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An Interpretive Phenomenological Analysis of the help seeking behaviours and coping strategies of male Nigerian international students
ByNancy Nsiah
Submitted in partial fulfilment of the degree of Doctor of Psychology (Clinical Psychology)
School of PsychologyFaculty of Health and Medical Sciences
University of SurreyJuly 2017
© Nancy Nsiah 2017
1
Statement of Originality
This thesis and the work to which it refers are the results of my own efforts. Any
ideas, data, images, or text resulting from the work of others (whether published or
unpublished) are fully identified as such within the work and attributed to their
originator in the text. This thesis has not been submitted in whole or in part for any
other academic degree or professional qualification.
Name: Nancy Nsiah
2
Overview of Portfolio
Part one of the portfolio presents a review of literature that explores the help seeking
behaviours of African immigrants in Western societies. Literature highlights four key
areas commonly found to impact help seeking pathways. These include (1)
alternative sources of support, (2) stigma, (3) differing conceptualisations of mental
health symptoms, (4) barriers to formal mental health services. Clinical implications
including the demand for the revision of professional support services are discussed.
Part two presents the empirical paper which investigates the help seeking experiences
of male Nigerian international students. This qualitative study uses interpretive
phenomenological analysis to explore the experiences of managing psychological
distress and the help seeking behaviours. Analysis revealed five main themes (1)
coping, (2) social network, (3) barriers to accessing support, (4) African identity and
(5) Masculinity. Respondents generally expressed a preference to engage in multiple
help seeking strategies primarily relying on independent coping and alternative
support through their social network and faith. The emerging themes highlight a
combination of influencing factors that impact on the help seeing experiences.
Clinical implications and limitations of the study are discussed.
3
Table of Contents
Acknowledgments ……………………………………………………………………5
Part One: Literature Review……………………………………………………...…..6
Part Two: Empirical Paper……………………………………………….………….45
List of Appendices………………………………………………….……………….99
Summary of clinical experience………………………………..………………….118
Table of assessments completed during training…………………………………..122
4
Acknowledgements
My heartfelt appreciation and gratitude towards the invaluable people who
contributed to supporting me throughout the completion of this dissertation. This
would not be possible without the blessings of wisdom and perseverance from the
Almighty God. I am truly blessed to have inspirational examples around me in both
the professional and personal capacity. My sincere gratitude to my husband who has
endured the burden of my frequent emotional offloading. Your unfaltering patience
and love is truly valued. Secondly, to my mother whose ongoing sacrifice, endless
patience and cooked meals made every day easier for me. I owe unreserved thanks to
my dissertation supervisor Linda Morison and external supervisor Dr Luke Sullivan
for their unwavering patience and encouragement throughout this entire process.
Additional thanks to my clinical tutor, Mary John for her encouragement, unbiased
support and continuous inspiration as a leader.
5
Part One: Literature Review
A review of the evidence on factors impacting on mental health help seeking for
African immigrants in Western Societies
6
Abstract
Literature identifies that despite the challenging circumstances often accompanying
the process of immigration, African immigrants in Western societies underutilise
professional mental health services. Four databases (PsychInfo, Psychology of
Behavioural Science Collection, Medline, PsychArticles) were used to identify
articles. Search terms extended from four themes; Immigration, Africa, Help Seeking
and Mental Health. Of the 997 papers found, 14 articles were reviewed. These papers
were individually assessed for quality and themes in line with the research question
were extracted. Literature indicated four common themes that impact on help seeking
pathways within this population; 1) the use of alternative, non-professional sources
of support, 2) practical and perceptual barriers to professional services, 3) differing
conceptualisations of mental ill health and 4) stigma. The nuances and similarities
within these papers are explored with consideration of the quality of evidence. The
studies reviewed offer useful insight into the factors impacting African Immigrants in
Western societies, in their decision to seek help for mental health difficulties. The
findings of the review are considered and wider clinical implications on professional
mental health service provision are discussed.
7
Introduction
Across Western Europe the rate of immigration has increased exponentially over the
last few decades (Castles, de Haas, & Miller 2013). However, alongside this, some
immigrants are forcibly displaced from their home country to escape political
repression, famine and civil war (Fazel, Wheeler & Danesh, 2005; Pumariega, Rothe
& Pumariega, 2005). The growing body of research documents the process of
migrating from one county to another as an emotionally challenging period which is
punctuated with separation from familiar cultural customs, language barriers,
changes in social standing, to name but a few (Bhugra & Becker, 2005).
Notwithstanding this, scholars have also documented increasingly negative attitudes
from members of the host population towards immigrants (Esses, Jackson &
Armstong, 1998). Often additionally burdened with poverty (Kaltman, Pauk & Alter,
2011), the amalgamation of these migration stressors are such that this group is at
significant risk of developing mental health disorders (Pumariega, Rothe &
Pumariega, 2005).
Despite the visible prevalence of immigration in Western societies, there is limited
understanding of the mental health of this population (Takeuchi, Alegria, Jackson &
Williams, 2007). Reflective of this, there has been a growing interest in not only the
mental health needs of immigrants (Pumariega, Rothe, & Pumariega, 2005), but
additionally the help seeking pathways that are used to alleviate distress (Beiser,
Simich & Pandalangat, 2003; De Anstiss, Ziaian, Procter, Warland, & Baghurst,
2009).
