Exploring African Immigrant Women’s Pre- and Post-Migration Exposures to Stress and Violence, Sources of Resilience, and Psychosocial Outcomes

Abstract

This qualitative study seeks to identify pre- and post-migration stressors experienced by African women who had immigrated to the United States along with the vulnerability and resilience factors that exacerbate or mitigate the negative health effects of these experiences. Seventeen interviews and six focus groups were conducted with 39 African immigrant women. Participants reported encountering experiences of political instability and armed conflict pre-migration and intimate partner violence pre- and post-migration. Religious faith was an important source of resilience for women. Findings support the design of culturally appropriate interventions to improve the mental health of vulnerable African immigrant women.

Introduction

African immigrants in the United States (i.e., those born in Africa and migrating to the United States [US]) are a rapidly-growing segment of the US population. In 2018, there were slightly more than 2 million African immigrants residing in the US, representing a 52% increase over 2010 population levels (Echeverria-Estrada & Batalova, 2019). Studies point to the disproportionate burden of health issues among African immigrant women, such as HIV/AIDS (Blanas et al., 2013; Kerani et al., 2008; Okoro & Whitson, 2017). African immigrants commonly migrate to the US for family reunification, social independence, job opportunities, and education. Other reasons for migration include experiences of pre-migration stressors, such as political disturbances in the home country, exposures to war or political violence, gender-based discrimination, and extreme poverty (Delara, 2016; Omenka et al., 2020). In contrast to immigrants (i.e., those who choose to migrate), refugees are forced to flee their home countries because of the imminent threat of persecution or harm posed by political or civil unrest, armed conflict, or natural disasters. Due to the vulnerabilities created by these forces, refugees are often at an even higher risk of experiencing various negative health outcomes before and after seeking refuge in the US (Omenka et al., 2020). Thus, because of their pre-migration stressors, many African immigrants already carry significant health vulnerabilities upon arrival in the US (Omenka et al., 2020).

Research into African immigrant health has advanced our understanding of the barriers that this group faces in improving their health and wellbeing. In a study of African immigrants’ healthcare experiences and unmet needs, factors such as traditional and religious beliefs; community stigma; language barriers; low health-care professional cultural competency; high healthcare costs; and a mistrust in healthcare institutions were found to strongly influence African immigrants’ ability to meet their healthcare needs (Omenka et al., 2020). African immigrants’ lived environments play a similarly important role in determining health outcomes. Poor nutrition, physical activity, safety, educational opportunities, and employment are all factors that African immigrants have identified as key determinants of their health (Adekeye et al., 2014; Showers, 2015). Further, racism, discrimination, and social isolation are themes that African immigrants frequently mention as sources of stress and causes of reduced mental and physical health (Akinsulure-Smith, 2017; Showers, 2015). Explorations into how African immigrants cope with the negative effects of these determinants have found that this population uses a wide array of coping strategies, including active problem solving, spirituality, and social support (Akinsulure-Smith, 2017; Saasa, 2019).

The unique health circumstances of African immigrant women have been explored but remain poorly understood. Gender-based violence perpetrated by an intimate partner, for example, is an important threat to African immigrant women’s health. While intimate partner violence (IPV) has been extensively studied in native populations, immigrant populations have been less frequently considered (Menjíıvar & Salcido, 2002). However, a growing body of literature on African immigrant women’s experiences with IPV is beginning to address this previous deficit (Akinsulure-Smith et al., 2013; Ting, 2010). This growing body of literature is improving our understanding of some of the barriers to improved health that African immigrant women encounter. Research, though, oftentimes treats immigration as the starting point for analysis, without much consideration given to African immigrant women’s pre-migration life experiences. Scholarship is needed that seeks to explore the challenging life events that African immigrant women encounter before, during, and after migration as well as the coping mechanisms used to address the negative psychosocial health effects of these experiences.

Another strand of immigration scholarship examines how pre-migration stressful experiences intersect with the post-migration stressors to affect a woman’s health status. These factors can be examined using a socio-ecological framework (McLeroy et al., 2003; Sabri, 2018). The socio-ecological model can also be used to identify stressors and areas of intervention at multiple levels within the social ecology as a way of addressing health disparities among African immigrant women (McLeroy et al., 2003). At the social level, determinants of health issues include lack of social support, social isolation, socio-economic status, and exposures to racism and discrimination in the community. At the community and health systems levels, determinants of health may include communication barriers, and economic barriers. At the cultural level, cultural identities can shape women’s responses to health. Cultural factors can influence women’s access to the healthcare system via their perceptions and interpretations of health symptoms, acculturation level, decision-making and communication with health providers (Delara, 2016).

