereas others need a more trauma-focused approach.

Cultural conceptions of mental health

Recently, researchers have undertaken more cross-cultural translations of measurement tools to improve mental health assessment. The validity of existing measurement tools and scales used to examine mental health and illness has been called into question due to cultural variability in disorder presentation (Choe et al., 2022; Prince, 2008). As most measurement tools are based on biomedical explanatory models that are constructed and developed within Western mental health contexts, some of these measurement tools fail to capture the range of symptoms of distress cross-culturally. Measures may misinterpret somatic responses or have noninvariant factor structures of latent variables across cultures (Rasmussen et al., 2015). However, valid mental health assessment is not simply achieved by distinguishing different disorder factors from Western conceptualizations; the assessment of trauma exposure and mental health in refugee groups should be relevant and applicable to different populations across cultures. Various cultural groups will have distinct symptom presentations to which researchers will need to be sensitive.

In addition to the debate on conceptual differences in mental health between Western and non-Western cultures, some scholars suggest that migrant experiences and identities also create distinct cultures that are products of transnational migration (Kirmayer, 2006). Cultures are dynamic and change based on choices individuals make as well as on the multiple aspects of these individuals’ identities and social locations (Kirmayer & Gómez-Carrillo, 2019). Because refugees continue to engage in multilayered social contexts by maintaining connections to their homes and building social networks in new locations, these dynamics simultaneously affect their ideas about mental health and many other aspects of their lives. Although previous studies have identified limitations related to refugee mental health diagnosis and intervention, such as the provision of invalid measurements or inappropriate services (Fazel et al., 2005; Hollifield et al., 2002), there is scant research examining how measurement, diagnosis, services, and social factors play out in the transnational context. The process of migration and resultant hybrid identities may also impact the prominence of various symptoms and correlates of common mental disorders (CMDs) in resettled refugee populations.

Some research has been undertaken with refugees to identify the correlates and symptoms of CMDs. Among Afghans, the number of reported traumatic experiences, older age, being female, low levels of social support or isolation, and higher levels of current stress (e.g., poverty, lower social support, poor physical health) consistently have demonstrated correlations with CMDs, such as depression and PTSD (Alemi et al., 2015; Gerritsen et al., 2006; Hamrah et el., 2021; Kalafi et al., 2002). In Iraqis and Syrians, older age, being female, difficulty with a new language, higher levels of current stress, more reported traumatic experiences, low social support, and lower religiosity or religious coping have been associated with depression and PTSD. However, older age and female sex or gender have demonstrated mixed findings in relation to mental health (Gleeson et al., 2020; Kaya et al., 2019; Naal et al., 2021; Selmo et al., 2021). In Central African nations, such as Rwanda and the Democratic Republic of the Congo, being female, having a lower level of educational attainment, and reporting higher levels of current stress have been correlated with CMDs, although religious centrality has also been associated with improved mental health (De Menil, 2012; Schweitzer, 2006). Additionally, separation from family has been associated with CMDs among displaced persons (Miller et al., 2018).

With the understanding that similar disorders present differently in diverse cultural groups, factors and symptoms known to predict mental distress, such as insufficient social support, trauma history, and income, may also vary in significance. Although measurement validity has been studied cross-culturally, correlates of CMDs have only been studied multiculturally—that is, there is some research in a variety of cultures but no known research that could help identify differences in the associations among multiple predictors in certain cultural groups compared with others, especially in displaced groups, where mental health symptoms may be impacted by hybrid identities (Prina et al., 2011). Understanding these differences in risk is a primary step in bringing mental health research to a global scale. Identifying the strength of correlates of mental health symptoms in various populations can aid in identifying risks, vulnerabilities, and protective factors, eventually helping to guide future intervention targets.

Present study

The extant literature has demonstrated etiological determinants of mental illness among refugees from various geocultural groups; however, much work remains with respect to identifying culturally specific predictors of mental distress. More specifically, there is a need to examine social determinants specific to refugees to guide treatment and prevention methods. There are numerous gaps in the literature that do not consider the nested hierarchical intercorrelations of refugee data within communities or households. This ignores variability not only at the individual level of analysis but also among and between social structures, such as households or communities. Therefore, the current study examined cultural variance in correlates (e.g., social support, satisfaction with resources, environmental quality) of mental health symptoms (e.g., PTSD, depressive, and anxiety symptoms) among participants from three main regions: Afghanistan, the Great Lakes region of Africa (Burundi, Democratic Republic of Congo, Republic of the Congo, and Rwanda), and Iraq and Syria. We hypothesized that (a) social support, satisfaction with resources, and environmental quality of life would demonstrate significant negative associations with outcomes related to symptoms of psychological distress and (b) associations between CMD symptoms and social support, satisfaction with resources, and environmental quality, would vary across geocultural groups.