Evidence suggests that whilst navigating through unfamiliar cultural contexts, many
immigrants do not seek help for psychological distress (Whitley, Kirmayer, &
Groleau, 2006). For example, studies have found that both immigrants and refugees
8
are less likely to seek out professional support through mental health services
compared to their host-born counterparts (Abe-Kim et al, 2007)
The prevalence of mental disorders is often found to be influenced by not only the
migration trajectory, but also the resettlement process in the host country (Kirmayer
et al, 2011). In considering attitudes towards psychological help seeking in Africans,
a distinction in social values lies in the collectivist views regarding the importance of
the interrelatedness of people and relationships (Wallace & Constantine, 2005). In
addition to collective responsibility, an additional six core primary principals of an
Africentric worldview, as proposed by Karenga (1965;1988) include unity, purpose,
creativity, faith, self-determination, cooperative economics and collective work.
Africentric principals suggest that there is an inextricable link between the core
principles and the psychological functioning of people of African descent. These
principals may provide a reservoir from which coping strategies and perspectives on
psychological wellbeing may be drawn from (Constantine & Blackmon, 2002).
Studies have found that stronger adherence to Africentrism was predictive of higher
self-concealment behaviours. Within the context of help seeking in mental health
settings, Wallace and Constantine (2005) suggest that this translates to a greater
reluctance in disclosing difficulties in professional support services. The framework
of individualist/collectivist cultures offers a valuable perspective in exploring
cultural differences. However, solely examining such constructs as unidimensional
categories may neglect the potential impact of migration as a mechanism for social
change, particularly as migration offers increasing opportunities for shifting
ideologies and sharing of cultural practices between host and immigrant populations.
Research proposes several explanations for the underutilisation of mental health
services for immigrants of African descent. These barriers include limited knowledge
9
on mental health wellbeing, inflexible work patterns and cultural customs.
Additionally, the help seeking behaviours of migrants may also be influenced by the
perception of mental health issues within their home country.
The following literature review offers an analysis of research on the factors
impacting on mental health seeking practices for immigrants from Africa within
Western societies. This review is comprised of articles that explore both barriers and
facilitators to the help seeking pathways and the subsequent impact on the utilisation
of health care for mental health difficulties. This in turn can help shape the
development of culturally informed, evidence based treatment for immigrants.
This review intends to explore Migrant, Refugee, Immigrant and Asylum seeker
populations; consequently it is necessary to define each term. Migrant refers to an
individual who moves from one country to another to reside in the host country for
more than a year, particularly to find work. The term Refugee describes an individual
who moves to a new country because of persecution or conflict and is unable to
return home. Asylum seekers, like refugees, have left their home country to seek
refuge in another country for their safety. They differ from refugees in their
submitted petition to remain in the host country. Immigrants are individuals who
migrate to another country with the view to reside there permanently (Gabrielatos &
Baker, 2008).
Method
Search Strategy and sources of data
In accordance with Preferred Reporting Items for Systematic Reviews and Meta
Analysis (PRISMA) guidelines (Moher, Liberati, Tetzlaff, Altman & the PRISMA
Group (2009), relevant papers were identified through searches on the following
electronic databases Medline, PsychInfo, ERIC and Psychology and Behavioural
10
Science Collection. Keywords extended from four theme areas: Immigration,
African, Mental health and Help seeking.
The following key words were used in the literature search strategy
1) Immigration
Immigra* or migrant* or refugee or “asylum seeker*” or migration or resettled
2) Africa
black or Afric* or afro or West Afric* or South Afric* or North Afric* or East
Afric*Algeria or Angola or Benin or Botswana or “Burkina Faso” or Burundi or
Cameroon or “Cape Verde” or “Central African Republic” or Chad or “Democratic
Republic of the Congo” or Djibouti or Egypt or “Equatorial Guinea” or Eritrea or
Ethiopia or Gabon or Gambia or Ghana or “Guinea Bissau” or Guinea or Ivory Coast
or Kenya or Lesotho or Liberia or Libya or Madagascar or Malawi or Mali or
Mauritania or Mauritius or Morocco or Mozambique or Namibia or Niger or Nigeria
or Republic of the Congo or Reunion or Rwanda or Senegal or Seychelles or “Sierra
Leone” or “Sao Tome” and Principe or Somalia or “South Africa” or Sudan or
Swaziland or Tanzania or Togo or Tunisia or Uganda or “Western Sahara” or
Zambia or Zanzibar or Zimbabwe
3) Help Seeking
“social support” or “informal support” or informal or “help seeking behaviour” or
utilise or utili*ation or utili*e or access or barrier* or seek* or professional
4) Mental Health
“service utilisation” or “mental health” or “mental illness” or “mental distress” or
“mental disorder” or “psychiatric illness” or “psychiatric disorder”
The search was initially conducted in 9th May -13th May 2016 and repeated to
identify if any additional studies were published between May 8th and May 12th 2017.
11
The database search produced 997 articles. The titles of the articles were then
screened with consideration to the inclusion criteria. The findings of the search were
limited to those published in English with a focus on mental health (MH) help
seeking, (through either formal or informal sources), and studies based within
Western countries. These included Australia, Europe and the United States.
Following the removal of duplicates, 68 papers remained. Secondary references were
identified by hand searching the reference lists, resulting in an additional 6 papers
being identified. The abstracts of the remaining articles were screened against the
inclusion and exclusion criteria (See Table 2 for a summary of the inclusion and
exclusion criteria). This resulted in 31 papers which were assessed for quality before
the final papers are identified.