Exposures to stressors at multiple levels of the socio-ecological model can significantly impact health. Stress is defined as a physiological and psychological response to external circumstances that individuals perceive that they do not have the resources to deal with (Lazarus & Folkman, 1984; Sabri & Granger, 2018; Schneiderman et al., 2005). Stressors over time take the form of toxic stress. Toxic stressors are characterized by their unpredictability, severity, and long-lasting nature and oftentimes give rise to maladaptive coping strategies (e.g., alcohol abuse) and biological vulnerabilities within individuals experiencing them (Sabri & Granger, 2018; Schneiderman et al., 2005). Repeated exposures to, or merely the threat of, violence is an example of a toxic stress. Since lifetime exposures to toxic stress are associated with negative health outcomes (e.g., cardiovascular diseases, poor reproductive health, and others), exposure to high levels of cumulative violence (both premigration and post-migration) is a significant health threat. Despite potentially similar life experiences, women may differ in their vulnerability and resilience to the development of poor health outcomes. Examples of resilience factors may include positive coping, positive beliefs, and ability to use social support. Women exposed to cumulative violence and other stressors who possess more resiliency factors are less vulnerable to negative health effects of cumulative violence and other stressors (Sabri & Granger, 2018). Even though studies have examined healthcare experiences and needs of African immigrants in the US, there is dearth of research specifically focusing on African immigrant women survivors of cumulative stressors. Therefore, drawing from a psychosocial stress model for coping, the objective of this study is to examine the effects of pre- and post-migration stressors (e.g., IPV, discrimination) and personal and external resources on coping and psychosocial outcomes in African immigrant women.

Methods

Design

Data for this article is drawn from semi-structured individual interviews and focus group discussions conducted with 39 African immigrant women. Individual interview and focus group guides were developed to explore African immigrant women’s experiences of pre- and post-migration violence, programs that they had participated in, strategies employed for stress management, their health concerns, perceptions of health risks in their communities, and views on how services could be improved to better meet the needs of these women. The advantage of individual interviews is that they allow researchers to more deeply probe personal experiences, feelings, and perceptions, most importantly on sensitive topics such as traumatic life experiences and the consequences of these experiences on respondent’s well-being. Alternatively, focus groups offer the advantage of providing useful insight into group’s shared understanding of a phenomenon in a short period. Individual interviews and focus groups lasted for 60 to 90 minutes and were audio-recorded using digital recorders. Both individual interview and focus group discussion participants were compensated $35 for their time. No participant from a focus group was interviewed individually. All study procedures were approved by the Johns Hopkins University institutional review board.

Data was recorded on demographic sheets, an adverse childhood experiences (ACE) questionnaire, and via audio-recordings during semi-structured in-depth interviews and focus group sessions. Demographic sheets recorded information pertaining to participants’ age, education, marital status, employment, country of origin, duration of time living in the United States, and experiences of violence. The ACE questionnaire measures respondents’ experiences with psychological, physical, or sexual abuse, household dysfunction, and neglect during their first 18 years of life on 10 items using dichotomous yes or no response options. Examples of household dysfunction included living with household members who abused substances, suffered from mental illness or were suicidal, or were ever incarcerated; having experienced parental divorce or separation; or having witnessed domestic violence. The ACE questionnaire’s score was calculated by summing the number of yes responses.

Theoretical model

An adapted version of Taylor and Aspinwall’s Psychosocial Stress Model guided the collection and analysis of qualitative themes and the writing of the manuscript (Figure 1) (Taylor & Aspinwall, 1996). The model theorizes individuals’ appraisal of stressful life experiences and how perceived personal and external resources influence health and psychological wellbeing (Kafetsios, 2014). According to the model, individuals’ stress appraisals and coping styles predict the psychosocial outcomes resulting from stressful life events. Further, external and personal resources can influence the relationship between a stressful life event and an individual’s psychosocial outcome by either potentially lessening the potential effect of the stressor, increasing an individual’s capacity to accurately appraise the stressor, or by improving an individual’s ability to employ productive coping strategies. External resources are acquired skills or assets, such as education or financial resources, while personal resources are either static of dynamic personality characteristics, such as self-esteem, resilience, or perceptions of social support. Since its first development, Taylor’s and Aspinwall’s model has been operationalized in a number of ways to fit researchers’ particular areas of research (Kafetsios, 2014; Masthoff et al., 2007; Michielsen et al., 2007). As the present study is qualitative in nature and does not include measures of the concepts of appraisal and coping, the focus of this article is to offer a description of African immigrant women’s pre- and post-migration stressors, their external and personal resources, and their psychosocial outcomes.

Figure 1.

Adapted psychosocial stress model for African immigrant women coping with traumatic and stressful life experiences.

Recruitment

Purposive and snowball sampling techniques were used in the recruitment of participants through the aid of African immigrant collaborators in the Virginia/District of Columbia/Maryland region (Sabri, 2018). The interviews were advertised using flyers, word of mouth, and by presentations at community meetings. Eligibility criteria included being (a) African born, (b) over the age of 18, (c) ability to speak English, and (d) having experienced cumulative trauma (two or more lifetime experiences of violence). Experiences of violence included childhood, adolescent, or adulthood abuse (e.g., physical or psychological abuse by a caregiver or sexual assault by a known adult); exposure to political violence or civil upheaval in the form of shootings, riots, or abduction; IPV (sexual, physical, or psychological); or domestic violence (e.g., physical or sexual assault by a household member other than the partner).