METHOD

Participants and procedure

The data analyzed in this study were collected as part of a randomized control trial of a community-based mental health intervention for recently resettled refugees, which was approved by the University of New Mexico Human Research Protections Office. Data collected at the first assessment point (i.e., prior to randomization) were used in the current analyses. See Goodkind and colleagues (2020) for additional study details and outcomes.

Participants were recently resettled refugees (N = 290) from 143 households. All participants resided in a city in the southwestern United States. Quantitative data were collected at each participant’s home in their native language via personal interviews with a bilingual and bicultural interviewer. Participants were nearly equally represented from three main geographic origins: Afghanistan (n = 103, 35.5%), Iraq and Syria (n = 95, 32.8%), and the Great Lakes region of Africa (n = 92, 31.7%). Just over half (52.4%) of participants were women. All refugees aged 18 years and older from these regions who had arrived in the United States within the past 3 years and were living in the city where the study took place were invited to participate; 88.8% agreed. Participants were excluded if they reported severe cognitive functioning difficulties, imminent suicide risk, severe mental illness, or participation in existing trauma-focused treatment. Only two participants were excluded due to these criteria and were referred for other treatment.

The research team, which included members of the geocultural groups represented in the sample, carefully selected the terms used to describe the three groups in this study. This was meant to recognize the distinct ethnicities and histories of these groups while acknowledging cultural, religious, and linguistic similarities that come from geographic proximity and shared cultural history. Although Iraqis and Syrians are nationally distinct and have political and historical differences, their dialects of Arabic are generally mutually intelligible, their cultural and religious backgrounds are similar, and they share similar experiences of forced resettlement, especially during the recent conflicts with Daesh or the Islamic State. The term “Great Lakes Africans” refers to people from the Great Lakes region of Africa, which includes the eastern and central African countries surrounding Lake Kivu, Lake Tanganyika, and Lake Victoria (i.e., Burundi, the Democratic Republic of Congo, Republic of the Congo, and Rwanda). The individuals in this geocultural group come from multiple ethnic groups but have similar cultural backgrounds, perspectives on health and well-being, and experiences of forced displacement and resettlement. Many of these countries were affected by interrelated conflicts and genocides. Additionally, many participants have traveled and resided in multiple countries in this region, making it difficult to articulate their country of origin. For these reasons, we used the term described to reflect individuals who were resettled from these regions.

Measures

All measures used in the study have a history of successful implementation with refugees and culturally diverse groups and were administered in the participant’s preferred language. Using the Translation, Review, Adjudication, Pretesting, and Documentation (TRAPD) process, they were translated and back-translated from English into Arabic, Dari, French, Kiswahili, and Pashto (Survey Research Center, 2016).

PTSD symptoms

The PTSD Symptom Checklist–Civilian Version (PCL-C; Weathers et al., 1993) is a 17-item self-reported measure of PTSD symptoms, per the criteria in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). Respondents rate answers on a scale ranging from 1 (not at all) to 5 (extremely). A total score is calculated (range: 17–85), with higher scores indicating higher PTSD symptom levels. The PCL-C has demonstrated strong psychometric properties (Ruggiero et al., 2003) and has been used or validated in all three geocultural groups represented in this study (Arnetz et al., 2013; Fodor et al., 2015; Ibrahim et al., 2018; Patterson et al., 2017). An advantage of the PCL-C is that it asks about symptoms in relation to generic “stressful experiences” rather than a specific traumatic event, which allows refugees to consider multiple potentially traumatic events relevant to their experience. In the present sample, participant scores ranged from 17 to 81 (M = 29.95, SD = 15.02), and Cronbach’s alpha was .95.