Table 2: Summary of inclusion and exclusion criteria
Inclusion Exclusion Sample population including
immigrants, refugees and asylum seekers.
Articles exploring help seeking in Europe, North America, New Zealand and Australia.
Peer reviewed empirical quantitative or qualitative articles
Published and unpublished studies including dissertations and thesis
Articles solely exploring help seeking for physical health conditions
Sample population is under 18 years
Solely non-African population Exploring help seeking only
from the perspective of health care professionals.
Articles focusing on prevalence of MH disorders and evaluating interventions.
Articles not written in English Help seeking within the
continent of Africa, Asia and South America.
The methodological quality of the qualitative papers were assessed using the
ten-item critical appraisal skills program (CASP) research checklist (CASP, 2013).
Mixed method studies that employed qualitative methods such as focus groups were
also appraised with this checklist. The papers were assessed against the criteria,
12
initially requiring all studies to meet the two essential screening questions; namely
stating the aims of the study and appropriate selection of methodology. The
remaining eight checklist items explored various validity criteria, including
appropriate selection of research design sampling, reflexivity, findings, ethical
issues, analysis of data and value of the research. Papers determined as reasonable
quality had a CASP score ≥7, similar to other reviews utilising this measure (Barley,
Murray, Walters & Tylee, 2011).
For quantitative studies, the Standard Quality Assessment Criteria for Evaluating
Primary Research Papers (Kmet, Lee & Cook, 2004) was selected to evaluate the
quality of each paper. Using the Kmet Guidelines, the studies were assessed against a
14-item checklist, where papers were allocated a score from a three-point response
scale, depending on the degree to which the criteria (that were applicable to the
study), were met. The quality threshold scores were categorised as strong (> 80%),
good (70–80%) or adequate (50–70%) (Millard, Elliott & Girdler, 2013), with
“strong” and “good” included in the final selection. A flow chart mapping the stages
of identifying eligible papers is outlined in Figure 1.
Data Analysis
Following quality assessment, 14 papers were identified as suitable. From these
papers key descriptive data were extracted and tabulated in an excel spreadsheet.
This included method of analysis, sample number/gender, country of origin, country,
length of time in the host country, summary of key findings and themes. Reading
articles several times permitted the identification of themes which indicated factors
impacting on mental health help seeking. Each study was assigned a colour
indicating each theme highlighted. On a separate document, with themes as headings,
13
all contributing sources were listed below to ease the organisation of the reported
findings.
14
Figure 1. PRISM Diagram
15
Table 3: Summaries of papers aim, grouped into qualitative; quantitative and mixed methods studiesQualitative Papers
Author, Year, Country
Participant Sample Description Aim of Study Methodology Analysis CASP Score
Shannon, Wieling, Simmelink-Mccleary, Becher
(2015) USA
34 Bhutanese, 23 Karen, 27 Oromo and 27 Somali Male/FemaleMean no. years living in USA for Somali sample: 5
Explore reasons refugees find it difficult to discuss MH effects of political violence
Focus Group Interviews
Thematic Analysis
8/10
Saechao, Sharrock, Reicherter, Whisnant, Koopman, Kohli, Livingston, Aylward
(2012)USA
30 first generation immigrants (5 from Sierra Leone, Eritrea and Ethiopia)
Mean no. years living in USA: 4-30 years
Understand stressors and barriers faced by immigrants after resettling in the USA.
Focus Group Interviews
Thematic Analysis
9/10
Donnelly, Hwang, Este, Ewashen, Adair & Clinton
(2011)Canada
10 immigrant and refugee women (2 Chinese and 5 Sudanese) living with mental illness
Explore how immigrant/refugee women access professional and social support services when coping with MH difficulties.Explore the barriers to accessing mental health care services.
1-1 in-depth Interviews
Ecological Conceptual Framework
8/10
Author, Year, Country
Participant Sample Description Aim of Study Methodology Analysis CASP Score
Papadopoulos, Lees, Lay & Gebrehiwot
106 Male/Female Ethiopian refugees for all ages 60+
Exploring experience of migration, adaptation and
Semi-Structured in depth interviews and
Thematic analysis?
7/10
16
(2004)UK
Immigration statuses include Indefinite Leave to Remain and Exceptional Leave to Remain.
settlement alongside health seeking beliefs and practices.
questionnaire.
Bettmann, Penney, Clarkson Freeman and Lecy(2015)USA
20 Somalian refugees, n=10 female and n=10 male from Somali and Somali Bantu communities.
Understand how Somali and Somali Bantu refugees describe/explain mental illness and their beliefs about treatment
Semi-Structured in depth interviews
Inductive Analysis
9/10
Onyigbuo, Alexis-Garsee & van der Akker(2016)UK
10 Nigerian adult male (n=5) and female (n=5) Christians.Mean number of years living in the UK was 12.6.
Exploring help seeking behaviours and barriers to professional healthcare utilisation
Focus Groups and 1-1 interviews
Thematic Analysis
9/10
Khawaja, White, Schweitzer and Greenslades
(2008)Australia
23 Sudanese Refugees (n=22) Christian and Muslim (n=1) faithNumber of years living in Australia ranged between 0-6 years.
Explore coping strategies across the trajectory of the migration experience.