Participants

Seventeen in-depth interviews (IDIs) were conducted with immigrant women from Eritrea (n = 2), Sudan (n = 2), Uganda (n = 4), Ethiopia (n = 6), Kenya (n = 1), Congo (n = 1), and Ghana (n = 1). Six focus group discussions (FGD) were conducted with 22 women from Ethiopia, Nigeria, Sierra Leone, Eritrea, and Sudan. Mean age of participants was 39.9 years (SD = 9.5) and duration lived in the United States was 11.1 years (SD = 8.21). Roughly 77% (n = 30) of the participants were employed, 67% (n = 30) were currently married, and 10% (n = 4) were either divorced or separated. Nearly two-thirds of participants (64%, n = 25) had earned a bachelor’s degree or higher, while data on five women was missing. The immigration status of the participants varied but each could be broadly categorized as having either immigrant or refugee status. While there exist important legal protections for those with refugee status that differentiate them from immigrants, for economy of language participants of the study are described in the article as African immigrant women.

Data analysis

Data analysis was conducted from using a qualitative descriptive approach. Within a qualitative descriptive approach content is analyzed in a manner allowing the researcher to stay close to the data. The objective is to create a straightforward and thorough description of the data that is comprehensible to the reader (Neergaard et al., 2009; Sandelowski, 2000). Qualitative description was chosen for strong ability to use participant’s own language to produce an uncomplicated but comprehensive summary of African immigrant women’s experiences with traumatic and stressful life experiences, resources available or required in order to cope with these experiences, and the psychosocial outcomes linked to these events (Kim et al., 2017). The principal investigator and a doctoral student separately read and coded interviews based on the pre-established overarching themes. Interview codes were assigned to appropriate overarching themes. Related codes were then collapsed into sub-themes in order to create typologies of codes falling under the study’s overarching themes. Thematic analysis was conducted using the qualitative data analysis software f4analyse (version 2.5) (audiotranskription, 2018). In order to establish trustworthiness throughout the research process an audit trail was created consisting of notes of activities. Recordings of experiences and debriefings encouraged researcher reflexivity. Data from individual interviews and focus group discussions were analyzed separately prior to triangulation. Triangulation of salient themes was performed by comparing codes from all individual interviews and focus group discussions.

Throughout the article iterations of both the terms trauma and stress are used to describe the difficult life experiences that African immigrant women interviewed have faced. Similar to Goodman et al.’s (2017) research of trauma, stress, and resilience in refugee and undocumented immigrant women, this article adopts Burstow’s (2003) definition of trauma as, “not a disorder but a reaction to a kind of wound. It is a reaction to profoundly injurious events and situations in the real world and, indeed, to a world in which people are routinely wounded” (Burstow, 2003; Goodman et al., 2017). In contrast, Lazarus and Folkman (1984) define stress as “a particular relationship between the person and the environment that is appraised by the person as taxing or exceeding his or her resources and endangering his or her wellbeing” (Lazarus & Folkman, 1984). Our use of the terms trauma and stress are informed by these definitions and applied in ways that were felt to best reflect interviewees’ experiences.

Results

Analysis of the qualitative data revealed women’s traumatic and stressful life experiences; the personal and external resources available to women that helped them negotiate the mental and emotional effects of these experiences; and the psychosocial outcomes they attributed to these experiences. The four overarching themes correspond to the three domains on the left side of the Adapted Psychosocial Stress Model and to the outcomes domain on the right side of the model: pre- and post-migration stressors, personal resources, external resources, and psychosocial outcomes. Psychosocial outcomes were subcategorized as either negative or positive outcomes. In the sections below, pseudonyms are used as participant identifiers for confidentiality purposes.

Stressful and traumatic life experiences

Most participants reported pre-migration traumatic and stressful life experiences that had a negative impact on their lives. Participants shared stories of having witnessed or experienced conflict, violence, persecution, family separation and torture that were often the events that led them to emigrate or flee from their home countries. Most frequently reported pre-migration trauma were exposures to political violence, armed conflict, and IPV. The traumatic and stressful life events post-migration most frequently reported were exposures to IPV, stress related to uncertain immigration status, and discrimination and lack of support by other community members.

Pre-Migration stressors

Political violence and armed conflict

Many women (n = 10) recounted heartbreaking stories of being forced to separate from their families and friends and stripped of their careers, personal assets, and social statuses in order to flee for their lives. They were forced to endure violence themselves and, perhaps worse, bear witness as it was brought upon loved ones:

During the war in African Liberia, I faced a problem that I never thought I was going to be released from. They killed my son. It was so sorrowful … I used to cry … [They] put him in a mattress and beat him to death … I had three die in the war (Juah, Liberia, FGD).