Depressive and anxiety symptoms

The Hopkins Symptom Checklist (HSC-25; Derogatis, 1974) is a self-report measure of anxiety and depressive symptoms that has been shown to be a valid measure of symptoms in refugee populations (Hollifield et al., 2002). Respondents rate 25 items on a Likert-type scale ranging from 1 (not at all) to 4 (extremely). Mean scores for items related to depression (15 items) and anxiety (10 items) can be calculated to create separate subscale scores (range: 1–4), with higher scores indicating higher levels of emotional distress. The HSC-25 has been used or validated in all three geocultural groups represented in this study (Hall et al., 2014; Wind et al., 2017). One item from the Depression subscale (“loss of sexual interest or pleasure”) was removed because research team members from the original study found this question to be culturally inappropriate. As the study sought to examine cross-sectional symptom correlates, cutoff scores were not used in the analysis. In the present sample, the mean total score for the full HSC-25 was 1.55 (SD = 0.60), and demonstrated excellent reliability, Cronbach’s α = .96.

Social support

The Multi-Sector Social Support Inventory Scale (MSSSI; Layne et al., 2009) was used to assess perceived past-month social support in three domains that are typically salient for refugees: family, ethnic community, and nonethnic community. Each of the three parallel scales includes the same nine items related to subjective attachment (e.g., “I feel like I ‘fit in’ and belong with the members of the African/Afghan/Iraqi and Syrian community”) and perceived support (e.g., “I can count on members of my family if I need help”). Response choices range from 0 (never) to 4 (almost always), and total scores can range from 0 to 4. Scores can be tabulated for each domain-specific subscale and for the total scale. For this study, the mean of all items was used to capture a global perception of social support, with higher scores reflecting higher levels of perceived social support (M = 1.92, SD = 0.71). The MSSSI has been used or validated in all three geocultural groups represented in this study (Sierau, 2019; Soller et al., 2018). In the present sample, Cronbach’s alpha values for family, ethnic community, and nonethnic community social support were .87, .92, and .89, respectively

Satisfaction with resources

The Satisfaction with Resources Scale (Sullivan, et al., 1992) asks respondents to rate how satisfied they are with the resources they have in 11 specific domains (e.g., education, health care, housing, employment). Items are rated on a 7-point scale and averaged, with domain-specific scores ranging from 1 to 7. Higher scores reflect higher levels of perceived satisfaction with resources in the community (M = 2.34, SD = 2.43). The scale has been used or validated in all three geocultural groups represented in this study (Goodkind et al., 2014). In the present sample, Cronbach’s alpha was .90.

Environmental and physical quality of life

The Environmental and Physical subscales of the World Health Organization Quality of Life Assessment (WHOQOL; WHOQOL Group, 1998) were used to examine environmental physical quality of life. Items are rated on a 5-point scale ranging from 1 (not at all) to 5 (an extreme amount). Total scores are calculated for each subscale, with higher scores indicating higher perceived quality of life in a given domain. The four-item Environmental subscale assesses participants’ feelings of safety, the health of their physical environment, and their access to needed information (M = 12.70, SD = 2.94). The four-item Physical subscale assesses respondents’ satisfaction with their health, energy, pain, and need for medical treatment (M = 10.88, SD = 3.20). The WHOQOL has been used or validated in all three geocultural groups represented in this study (Al Sayah et al., 2013; Bowden et al., 2003; Mwanyagala et al., 2010; Shayan et al., 2021). In the present sample, Cronbach’s alpha values were .79 for the Environmental subscale and .80 for the Physical subscale.

Trauma exposure

Trauma exposure was assessed using a checklist that included items from the Adolescent Self-Report Trauma Questionnaire (Horowitz et al., 1995), the Harvard Trauma Questionnaire (Mollica et al., 1992), and the PTSD Symptom Scale (Falsetti et al., 1993). A panel of researchers and cultural experts from the geocultural groups represented in the sample selected various items from these previously validated measures specifically for this study to best capture the experiences of these forcibly displaced groups; however, the checklist’s psychometric properties have not been assessed. Participants were asked if they had personally experienced various potentially traumatic events, such as “being witness to a physical assault, beatings, or torture” and “imprisonment (including being held in a concentration camp).” The checklist included 27 dichotomous items (i.e., 1 for “yes,” 0 for “no”), with possible scores ranging from 0 to 27. Higher scores indicated exposure to more traumatic events. In the present sample, the mean score was 8.00 (SD = 6.46).

English proficiency

Perceived English proficiency (PEP; Rumbaut, 1989) was measured as the mean of four items that asked participants to rate how well they understand, speak, read, and write English. Response choices ranged from 0 (not at all) to 3 (like a native), and total scores were calculated and averaged (range: 0–3; M = 1.08, SD = 0.66). Higher scores reflect higher degrees of perceived English proficiency. PEP has been shown to be highly correlated with objective measures of English proficiency (Rumbaut, 1989). In the present sample, Cronbach’s alpha was .92.