Interviews Interpretive Phenomenological Analysis
8/10
Asgary & Segar
(2011)USA
35 Asylum seekers and 15 staff from community organisation providers (85% males primarily from African countries).Less than two years residence
Explore interrelated barriers to care for asylum seekers
Focus groups and semi-structured interviews
Thematic analysis
8/10
Quantitative Papers
Author, Participant Sample Description Aim of Study Design and Measures* Analysis
17
Year, CountryOrjiako and So(2014)
USA
n=669 Male/female adults with citizenship in regions of sub-Saharan Africa
investigates cultural-specific factors related toacculturation that can lead to MH symptoms and affect their use of mental health services. Factors including English language proficiency, level of education, length of residence in host country, family support and use of alternative treatment
Archival data from 2013 NIS Survey
NIS Questionnaire, Acculturation Framework
Several statistical methodologies including: Bivariate correlational analysis, Logistic Regression analysis and Linear Regression analysis
Nadeem, Lange, Edge, Fongwa, Belin & Miranda(2007)
USA
15, 383 females, US born black, Black immigrant and Latina. Country of origin of immigrant black women (including Caribbean and African) were unavailable.
Examine the extent to which stigma related concerns regarding MH impact on the underutilisation of MH services.
Administered orally the primary care evaluation of mental disorders measure was used.
Logistic regression
*NIS-New Immigration survey
18
Mixed Methods Papers
Author, Year, Country
Participant Sample Description Aim of Study Methodology Measures Used* CASP Score
Piwowarczyk, Bishop, Yusuf, Mudymba, & Anita Raj, (2014)USA
Focus Group SampleCongolese (n=15) and Somali (n=16) female refugees aged >18Refugees, US citizens, Asylum seekersSurvey SampleN=296 Female Congolese and Somali
Examine the conceptualization and experience of mental illnessExplore attitudes/beliefs towards treatment Examine barriers to treatment uptake
Focus Group and Survey Behavioural Risk Factor SurveillanceSystem Survey
8/10
Markova, Sandal(2016)
Norway
101 male (n=53) and female (n=42) Somali refugees
Investigate lay explanatory models of depression and preferred coping strategies
Focus group interview (n=10) and survey with vignette (n=101)
GHSQ 7/10CCD-CI
Knipscheer & Kleber
(2008)
Netherlands
133 Adults (18 years +) born in Ghana or had at least one parent there. N=97 non-clinical population n=36 clinical population
Explore service utilization, delay before consultation and understanding of help seeking within Ghanaian population
Focus groups and in-depth interviews
GHQ 9/10
Palmer (2006)
UK
7 Somali service users from a refugee community centre and 8 representatives of Somalian community organisations
Assess perceptions of mental illness and the barriers to utilising professional services in the local area.
Semi-structured interviews
Data on community project outcomes.
8/10
*GHSQ – General Help seeking questionnaire, CCD-CI – Cross Cultural Depression Coping Inventory, GHQ – General Health Questionnaire las – Lowlands Acculturation Scale
Table 4: Summary of findings for studies (in same order as presented above)
19
Authors, year, country Key Factors Identified Limitations/strengthsShannon, Wieling, Simmelink-Mccleary, Becher
(2015)USA
Stigma: barrier to discussing MH.Rejection: fear of isolation from communities if they disclosed MH difficulties.
Strengths: Consulting cultural leaders in the analysis and interpretation of data to enhance credibility. Consideration of cultural practices by interviewing men and women separately.Limitations: Focus group methodology limited the variability across demographic variables including culture, age etc.
Saechao, Sharrock, Reicherter, Whisnant, Koopman, Kohli, Livingston, Aylward
(2012)USA
Barriers to Professional care: (also identified as some sources of stress) Language barriers, competing cultural practices, economic, stigma, discrimination limited understanding of MH treatment, lack of MH services in country of origin.
Strengths: Conceptual model developed informing practical suggestions on engaging immigrant populationsLimitations: Small sample size (n=30) with relatively few participants from each ethnic group. Large variation in stage of resettlement and differing degrees of acculturation across participants - not controlled for.
Donnelly, Hwang,Este, Ewashen, Adair & Clinton
(2011)Canada
Barriers to Professional care: Lack of awareness, fear of stigma/consequences from professional services and ethnic community Alternative Strategies: informal support (family significant protective factor) and self-care strategies.
Strengths: Considers barriers from the perspective of clinical populations. In-depth consideration of implications on clinical practice. Limitation: Small sample size, limits generalizability of study to larger Sudanese refugee/immigrant population. Refugees have more formal support services catering to their specific needs compared to those who immigrate by choice.At times, unclear which themes were identified by each ethnic group – no table of participants with pseudonym to clarify corresponding quotes.
Papadopoulos, Lees, Lay & Gebrehiwot
(2004)UK
Alternative Sources of support e.g. social network, traditional medicine, consulting spiritual leads.
Strengths: Study used both Ethiopian and non-Ethiopian researchers throughout analysis process. Respondents preferred language was offered as an option to facilitate disclosing of experience. Limitation: Ethiopian researchers may have explored alternative avenues in the interview due to “insider” knowledge. No explicit reference on how ethics were managed. Sampling approach limits the applicability of the
20
findings to Ethiopian refugee communities.Bettmann, Penney, Clarkson Freeman and Lecy
(2015)USA
Mental illness was primarily described by respondents as physical symptoms. Most participants would get help from hospitals, however some were unaware of the treatment and location of services.Talk therapy was not endorsed.Causes of mental illness were understood within a spiritual/religious framework which then influenced the use of religious strategies to cope.