A number of these episodes were designed to harm or threaten women’s sense of safety. “They put me in prison a couple of times”, said Zala (Ethiopia, IDI). As many women came from countries with repressive governments, extra-judicial violence was a common occurrence for those who were perceived as a threat to their governments. Fimi was a lawyer and an activist who focused on issues related to violence against women. She shared her experience of being target of abuse:

I was a lawyer … working with an NGO to fight against violence against women. I was defending women who were raped, who were violated by [their husbands]. Most people didn’t like me because of that job. There were many conspiracies against me. They sent people to beat me (Fimi, Congo, IDI).

Despite their success in gaining asylum in the United States, the traumatic memories of these events still provoked fear and anxiety among participants:

I was afraid of my own shadow because I felt like somebody’s going to hang me even here. I used to feel like somebody would abduct me. I’m afraid of abduction. Nobody knows where you are. You are just taken. That’s what happened back home (Kia, Ethiopia, IDI).

Intimate partner violence

Intimate partner violence was cited as a significant source of stress for some women even before they migrated to the U.S. (n = 5). The experiences of IPV included physical abuse, threats of violence, and emotional abuse. For Abebi, the violence began to escalate as she planned her travel to the US:

I slept with my eyes open all night. I had to lock him in a room and sleep in the living room … My mother was calling me by the minute, like “are you okay. He will probably kill you before you go to America” (Abebi, Nigeria, FGD).

Due the custom of a paying bride price in many African immigrant women’s home countries, women’s families were not always supportive of them leaving their abusive spouses, for fear of being expected to repay these bride prices:

They [spouses] say, “I paid for you.” They treat them like property. The woman becomes the property of the man. He can do anything with her, if he’s an abuser, when it comes to divorce or separation or the woman plans to leave, the family of that women, they don’t want to refund whatever this man paid (Abbo, Uganda, IDI).

Post-migration stressors

Traumatic and stressful experiences did not end once respondents arrived in the US. Many of the same issues surrounding gender norms and power disparities persisted and would lead to ongoing or new experiences of IPV.

Intimate partner violence

Six women shared their experiences of IPV after migrating to the US. Liya married a man she thought would be a loving spouse who would help to bring stability to her life:

Right after marriage, everything was turned upside down. The person that I thought I knew was totally different … started to be very controlling in every sense (Liya, Ethiopia, IDI).

Participants perceived factors such as being on a dependent spouse visa, financial dependence on a spouse, and language barriers placing women at greater risk for IPV:

What [do African immigrant women] have? Let’s see, the husband is working. He gives her money. She gets shelter to live with him. What she has? Even if he hurts her, even if he beats her, she doesn’t tell anything. She doesn’t have any solution outside … Where would she go? Where would she turn to then? (Nyala, Ethiopia, IDI).

While paying a bride price becomes a less common practice following immigration, women who experienced IPV reported that some families still pressured them to stay with their husbands in order to ensure that they would not be asked to reimburse these bride prices:

There are so many reasons why they [families] tell them [women] to stay, because that is what they call “bride price,” whereby when a woman gets married, the man pays to their parents. In most cases, the parents have eaten all the money they give them. If the woman has to go back, they have to refund it. They fear that if they tell this woman to leave the man, they will be asked to refund whatever he paid (Abbo, Uganda, IDI).

Uncertain immigration status

“Very stressful with this whole immigration process” is how Zala described her experiences with maintaining her immigration status. Numerous women reported that the complexity of immigration law and a perceived harshening sentiment toward immigrants to the US made them fearful that their immigrant status risked being revoked (n = 6):

There are a lot of uncertainties … It’s economically draining for us. Families are broken apart, and that’s emotionally [draining]. It takes five years, six years, seven years. That changes your life in a very significant way … I don’t feel like I’m in the U.S. sometimes. The first impression that I had for this country changed a lot because this is a country of law. This is a country of freedom. This is a country of democracy. I can’t imagine somebody’s case in a country for these many years. I feel like this is not U.S. (Zala, Ethiopia, IDI).

Long, complex immigration processes force families to spend years apart:

I have missed my children when the younger one was four years old and my other boy was six. Now—it is four years, and my appointment is not even close (Zala, Ethiopia, IDI).

During these years, women waiting for their immigration application to be processed are oftentimes not allowed to find work legally. This inability to seek employment hinders their economic independence and integration into American life. In the event that women’s visa applications are sponsored by their spouses their economic dependence increases the risk that they will be unable to leave potentially abusive relationships, similar to those experiences described earlier. Unable to seek employment legally, Achen was forced to work informally in order to pay her family back for room and board. Sadly, she quickly found herself in an exploitative situation:

My cousin, when I came to [the U.S.], did not help me to get the papers. She just kept me to work for her … She was paying me $3.00 per hour … Poverty encourage women to submit for anybody. To admit for anything (Achen, Uganda, IDI).

A persistent fear of deportation extended not only to immigrants, but also asylum seekers who had a justifiable fear of experiencing violence in their countries of origin if they were forced to return:

The whole problem you have is the asylum. While you are an asylum seeker, you really have nothing. I mean it’s just [as if] the sky is falling on you (Aisha, Ethiopian FGD).