Demographic characteristics

Demographic covariates were included as independent variables and retained based on statistical significance and model performance. These variables included gender, age, national origin, time in the United States, household size, and monthly income. Gender was measured as a dichotomous variable (1 = female, 0 = male). Age was measured continuously (M = 34.60 years, SD = 11.53, range: 18–71 years). National origin was dummy-coded into three separate items to assess origin being either Iraqi or Syrian (yes = 1, no = 0), Afghan (yes = 1, no = 0), or Great Lakes African (yes = 1, no = 0). Monthly income (USD) was measured using a single continuous variable, with the income ranging from $0 to $3,000.00 (M = $706.79, SD = 667.77).

Data analysis

A multilevel random-effects regression model, which uses maximum likelihood estimation, was run using the glmmTMB package in R (R Foundation for Statistical Computing, 2022). Individuals at Level 1 were nested within households at Level 2 (Brooks et al., 2017). The R package InteractionPoweR was used to establish the power of testing for interaction effects and showed the sample size of 290 provided .92 power to detect small-to-medium interaction effects on outcomes. Interaction and correlation weights of .1–.2 for the power simulation were used based on initial findings from Goodkind and colleagues (2020). There were no missing data for the variables assessed in this analysis.

We tested for the direct effects of the expected correlates of PTSD, depressive, and anxiety symptoms and the interaction effect for each regional group in the sample (i.e., Iraqi and Syrian, Afghan, and Great Lakes African) as a moderator of the strength of the associations between these correlates on symptoms. A significant interaction would indicate that the correlate plays a more substantial role in strengthening or weakening associations with mental health symptoms for a given particular regional group. For models with PTSD symptoms as an outcome, a zero-inflated Poisson distribution was used. For models with depressive and anxiety symptoms as outcomes, a log transformation was used, as the distribution was underdispersed. An unstructured covariance matrix was used in these analyses, which has been shown to be preferable when using a small number of longitudinal repeated measures (Brooks et al., 2017; Littell et al., 2000).

For the present study, there were two stages of analyses: We first aimed to identify correlates of CMD symptoms for the entire sample and then assessed whether the strength of the correlations changed when geocultural region was included as an interaction term. Akaike information criterion (AIC) and Bayesian information criterion (BIC) scores were calculated at both stages to quantify model parsimony and goodness of fit. An interaction model with a lower AIC or BIC than the null model would suggest a better performance, outweighing the added complexity of the interactions. Using the baseline assessments as a guide, several measures of latent variables were selected based on past research suggesting their potential influence on symptoms of emotional disorders in this sample (Goodkind et al., 2020). Variables representing social support, satisfaction with resources, environmental quality of life, physical quality of life, gender, the extent of trauma history, income, and English proficiency were entered as independent variables for the entire sample, with depressive, anxiety, and PTSD symptoms as outcomes. For predictors that were found to be significantly correlated with an outcome, the second set of analyses added geocultural origin as an interaction term with each of the significant predictors to determine if these variables were more substantially related to CMD symptoms based on geographical background. An insignificant interaction with geographic origin was taken to imply that a variable was not related to the outcome for that group but rather that the association between the variable and CMD symptoms was not significantly different for that group than for the other groups.

RESULTS

Direct effects

To determine which predictors were most appropriate, all hypothesized correlates of psychological distress were entered for the full sample. When income was entered, the PTSD symptom model was overparameterized and would not run; thus, it was removed from the analysis. For depressive symptoms as the outcome, social support, B = 0.01, SE = .004, p = .009; satisfaction with resources, B = −0.04, SE = .01, p = .002 physical quality of life, B = −0.02, SE = .003, p < .001; gender, B = −0.04, SE = .02, p = .030 and trauma exposure, B = 0.005, SE = .002, p = .001, were significant. Environmental quality of life, B = −0.007, SE = .004, p = .063, was nonsignificant, but because the p value was .06, it was kept in the model for the interaction analyses. English proficiency was nonsignificant and was not included in subgroup analyses. For anxiety symptoms, social support, B = 0.01, SE = .004, p = .002; satisfaction with resources, B = −0.03, SE = .004, p = .004, physical quality of life, B = −0.02, SE = .003, p < .001, gender, B = −0.05, SE = .02, p < 001, and trauma exposure, B = 0.007, SE = .002, p < .001, were significantly correlated. The associations between environmental quality of life and English proficiency were nonsignificant and, therefore, not included in the interaction analyses. For PTSD symptoms, significant associations were observed with satisfaction with resources, B = −0.08, SE = .02, p < .001; physical quality of life, B = −0.03, SE = .006, p < .001; gender, B = −0.07, SE = .03, p = .007; and trauma exposure, B = 0.03, SE = .003, p < .001. Social support, English proficiency, and environmental quality of life were not included in interactional analyses due to nonsignificant direct effects. See Table 1 for summary of initial correlates.