Strengths: Validity of data analysis as themes were re-checked with two participants for further verification.Limitations: Findings not generalizable given the small sample size. Interviews conducted in English rather than participants native language which may have limited information offered. Similarly prompts using terms such as “mental health” may have limited response because of the difference in conceptualising mental health issues.
Onyigbuo, Alexis-Garsee & van der Akker
(2016)UK
Religious and cultural beliefs serve as barriers to healthcare utilisation.Social support also utilised through family and religious groups.
Strengths: Participants from 4/6 geo-political regions in Nigeria thereby diversifying the respondents and improving generalisability of findings. Considered impact of religion/culture on pre-migration help seekingLimitations: Other religions not explored. Interviews conducted in English which was the respondents second language – meanings may have differed
Khawaja, White, Schweitzer and Greenslades
(2008)Australia
Social support and personal coping strategies were most utilised. Cognitive strategies included reframing. Social strategies varied across the migration trajectory with social networks expanded outside of family and friends.
Strengths: Explored coping strategies across the migration trajectory Limitations: snowball sampling strategy, those outside of the social communities may have reported differing views.
Asgary & Segar
(2011)USA
Inter—related barriers on individual, provider and wider system levels. Individual barriers include perceived discrimination of services. Structural barriers include costs, no access to interpreters and resettlement challenges. System barriers include inadequate community support.
Strength: Considers both service user and community organisation staff perspectives, the latter is able to attest to commonalities amongst other service users who did not participate in the study. Limitations: predominantly male participant sample which could have benefited from exploring whether aspects of masculinity impacted on help seeking. Limitations also in generalisability of findings to wider refugee population as asylum seekers experience unique barriers.
21
Knipscheer & Kleber
(2008)Netherlands
Participants reported no difficulties asking for help in formal services.Help seeking reportedly more challenging with traditional services – higher level of shame/stigma associated.Low rates of consultation with informal sources of support – due to increased urbanisation and younger population.
Strengths: Although limited sample size, they used a sample of non-clinical and clinical populations thereby improving generalisability. Used measures that have been validated in other African populationsLimitations: Recruited sample from community groups, thereby not representing isolated parts of the community.
Palmer (2006)
UK
Fear/Mistrust of professional services, language barriers and preoccupation with social issues including immigration, serve as barriers to professional sources of support.Mental illness not perceived as a medical issue but rather within the framework of spirituality
Strengths: Benefits from triangulation approach which adds depth to the investigated phenomenon. Draws on both service user and professional perspectivesLimitations: Unable to draw comparisons to other ethnic groups given the limited sample size.
Piwowarczyk, Bishop, Yusuf, Mudymba, Raj(2014)
USA
Symptom Perception: MH Treatment only required for severe symptoms e.g. PsychosisCauses of MH: supernatural causes, post-migration stressors and experiences related to civil war.Alternative Support: Typically consult spiritual/religious/traditional healers (ufumu) Barriers to Professional care: limited understanding of Western MH treatment, illness conceptualization and stigma, unwilling to disclose private information,
Strengths: Utilising both focus groups and surveys to elicit beliefs which would help provide a multifaceted exploration of the research aim.Limitations: Increased risk of socially desirable answers being provided by participants using interpreters to complete surveys. Additionally, limited applicability to broader Somali and Congolese refugee communities within United States.
Markova, Sandal(2016)
Norway
The preferred sources of help for the vignette was social support and religious community rather than professional support.Preferred coping strategy was religious practice (e.g. prayer, reading Quran), and alternative treatments (e.g. leisure activities, avoid thinking too much).Least preferred included medication, other drugs or alcohol, denying presence of symptoms.
Strengths: Refugees sampled through a compulsory introductory program for recent refugees thereby reducing sampling bias.Limitations: Did not explore effectiveness of coping behaviour. focus groups may have influenced by social desirability and limited opportunities for variations in this belief being communicated
22
Orjiako and So(2014)
USA
Proficiency in the English language was predictive of help-seeking behaviour English proficiency (p = .010) Higher level of education was positively associated with seeking help from sources outside the family (p =.002).English proficiency was negatively associated with depressive symptoms (p= .026).Increased attendance to religious services was not predictive of depressive symptoms.
Strengths: Considers the impact of variables including education, income and length of duration in the United States.Limitations: The study measured family support by the number of family members living with the participant, which does not account for the variance in interpersonal relationships or impact of social stigma that may influence the use of family as a support mechanism.
Nadeem, Lange, Edge, Fongwa, Belin & Miranda(2007)
USA
Stigma reduces likelihood of using formal mental health services. Respondents anticipated being discriminated against and a lack of trust towards formal services
Strengths: Comparison of immigrants with US-Born black populations
Limitations: Correlational study therefore limiting the conclusions that can be drawn. Study relied on self-report so may not reveal the intricate decision making that is involved in treatment seeking process. Study did not specify relations between variables based on the country of origins (which is important given the heterogeneous cultures that comprise the Caribbean, Latino and African cultures.
23
Results
Summary of papers
This review examined 14 papers that reported various barriers to help seeking for
immigrants of African descent in Western countries; namely Europe, UK, Australia
and the USA (See Table 3). Eight of these papers are qualitative studies and an
additional two are quantitative studies. Further to this four of the reviewed studies
utilised mixed methods designs. Across the studies, participants migrated from
several African countries including Ghana, Somalia, Congo, Nigeria, Sudan, Sierra
Leone and Eritrea. Within the studies, the length of reported stay ranged from less
than 2 years to up to 40 years. Participants were of varying migration status including
refugees, asylum seekers and indefinite leave to remain. The summary below offers
an overview of the themes identified across the studies, and nuanced findings
identified in papers.