Women discussed how immigrant communities remain fearful of those in positions of authority:

When I got here, my cousin said everybody you see is a security officer. When you ask a question … talk to someone, they will know and will deport you. Whenever I would see a policeman around me, I would get scared (Achen, Uganda, IDI).

Fears of deportation also serve as a barrier to seeking health care and social services when women are afraid that professionals within these structures will report to them to authorities if they have overstayed a travel visa. When discussing barriers to women accessing mental health services, Angavu (IDI) said this:

Most [immigrant women] are reluctant to seek help especially if they don’t have papers. They’re scared, so they just try to live with it. You never know now who you can trust. Some people are just scared (Angavu, Kenya, IDI).

Discrimination

Women reported experiencing discrimination (n = 4) after immigrating to the US. Women spoke of overt forms of discrimination that they felt they had experienced:

A white lady hit my car from the back, and I hit the car in front of me. When the police came, because she was white, they believed her, but didn’t even listen to me. Even when my husband wanted to talk, he didn’t let him even talk (Roxana, Sudan, IDI).

Discrimination at work, for some, meant that their income also suffered:

There is always discrimination at work. When they make the schedule if there are not enough hours, they always put your hours off, and keep other people working all the time (Nasiche, Uganda, IDI).

Lack of community support for disclosure of abuse or its impact

Women often faced scrutiny from community members for disclosing stressful or traumatic experiences or the symptoms related to these events. Some women (n = 11) reported that both in their countries of origin and in the US, women who reported experiences of IPV or depression or post-traumatic stress (PTS) symptoms related to violence or traumatic events were at risk of being ostracized from their community. In many instances, patriarchal community norms were more likely to condemn women for reporting experiences of IPV than they were to hold perpetrators accountable:

Ethiopians are not encouraged to disclose problems. Especially when it comes to violence it is considered a taboo or a shame thing. It’s considered as a thing that shouldn’t be disclosed with outsiders (Aamira, Ethiopia, IDI).

Symptoms of depression or PTS were also heavily stigma-tized in the communities in which participants lived. This stigma creates a considerable barrier to seeking help for women dealing with health issues. Stigma also relates to religious beliefs:

Nobody admits that mental illness is a normal illness. It’s considered like it’s religious—you got it maybe because somebody in your family has a scene that God was really sad about, and you’re penalized for that, or something like that (Liya, Ethiopia, IDI).

Personal resources

In the Adapted Psychosocial Stress Model, personal resources are those personal characteristics that support healthy and productive appraisal and coping habits and help to mitigate the damaging effects of traumatic and stressful experiences on women’s emotional and physical wellbeing. The most frequently cited personal resources were religious faith, physical exercise, and artistic expression.

Religious faith

Expression of religious faith was the most common stress management technique (n = 14) mentioned by respondents. Women expressed their deep commitment to their religious beliefs and indicated that these beliefs offered them emotional comfort during periods of stress:

When I kneel down and cry to the Lord, I get up with relief. When I wake up thinking, … about stuff, abusing me, scaring me … I jump up from bed, go to my knees, call up the Lord and cry to the Lord. It has help me a lot (Achen, Uganda, IDI).

In addition to describing feelings of peace, these practices also help them maintain their connections with immigrant diasporas and home country cultures, thereby bolstering the external resources discussed in the following section:

I decided I’m just going to go to D.C. because I thought there is a large community of Ethiopians here, and especially there’s a large pool of churches here and there—I just want to feel at home someplace (Liya, Ethiopia, IDI).

Despite the comfort they provided some, several women also pointed to the role of religion in enforcing patriarchal cultural norms that hold women subservient to men, exposing them to risks for future abuse.

People trust [the Church], but I don’t trust it in the sense that they are the ones who are continuing the culture that’s against women (Lola, Ethiopia, FGD).

The church doesn’t allow most of our residents to just get divorced for example … She’s a female so she has to keep her family- she needs to be strong … She pretends to be okay while she’s not okay (Zala, Ethiopia, IDI).

Exercise

A number of women (n = 6) relied on exercise as a means to manage stress. Exercise involved swimming, walking, running, going to the gym, and practicing yoga:

You just exercise, burn stuff out, sweat, and this will relieve you, also, because you will get a lot of oxygen. The blood is circulating. It will definitely relieve something. For me, it works (Aisha, Ethiopia, FGD).

Exercise helped me a lot. Whenever I go swimming, I’d come out really feeling good (Abbo, Uganda, IDI).

Artistic expression

Artistic expression in the form of journaling, composing poetry, and dancing were important means for women (n = 5) to express and process their emotions related to past or ongoing stressful experiences. One Liberian woman said this about writing about her experiences during the Second Liberian Civil War:

… I cannot even express my experience because it’s something you don’t want to talk about … I’m not going to feel comfortable to tell you some of the things that I went through during the war, but I felt freed when I wrote it down (Juah, Liberia, FGD).