TABLE 1.

Interaction results for three models with the Iraqi/Syrian reference group

Variable PTSD symptoms Depressive symptoms Anxiety symptoms
Estimate SE Estimate SE Estimate SE
Fixed effects
 Intercept 3.64 0.096*** 0.216 0.06*** 0.144 0.06*
Independent variable
 Social support 0.005 0.004 0.012 0.005*
 Satisfaction with resources −0.087 0.0214*** −0.044 0.013*** 0.044 0.013***
 Physical quality of life −0.024 0.007*** −0.02 0.004*** −0.02 0.004***
 Gender −0.045 0.035 −0.036 0.03 −0.046 0.023*
 Traumatic events 0.022 0.003*** 0.003 0.002 0.004 0.002
Independent Variable x Iraqi/Syrian Reference
 Social support 0.001 0.009 −0.01 0.009
 Satisfaction with resources 0.013 0.037 0.024 0.026 −0.001 0.026
 Physical quality of life −0.02 0.011 0.001 0.008 0.004 0.008
 Gender −0.11 0.052* −0.046 0.38 −0.051 0.038
 Traumatic events 0.011 0.006 0.012 0.004** 0.015 0.004***
−2 residual log-likelihood −1,072.0 161.0 167.9
AIC null 2,210.2 −269.7 −288.3
AIC 2,167.9 −294.0 −307.7
BIC null 2,246.9 −240.3 −258.9
BIC 2,212.0 −242.6 −256.4
N 290 290 290
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Note: PTSD = posttraumatic stress disorder; AIC = Akaike information criterion; BIC = Bayesian information criterion.

Interaction effects

Iraqi and Syrian geocultural background

Regarding the interaction effects between independent variables and geocultural background, only trauma exposure had a stronger association with both depressive symptoms, B = 0.01, SE = .004, p = .003, and anxiety symptoms, B = 0.01, SE = .004, p < .001, for Iraqi and Syrian participants compared with Afghan or Great Lakes African participants. However, trauma exposure was not a significantly stronger predictor of PTSD symptoms for Iraqis and Syrians, p = .092. The geocultural background interaction effect was significant for gender and PTSD symptoms, B = −0.11, SE = .05, p = .035, indicating that Iraqi and Syrian women had lower vulnerability for PTSD symptoms than Afghan and Great Lakes African women (see Table 1 for a complete list of findings).

Afghan geocultural background

Among Afghan participants, a significant negative interaction was observed between depressive symptoms and social support, B = −0.02, SE = .008, p = .006, indicating that social support was less related to depressive symptoms for Afghan participants than for those in the other geocultural groups. We did not find any significant interactions for anxiety symptoms in this group. For PTSD symptoms, there was a negative interaction for physical quality of life, B = 0.02, SE = .011, p = .037, indicating that physical quality of life was less strongly related to PTSD symptoms for Afghan participants compared with other groups (see Table 2 for a complete list of findings).

TABLE 2.