Theme 1: Alternative sources of support to professional mental health
services. Consistent with Africentric values, several papers evidence immigrants
utilising informal social sources of support during periods of mental distress. Sources
of support in this category include family, herbalists, traditional healers and faith
leaders (Papadopoulos, Lees, Lay & Gebrehiwot, 2004; Knipscheer and Kleber,
2008; Donnelly, Hwang, Adair & Clinton, 2011; Onyigbuo, Alexis-Garsee & van
den Akker; 2016). The use of religion/spirituality was cited as a popular source of
support across several studies (e.g. Onyigbuo et al, 2016; Khawaja, White,
Schweitzer and Greenslades, 2008). These methods included reading religious texts,
prayer and seeking advice from spiritual leaders. The desire to use spiritual healing
strategies was reportedly perpetuated by its proposed cure approach, as opposed to
24
symptom management. Belief in the efficacy of these methods was strong
irrespective of previous experiences of poor outcomes (Onyigbuo et al, 2016). Whilst
the use of religious coping strategies was identified as a barrier to utilising
professional healthcare, participants favoured the use of professional support services
over spiritual sources of support, if they deemed there was a physical risk of harm to
others (Johnsdotter, Ingvarsdotter, Ostman & Carlbom, 2011).
In contrast, Knipscheer and Kleber’s (2008) study found both age and urbanisation
had an impact on the pattern of help seeking, with older participants being more
likely to seek support from faith leaders. In a sample of first and second generation
Ghanaian immigrants in the Netherlands, interviews from a sample of non-clinical
(n=97) and clinical populations (n=36), reported only a quarter of the sample
consulted traditional healers. The chief findings of the study evidence that whilst
both formal and informal sources of support were accessed; only a quarter of the
sample initially consulted traditional healers, religious leaders or herbalists. They
suggested this pattern of help seeking reflected a younger and more urbanised
immigrant population. A preference for social support from parents, family
authorities and partners was also commonly reported (e.g. Markova and Sandal,
2016; Donnelly et al 2011). This assisted participants to cope with mental health
difficulties through distraction from excessive worries and having a social outlet to
release emotions. This was found in Markova et al. (2016) study, where participants
were offered a vignette describing a moderately depressed character and were asked
to help seeking strategies. The preferred coping strategies of the respondents were
explored in separate focus groups for men and women. Findings echoed a preference
for social support from parents, family authorities and partners, with prominent
figures within Somalian Refugees often serving as gatekeepers to MH services. A
25
strong ethnic identity and adherence to Africentric values included obeying the
opinion of elders, fathers and spiritual leaders within their community.
However, there are barriers to utilising the social support network as having an
alternative source of support did not always equate to individuals feeling
comfortable. This was evidenced in Donnelley et al. (2011) study which revealed
that whilst social support was identified as an important component in managing
mental health, participants would only do so if they felt “overwhelmed” or
“helpless”. These narratives stemmed from expressed resentment about previous
experience of disclosing mental health difficulties, which were not met with
acceptance from their family.
The utilisation of social networks varied across the migration trajectory. Khawaja et
al. (2008) uniquely highlighted how the support accessed was influenced by the
migration trajectory. Strategies used during the transition period typically mirrored
those adopted during the pre-migration period. The pre-migration period saw the use
of family and friends in Sudan for support; however this network broadened to
religious groups and neighbours within the host countries because of the breakdown
of traditional support networks.
Across the informal sources of support, studies showed that multiple coping
strategies were often practiced. In Khawaja, White, Schweitzer and Greenslades
(2008) paper, they found that alongside faith, additional personal coping strategies
included cognitive reframing and the normalisation of traumatic experiences.
Similarly, Papadopoulos et al. (2004) qualitative study of Ethiopian refugees
evidenced the use of social networks and personal coping strategies in the UK.
Respondent’s favoured social and independent coping strategies including talking to
friends, thinking through difficulties and keeping busy.
26
Health Care System Barriers
Papers reported in this theme explored the impact of barriers to professional
psychological health services including cost, awareness of service provision and
perceptions of treatment effectiveness within African immigrant communities.
Practical barriers to accessing psychological treatment were identified in Saechao et
al. (2012) small scale qualitative study of first generation immigrants in the United
States. They reported that African participants implicated costs of health care
insurance; lack of knowledge of services and competing cultural practices as barriers
to professional MH services. As healthcare is offered freely in the UK, the barrier of
cost was controlled in Palmer’s (2006) study of a Somalian community in the
borough of Camden. The study assessed the perception of mental illness and barriers
to utilising formal services and showed that the counselling profession was not
recognised within Somali culture. Such findings echo the findings of Saechao et al.
(2012) who identifies limited service knowledge reducing the uptake of professional
services.
Additional practical barriers included limited fluency in the host countries language,
coupled with a limited professional translation service provision (Donnelley et al,
2011), which effectively disables respondents from accessing mainstream services.
In some cases, participants reported services using family members as interpreters,
with predominantly negative experiences.