External resources

Within the adapted Psychosocial Stress Model, external resources are those social networks and services that women depend upon to cope with past and ongoing adverse experiences. Women shared various resources that have helped them deal with the emotional and physical effects of their stressful life experiences. They also provided thoughtful recommendations on how present services could be adapted to better need their needs. These included availability of culturally appropriate mental health services and comprehensive empowerment programs designed to meet women’s material needs.

Resources to address emotional needs

Respondents (n = 10) viewed mental health care as an important service that would help them in negotiating the stressful life experience of immigration and in addressing memories of past traumatic experiences:

Getting psychological help would always be great to get because there are just so many traumas in our community (Faven, Eritrea, IDI).

Despite there being wide support for improving the availability of mental health services for African immigrant women, participants also discussed the common misconception amongst members of African immigrant communities that such seeking such services suggests, as Leila (Sudan, FGD) said, that “you are crazy, you are losing your mind or stuff.” Some respondents, when addressing the stigma around mental illness, suggested that services should not even mention mental health:

Look for the right phrase or wording. [Don’t] say, “mental health issue,” but just something … just based on the symptom, how she’s feeling, and a conversation that this is treatable, like less “that’s it for her” (Zuri, Ethiopia, FGD).

Comprehensive services including services fulfilling basic needs and economic empowerment

Participants spoke frequently of them importance of providing for their children’s and their own material needs. Having experienced low-paying employment, unpredictable work schedules, and financial dependence on others, respondents (n = 7) believed that meeting their daily financial needs was critical:

Everything starts with the basic need … for me, getting that ten bucks an hour job is more important than spending two or three hours with you, talking about these things that made me crazy already (Liya, Ethiopia, IDI).

Several mentioned that so long as they remained financially dependent on a spouse or other family member, they were at risk of abuse:

I think economic empowerment is key. If a woman is empowered economically, she can take care of herself and her kids, then the abusive problem may reduce. If the man is her only bread provider, if he is the only one who puts food on the table, he has every right to abuse this woman (Abbo, Uganda, IDI).

Knowledge and awareness of available resources

Women (n = 9) noted that many public agencies and non-governmental organizations already existed with the goal of providing social services. However, women remained unsure of how to access these resources:

I don’t know if the Ugandan women are aware of the WIC program. The program provides pregnant women, infants, and children food to eat (Nasiche, Uganda, IDI).

Social support

“We believe in talking and socializing among ourselves”, explained Aida (Ethiopia, IDI). For a number of women (n = 10), turning to their family and friends in search of emotional comfort was another means by which to manage symptoms of stress:

You start from scratch. Everything here is different … the lifestyle. You make new friends. Everything is difficult. The thing that I do usually to survive or to overpass this feeling is usually self-counseling for myself. I try to find my friends and discuss about it to get relief from the stress (Aamira, Ethiopia, IDI).

However, similar to seeking help from some religious institutions, family and friend networks risked giving harmful advice that would leave women vulnerable to future harm:

If your husband is abusing you, they [other women] don’t say, “Go get a divorce,” but instead they tell you to be patient, to pray and deal with it through patience (Faven, Eritrea, IDI).

Psychosocial outcomes

The final domains of the Adapted Psychosocial Stress Model are the negative and positive psychosocial outcomes that resulted from the interplay between women’s stressful and traumatic life experiences and their personal and external resources. Interviewees spoke about how their existing personal and external resources had either been insufficient in helping them to cope with their stressful and traumatic experiences or had given them the resilience to transcend these events.

Negative outcomes

Negative emotional responses to past events were commonly discussed by interviewees (n = 8) and marked by feelings of hopelessness, anxiety, depression, and anger. The trauma of migration left some women feeling as if their lives had been upturned and had lost all prior meaning. These feelings were particularly salient for Zala, who was forced to leave her children in Ethiopia when she fled:

It’s impacting everything in my life. I feel like my life has stopped. I had to leave my education which I worked very hard for more than four years. I never got my Ph.D. It’s like that for everything. I had to leave everything that I worked hard for-my house … my car … everything (Zala, Ethiopia, IDI).

Unresolved traumatic experiences from the past left women vulnerable to trigger events. In Kia’s case, this happened when she was stopped by a policeman:

After he gave me my driving license, ticket, and things, I went somewhere else. I had a job … but I was unable to do [it] because I was already shaken, intimidated, and I cried. I stopped somewhere where there was no high traffic, and I just cried in my car. Life shouldn’t be like this. I shouldn’t be intimidated like this (Kia, Ethiopia, IDI).

More recent traumatic post-migration experiences similarly left women with a complex array of negative emotions:

I feel like I’m scared that, at any moment, he could beat me … When he gets angry, he just throws things in the house … I would get so mad … I almost feel like crying … I felt totally isolated (Liya, Ethiopia, IDI).

Positive outcomes

Respondents (n = 6) spoke about the positive effects of external (e.g., social support) and personal resources (e.g., religion and faith) on their ability to overcome earlier traumatic and stressful life experiences.

I think part of the reason why I didn’t feel depressed or anxious is faith, because when you grow up as a Muslim, you grow up. Everything’s going to be okay. God will take care of it. Just forgive … (Mariatu, Sierra Leone, FG).