Interaction results for three models with the Afghan reference group

Variable PTSD symptoms Depressive symptoms Anxiety symptoms
Fixed effects Estimate SE Estimate SE Estimate SE
 Intercept 3.95 0.101*** 0.293 0.07*** 0.215 0.07*
Independent variable
 Social support 0.019 0.006*** 0.02 0.006***
 Satisfaction with resources −0.087 0.024*** −0.041 0.103** −0.047 0.015**
 Physical quality of life −0.042 0.007*** −0.028 0.004*** −0.026 0.005***
 Gender −0.051 0.032 −0.027 0.233 −0.054 0.024*
 Traumatic events 0.022 0.003*** 0.004 0.002 0.007 0.009**
Independent Variable x Afghan reference
 Social support −0.024 0.009** −0.016 0.009
 Satisfaction with resources 0.005 0.037 −0.001 0.027 −0.007 0.024
 Physical quality of life −0.023 0.011* 0.013 0.007 0.011 0.008
 Gender −0.069 0.059 −0.058 0.039 −0.022 0.04
 Traumatic events 0.007 0.007 0.007 0.004 0.001 0.004
−2 residual log-likelihood −1,093.8 149.1 155.1
AIC null 2,210.2 −269.7 −288.3
AIC 2,211.7 −270.2 −282.3
BIC null 2,246.9 −240.3 −258.9
BIC 2,255.7 −218.8 −230.9
N 290 290 290
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Note: PTSD = posttraumatic stress disorder; AIC = Akaike information criterion; BIC = Bayesian information criterion.

Great Lakes African geocultural background

For depressive symptoms, there was a positive interaction with gender, B = 0.11, SE = .04, p = .008, and a negative interaction for trauma exposure, B = −0.01, SE = .003, p < .001, when Great Lakes African was entered as an interaction term. This indicates that Great Lakes African women were especially vulnerable to depressive symptoms compared to women from the other groups, but that trauma exposure was less strongly related to depressive symptoms for Great Lakes African participants compared with the other geocultural groups. These findings were replicated for PTSD symptoms, with African women demonstrating a significantly higher vulnerability for PTSD symptoms than women in the other geocultural groups, B = 0.20, SE = .06, p = .005, and trauma exposure emerging as a less substantial predictor of PTSD symptoms for Great Lakes Africans than for other geocultural groups, B = −0.02, SE = .006, p = .002. Similarly, the interaction effect between anxiety symptoms and trauma exposure was significant and negative when Great Lakes African origin was included as an interaction term, B = −0.01, SE = .003, p = .002, indicating that trauma history was a weaker predictor of anxiety symptoms for this group than for the other geocultural groups. We did not observe a significant interaction between Great Lakes African background and gender for anxiety symptoms (see Table 3 for a complete list of findings).

TABLE 3.

Interaction results for three models with the African reference group

PTSD symptoms Depressive symptoms Anxiety symptoms
Fixed effects Estimate SE Estimate Estimate SE Estimate
 Intercept 3.81 0.093*** 0.193 0.06** 0.111 0.064
Independent variable
 Social support 0.001 0.005** 0.004 0.005
 Satisfaction with resources −0.072 0.021*** −0.036 0.013** −0.037 0.014**
 Physical quality of life −0.032 0.006*** −0.02 0.004*** −0.016 0.004***
 Gender −0.13 0.03 −0.076 0.02*** −0.078 0.022*
 Traumatic events 0.034 0.003*** 0.014 0.002*** 0.014 0.002
Independent Variable x African reference
 Social support 0.009 0.009 0.015 0.01
 Satisfaction with resources −0.015 0.04 −0.018 0.024 −0.020 0.025
 Physical quality of life −0.001 0.012 −0.004 0.007 −0.007 0.008
 Gender 0.203 0.059** 0.107 0.04** 0.061 0.042
 Traumatic events −0.016 0.006*** −0.013 0.003*** −0.011 0.004**
−2 residual log-likelihood −1,071.4 162.8 167.7
AIC null 2,210.2 −269.7 −288.3
AIC 2,166.7 −297.7 −306.0
BIC null 2,246.9 −240.3 −258.9
BIC 2,210.7 −246.6 −254.6
N 290 290 290
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Note: PTSD = posttraumatic stress disorder; AIC = Akaike information criterion; BIC = Bayesian information criterion

DISCUSSION

The present study aimed to determine whether the strength of established correlates of CMD symptoms varied by geocultural background in a sample of recently resettled refugees. Among Afghans, Iraqis and Syrians, and Great Lakes Africans, the results showed that there were interaction effects between geocultural background and several CMD correlates, indicating some variation in predictors of emotional distress by geocultural background. This variation is consistent with prior research suggesting major measurement noninvariance by culture for mental health disorders (Kuittinen et al., 2017; Rasmussen et al., 2015) but moves the research further by providing direct comparisons between refugees from different regions.

In particular, the findings showed that prior traumatic experiences were especially strong correlates of depression and anxiety symptoms for Iraqi and Syrian individuals, physical quality of life was more strongly related to PTSD symptoms for Afghan individuals, and African women were especially vulnerable to symptoms of all three mental health disorders compared to other women.