Several papers also highlighted participants’ hesitation to disclose sensitive
information, as a barrier to accessing professional care, despite 60.5%
acknowledging (either strongly or slightly) the effectiveness of treatment
(Piwowarczyk, Bishop, Yusuk, Mydymba & Raj, 2014). Similar concerns of being
27
perceived as weak alongside feelings of distrust towards professional services, served
as additional barriers (Knipscheer & Kleber, 2008). Whilst there was an awareness of
mental health issues amongst those who proactively sought help, professional
services were often delayed until the crisis phase of the symptoms (Donnelley et al,
2011). Amongst other factors, the fear of unknown consequences of receiving a MH
diagnosis (e.g. losing family, deportation) and mistrust of Western models of
treatment were also identified.
Stigma
Research has examined and supported the concerns that stigma often associated with
mental illness, is deep rooted within African immigrant communities and may serve
as a barrier to seeking help for mental distress. The perception of stigma can be
anticipatory (anticipating being treated unfairly), and can arise from individuals own
stigmatising attitudes or behaviours towards others with mental illnessor stigma
associated to seeking or receiving treatment. Concerns around stigma may delay help
seeking or result in respondents attempting to conceal their illness to avoid negative
evaluations (Saechao,2012; Shannon, Wieling, Simmelink-McCleary & Becher,
2015;).
Examined further in Nadeem, Lange, Edge, Fongwa, Belin and Miranda (2007)
mixed methods study, they explored whether stigma accounted for the
underutilisation of formal mental health services. Nadeem et al. (2007) conducted a
screening program for a sample of women with depression and found they were three
times more likely to report concerns about the stigma of mental health conditions
compared to their US-born White counterparts.
Challenges in openly communicating about MH issues stemmed from feelings of
shame and beliefs that talking will not resolve the issue. For example, Wieling,
28
Simmerlink-Mcckeary and Becher (2015), noted that shame was cited as a prominent
factor in discussing experiences where the fear of being isolated from their
communities often perpetuated the stigma of sharing MH difficulties within this
sample.
The impact of stigma also extended to include family. Scuglik, Alarcon, Lapeyre,
Williams and Logan (2007) highlight the influence of stigma on the family as a
barrier to accessing both professional and informal sources of support. Caregivers
reported on the stigma of mental illness on the wider family, e.g. if a daughter is
mentally unwell this will tarnish her chances of being married, thereby resulting in
her remaining dependent on the family. Similar views were reported by
Piwowarczyk et al. (2014) and Donnelley et al. (2011) study, where respondents pre-
empted the consequence of being labelled as having a mental illness, including a fear
of being stigmatised by healthcare providers and ethnic community members.
Consequently, Somalian immigrants described the need to hide their psychological
distress, for fear of being describes as “waali” (mentally unfit).
Conceptualisation of mental health symptoms
Research evidenced how cultural disparities in the conceptualisation of mental
illness, alongside the expectations around tolerating lower levels of distress, can
serve as a barrier to accessing support. Differing perceptions of mental illness within
African immigrant populations may result in long term implications of engaging with
services at crisis point where behavioural expressions of illnesses become more
profound. This was noted in Bettmann, Penney, Clarkson Freeman and Lecy’s
(2015) U.S. qualitative study of 20 Somalian refugees. An inductive analysis of 1-1
interviews revealed some participants understanding of symptoms of psychological
distress solely through observable behaviours. Contrary to most studies, many
29
participants stated they would access professional help; however talking therapies
were not endorsed. Discussing symptoms with professionals was hypothesised to be
limited to the assessment of suitably prescribed medication.
Literature within this theme also considered the use of language and how this shapes
the conceptualisation of mental health symptoms. For example whilst emotional
distress is recognised within Somalian communities in the US, Piwowarczyk et al.
(2014) reported that participants use of the word “Qulub” would appropriately
describe symptoms of depression, however it was often used within Somali
communities to explain symptoms synonymous with psychosis. Within the same
study, differing conceptualisation of mental illness across both the focus groups and
survey, revealed a perception that treatment was solely reserved for severe symptoms
such as psychosis. Cultural interpretations of distress were also considered as part of
Palmer’s (2006) study, where community workers revealed “depression doesn’t exist
in our language”.
30
Discussion
The process of immigrating coupled with transitioning to a new country has been
associated with an increased risk of developing mental disorders and the resulting
impact on the psychological wellbeing. This risk is further compounded by a
multitude of challenges, some of which include linguistic barriers, discrimination
and, a separation from familial networks. This review aimed to synthesise and
critically evaluate studies exploring the factors impacting on help seeking for mental
distress for immigrants from Africa.
Findings evidenced the multifaceted influences on help seeking for mental distress
within the African immigrant population, through which, four reoccurring themes
were identified; (1) the use of alternative sources of support; (2) conceptualisation of
mental health; (3) stigma and (4) health care system barrier.
Alternative sources of support reflected the use of non-professional systems
including social support, religion and self-management strategies. Commonly
identified within the studies was the use of social support networks as alternative
support to professional services. Utilising familial support is commonly practiced in
Africa (Alem, Jacobsson & Hanlon, 2008). The role of family in providing mental
health care is complimented by the social organisation of networks within African
society and aligned with Africentric values of communalism. In the absence of public
welfare programs, the customary practice of depending on extended family often
serves as a substitute to meeting the economic, social and health needs of the
individuals (Aldous, 1962). These values are intrinsically carried forward during the
migration process (Obasi & Leong, 2009).