For others, possessing the financial resources necessary to take care of their loved ones and themselves helped to buffer against negative feelings brought on by past experiences:

The only thing that helped [me overcome past experiences] is my job and health insurance. At least for your children, you have to make sure that [they are] in good health … To me, I have peace of mind. I take care of my business, my work and home (Lahari, Ghana, IDI).

Having supporting family and friends was key to negotiating the negative emotions from previous stressful experiences. For Liya, being invited to participate in an interview for this study and sensing that she was in a safe and supportive environment gave her the confidence to speak openly about her experiences. She explained that the act of telling her story was cathartic:

Talking through all these stories, I feel like I’m a hero. I really appreciate your time, and I feel so great that I [am able] to help in this (Liya, Ethiopia, IDI).

Discussion

This research is significant for its contribution to our understanding of the common traumatic and stressful life experiences that African immigrant women face and personal and external resources they frequently utilize to cope with these experiences. Past research indicates that different migrant groups with varying pre- and post-migration experiences differ in their stress responses and coping patterns. These different immigrant groups may utilize different coping strategies based on their acculturation experiences, cultural backgrounds, and available resources (Kuo, 2014; Noh & Kaspar, 2003; Yoshihama, 2002). Understanding the unique stress responses and coping patterns of African immigrant women can serve to improve the cultural relevance of support services targeting these groups (Covington-Ward et al., 2018).

African immigrant women in this study described experiencing many sources of pre- and post-migration stress and trauma. A large number of participants reported pre-migration experiences of political violence and armed conflict. For many of the women, these traumatic experiences are what forced them to immigrate to the United States as refugees. Immigrant and refugee women often find themselves in situations characterized by reduced socioeconomic status, high unemployment, acculturation difficulties, poor access to medical care, and increased vulnerability to exploitation and abuse (Bogic et al., 2015; Rozanov et al., 2019; Sabri et al., 2018).

Intimate partner violence, for some women, was a push factor for migration to the US, while for others it was a consequence of increased vulnerability following migration. Immigrant women are frequently at a high risk for victimization by their intimate partners (Sabri et al., 2018). Immigrating alone with an uncertain or undocumented immigration status, a low level of English proficiency, limited economic opportunities, and poor access to community resources means that African immigrant women are often socially isolated and heavily dependent on male partners. Within these circumstances immigrant women become vulnerable to numerous forms of abuse and violence (Gkiouleka et al., 2018; West, 2005).

Exposure to severe and chronic toxic stressors such as the ones chronicled by participants have tremendously negative health effects. African immigrant women are at an increased risk of experiencing symptoms of toxic stress as compared to white, native born reference groups (Gkiouleka et al., 2018; Goodman et al., 2017). The cumulative toll of pre- and post-migration toxic stressors combine in some immigrant and refugee populations to establish vicious cycles of worsening systemic pathophysiology, altered brain architecture, maladaptive coping responses to new stressors, and a high burden of mental health difficulties (Bogic et al., 2015; Rozanov et al., 2019; Sabri & Granger, 2018).

The deleterious effect of these combined toxic stressors on mental and physical health does not appear to stop at first-generation African immigrant women. Transgenerational effects of these traumatic experiences have also been recorded. For instance, maternal histories of conflict-induced health harms are theorized to interact with displacement-related vulnerabilities to negatively affect the antenatal and early life brain development of refugee women’s children. This can lead to mental health problems later in childhood and on into adulthood of the children of African immigrant women (Devakumar et al., 2014; Vaiserman, 2015).

Recommendations for mental health service providers

Listening to immigrant women’s voices and thoughtfully considering the factors that place them at risk for trauma and abuse is a useful and necessary step in designing effective policies and support programs that will reach African immigrant women who are often marginalized by language, culture, and immigrant status. One area in which support can be improved is through mental health service provision. Similar to related studies, the interviews conducted during the course of this research suggests stigma, language, and cultural norms surrounding mental health issues and services create a formidable set of barriers to treatment of symptoms that result after traumatic experiences (Nadeem et al., 2007; Salami et al., 2019). Mental health professionals serving African immigrant women should emphasize earning the trust of their clients when seeking to establish a therapeutic relationship. Ensuring client confidentiality and displaying cultural humility when encountering cultural norms and practices perhaps dissimilar to their own are fundamental to building this trust. The important effect of positive individual interactions between mental health providers and their African immigrant women clients should not be underestimated.

Mental health providers and organizations should also look to alternative community-based models to deliver mental health support. Group-based counseling led by community health workers is one method to consider when attempting to deliver mental health messages to African immigrant women. In Minnesota, for instance, one study delivering a cognitive behavioral therapy program to Somali immigrant women by female community health workers indicated that after attending the intervention meetings participants reported gaining skills in stress reduction and anger management (Pratt et al., 2017). While the literature on such community-based models of mental health care being employed in the United States is limited, such models could improve cultural acceptability of mental health services while also serving to make them more accessible to those most in need of them.