Interestingly, although trauma history was more strongly linked to depressive and anxiety symptoms among Iraqi and Syrian participants compared to those from other geocultural backgrounds, the same pattern did not emerge with regard to PTSD symptoms. These results suggest that for PTSD, a disorder characterized by the emergence of symptoms following exposure to traumatic sequelae, links between trauma history and symptom development were similar across groups, but higher degrees of trauma exposure were more likely to result in symptoms of depression and anxiety among Iraqi and Syrian refugees. In addition, negative interaction effects were observed for both physical quality of life and gender with regard to PTSD symptoms, indicating that these variables were less predictive of mental distress for Iraqis and Syrians than for those in other groups. It is possible that Iraqi and Syrian women in this sample were less vulnerable to the gender disparity in mental health compared with other groups. Future research should explore this to see if there are protective factors relevant to Iraqi and Syrian women that help reduce gender disparities in depression, anxiety, and PTSD symptoms that have been reported consistently in the literature (Afifi et al., 2007).

Physical quality of life was more strongly related to PTSD symptoms for Afghan participants compared with other groups. This could mean that symptoms of mental distress were more likely to somaticize in the Afghan subsample (Rohlof, 2014) or that Afghan participants experienced more sleep difficulties related to their symptoms. It is also possible that Afghan participants were more prone to physical injury compared with their counterparts in other groups, potentially due to previous or current life experiences. Social support and gender were less strongly associated with depressive symptoms for Afghan participants compared with other groups. Similar to the Iraqi and Syrian subsample, it is possible that Afghan women are less vulnerable to gender disparities in mental health (Afifi et al., 2007). Identifying protective factors relevant to both Iraqi and Syrian women and Afghan women could help guide individual intervention strategies and public health measures to bolster and encourage these features in other communities, and future research should aim to determine which factors are especially protective for these women. It is unclear why social support was less related to depressive symptoms for Afghan participants; this is another important avenue for future research.

For Great Lakes African participants, the main findings were related to the correlates of trauma history and gender. We observed significant negative interactions between symptoms of distress and trauma history for all three CMD outcomes in this group, indicating that the number of prior traumatic events was less significantly related to psychological symptoms for Great Lakes Africans compared with participants from other regions. However, women in this group had a higher risk of depressive and PTSD symptoms than women in the Afghan and Iraqi and Syrian groups. This finding could be due to an underreporting of distress symptoms among Great Lakes African men or because fewer resources are offered to African women who, therefore, are more at risk than men.

The current findings represent a promising exploratory step in improving a culturally sensitive understanding of CMDs and targeting interventions based on variable symptom presentation. However, there were some limitations to the study. Primarily, although the findings point to culturally different etiologies, they are cross-sectional. Future researchers should seek to replicate these results longitudinally and test if treatments that target significant predictors of mental health outcomes based on culture-specific variables produce superior outcomes. In addition, it is important to note that this sample included forcibly displaced members of the three main geocultural groups who resettled in one city in the United States; the findings may not be generalizable to individuals from these regions who are still living in their home countries or those who resettled in culturally similar neighboring countries. Finally, qualitative research that explores participants’ perspectives on why certain variables are more strongly related to depressive, anxiety, and PTSD symptoms for certain groups would help to further contextualize these findings and potentially lead to more actionable understandings.

Despite these limitations, the present research is promising in its demonstration that some correlates of mental health problems were more strongly or weakly linked to symptom development among different geocultural groups. These findings add to and support future research in two distinct areas. First, the findings justify further inquiry into cultural predictors of mental health as factors to consider in personalized medicine. Improving understanding of mental health predictors is critical to increasing the accessibility and effectiveness of mental health treatments for non-Western groups, especially those with transnational backgrounds or displacement experiences. Second, the divergent significance of various psychological distress correlates replicates other research in this area, justifying research into validating culturally specific measures of distress for more varied populations to improve assessment sensitivity.

OPEN PRACTICES STATEMENT

The study reported in this article was not formally preregistered. Neither the data nor the materials have been made available on a permanent third-party archive; requests for the data or materials can be sent via email to the senior corresponding author at jgoodkin@unm.edu.

Acknowledgments

This work was supported by a grant awarded to Jessica Goodkind from the National Institute of Minority Health and Health Disparities (R01MD007712).

Footnotes

The authors have no conflicts of interest to disclose.

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