Intimate partner violence is a phenomenon widely experienced by participants of this and similar studies and frequently a reason for seeking mental health services (Akinsulure-Smith, 2017; Akinsulure-Smith et al., 2013; Ting, 2010). While mental health service providers’ inclination might be to ensure that their clients leave these abusive relationships, it is important to prioritize client goals. At times this might involve accepting that the client is not ready to leave the relationship, perhaps due to the deep cultural importance of marriage (Ting, 2010). In such cases providers should focus on educating their clients and helping them to develop a safety plan. Electronic safety decision aids are available that allow women in abusive relationships to discretely appraise their current living situation and create a safety plan that aligns with their priorities (Alvarez et al., 2018). Such a safety decision aid can serve as helpful complementary tool to the services provided by a skilled mental health professional or social worker.

While understanding that their mental health was important, participants of this study also stated their needs for housing, stable employment, and physical safety. Community-based organizations (CBOs) in the Maryland/DC/Virginia region have provided for years important services to immigrant groups unable to access public programs. These services include providing legal representation, housing, financial literacy, employment opportunities, healthcare, child care, and youth development programs (de Leon et al., 2009). Such groups support the economic advancement of immigrant individuals and families and offer services similar to those requested by participants. Coordinating with CBOs in order to integrate mental health services into their structures could better meet the large unmet demand for such care while also providing the comprehensive immigration services that African immigrant women require (Venters et al., 2011).

Recommendations for community-based organizations

Community-based organizations should look to partner with faith-based organization (FBOs) that serve African immigrant communities. Partnerships between CBOs, with knowledge of public services, and FBOs, with access to networks of African immigrant women, would improve the delivery of valuable services in order to increase African immigrant women’s external resources and, as a result, increase their ability to cope with past experiences. While FBOs and the social networks that compose them can offer supportive environments and a sense of belonging to African immigrant women, participants of this study cautioned that they also risk reinforcing gender-inequitable cultural norms that expose these women to numerous forms of gender-based and intimate partner violence. Several women observed that religious community members would blame victims for experiencing abuse and encourage women to return to their abusers, rather than seeking help. These stories parallel findings by Akinsulure-Smith et al. (2013) and Akinsulure-Smith (2017), who noted that some West African immigrant women who sought support and guidance from community and religious leaders following experiences of abuse would be blamed for contravening existing gender norms and expectations (Akinsulure-Smith, 2017; Akinsulure-Smith et al., 2013). CBOs seeking to partner with African immigrant FBOs in order to better serve African immigrant women must ensure that religious leaders in these institutions endorse gender-equitable norms that support and protect immigrant women’s autonomy and safety.

Recommendations for researchers

There is a need to still better understand the models of care that best deliver social services to African immigrant women. Community-based participatory research models in which community members are engaged in developing study priorities and methods are preferable to hierarchical research methods for their ability to foster community trust and engagement (Christopher et al., 2008; Oppenheim et al., 2019).

Researchers should also seek to further investigate how African immigrant communities perceive and define IPV and the risk factors for IPV that are specific for African immigrant women. Results of this study indicate that there are certain factors that increase African immigrant women’s risk for experiencing IPV, exploitation, and related forms of abuse. Risk factors such as, social isolation, uncertain migration status, economic dependence, and changing gender roles merit further exploration. Most scholarship addressing this topic, however, has involved qualitative methods and small samples sizes (Akinsulure-Smith, 2017; Akinsulure-Smith et al., 2013; Ting, 2010; West, 2016). While earlier qualitative findings serve the important function of describing the phenomenon of IPV in relation to smaller African immigrant communities, future inquiry should employ quantitative methods and larger sample sizes in order to improve generalizability of these findings. Further analyzing how survivors and community members perceive IPV and it effect on individuals and families will inform future prevention efforts.

Limitations

The sample of immigrant women interviewed for this qualitative study was purposively selected for having personal histories marked by highly stressful of traumatic experiences which limits the generalizability of this study’s findings to the larger population of African immigrant women living in the US. The Adapted Psychosocial Stress Model for coping with traumatic and stressful life experiences guided the transcript coding and interpretation and manuscript structure. While the authors sought to elucidate features of the conceptual framework through the voices of the women interviewed, we were unable to isolate and explore the appraisal and coping dimensions of the framework. However, examination of African immigrant women’s traumatic and stressful experiences and the external and personal resources at their disposal is an important contribution to clarifying the unique set of independent variables and moderating factors that influence African immigrant women’s psychosocial outcomes.

Conclusion

African immigrant women face a unique combination of risk and protective factors to their psychosocial health. Many African immigrant women are born in countries that have histories marked by political and civil conflict and traditional cultural contexts that value the rights of men over those of women. Upon migration the United States African immigrant women risk marginalization due to language, migration status, unemployment, social isolation, racism. However, these women also demonstrate great resilience despite these factors. These interviews give voice to African immigrant women and serve as an important source of information for designing culturally relevant comprehensive services aimed at supporting and empowering African immigrant women.