A preference for social support networks was not void of its own challenges. For
refugees and asylum seekers, forced separation from social networks are commonly
31
experienced as part the circumstances surrounding the migration trajectory. Attempts
to develop new social networks may be thwarted by language barriers and variances
in the perception of western countries being perceived as “individualistic”
(Papadopoulos et al., 2004). The separation from familiar networks can lead to
limited access to long term, trustworthy relationships which may be considered as
appropriate to disclose personal information. Most studies failed to consider the
quality of social relationships and the factors that encouraged the use of this
mechanism. For refugees and asylum seekers, forced separation from familiar social
networks are commonly experienced however few studies (e.g. Khawaja et al., 2008)
considered the impact of the migration trajectory on the selection of help seeking
sources.
Spiritual or religious causes of MH difficulties were frequently cited across
literature. Studies have evidenced the salient role of religion amongst Africans as an
influential role in their cultural identity (Kamya, 1997). The review was unable to
determine whether varying adherence to religious beliefs impacted on help seeking
practices. Arguably, seeking support through spiritual resources could reflect
religious virtue or a fear of punishment/judgment from within their faith. It would
then follow that actively seeking help through professional MH services may be
viewed as conflicting with religious principles. Knipscheer & Kleber (2008) study
differed in their findings as it evidenced a growing shift from using traditional
healers. Alongside this there was increasing stigma associated with this method of
coping, which was attributed to an increasingly younger and more urbanised
immigrant population. However, in recruiting samples primarily from community
programs, this study failed to consider the perspective of isolated groups who have
not engaged in formal support systems.
32
The increasingly heterogeneous immigration population, calls for an understanding
of the unique health needs of specific ethnic groups to inform culturally appropriate
provisions of care (Pavlish, Noor & Brandt, 2010). Whilst the review identified
similar themes across most studies, the findings highlight that the variations in
individual experiences, cultural practices, exposure to psychoeducation, age and
gender are also important to consider as independent factors. An example of this is in
the experiences of refugee’s verses asylum seekers and immigrants or exploring the
variance between male and female help seeking behaviours.
Individual differences requiring further consideration include an understanding of
MH provision within the continent of Africa. There is a notably high prevalence of
communicable disease and low life expectancy in Africa, often resulting in the
allocation of financial resources towards the development of MH programs and
policies (Jacob et al., 2007) becoming side-lined (Wilson, Taghi Yasamy, Morris,
Novin, Saeed & Nkomo, 2014). Within this review no studies considered
immigrants from countries in Africa who have been evidenced to have better MH
provision. Even within the studies found, limited reference was made regarding the
provision of MH services within that country and its impact on help seeking. For
example, Khawaja (2008) study considered pre-migration help seeking behaviours
and whether current practices are synonymous with former patterns of seeking
support in host countries.
Whilst several studies have highlighted the lack of knowledge of mental illness and
have called for increasing psychoeducation, within this understanding is the
underlying assumption that divergent views from biomedical frameworks for mental
illness need to be corrected to improve service utilisation. Atilola (2016) highlights
33
the need for respect for culturally entrenched conceptualisations of MH. This is
particularly important to consider in public health education initiatives.
This review primarily consisted of qualitative studies within which the individual
studies were limited by several methodological issues including the recruitment
procedures of immigrant populations. For example, sourcing participants from local
community groups potentially introduces systemic bias, thereby limiting the
inclusion of experiences of more marginalised communities (May et al., 2014).
Studies such as Khawaja et al. (2008), note the limitation of a small sample size and
the dependence on snowball recruitment strategies. Donnelly et al. (2011) further
comments on the difficulties of recruiting from immigrant communities due to
“unfamiliar[ity] with the research process” and the stigma associated with mental
health.
Additional challenges are also identified in the acquiescent cultural response bias that
has previously been reported amongst African respondents (Furnham, 1999). These
factors highlight the need for researchers to recognise the power imbalance that may
be experienced in marginalised communities, which studies in this review typically
mitigated by using community leaders or interpreters. This power imbalance
however, is potentially still evident as non-immigrant African interviewees in such
positions may be perceived as more educated. Consequently in an effort to maintain
status and acceptance from ethnic communities, some participants may not be willing
to engage in research that explores their own vulnerabilities. Authors generally
recognised how limited proficiency in the host country language may influence the
respondents’ ability to describe symptoms and express concerns around their mental
wellbeing. Some studies considered “Africans” as a single group, thereby
34
overlooking the variations in culture and customary practices which may impact on
help seeking behaviours.
Often researchers did not comment on their reflective stance, which limits the
understanding of how the interpretation of results may have been subject to influence
from their own clinical or personal experiences. Some studies were mindful of the
cultural influence in the research method, thereby potentially aiding richer
information to be elicited. For example, in Markova et al. (2016) study, they used
focus groups which were split into male/female participants. However, the responses
obtained during focus groups may have been influenced by social desirability factors.
This may have limited opportunities for variations in beliefs regarding alternative
sources of support being communicated.
Some studies used a multi-method participatory model whereby community
members were recruited to facilitate interviews in the respondent’s native language
and support the analysis alongside research staff. Whilst using researchers of similar
cultural backgrounds facilitated the attainment of culturally sensitive information,
using semi-structured interviews may have resulted in a bias exploration of themes
(Papadopoulos et al., 2004). Across the qualitative papers there was limited
opportunity to report on the intricacies within the findings. For example
byconsidering the quality of social relationships or the impact of stigma in
preventing the use of social networks (Orjiako et al., 2014).
Knipscheer (2008) study demonstrated strengths through the inclusion of a sample of
non-clinical and clinical participants, thereby improving generalisability. Similarly in
their use of measures that have been validated within other African populations.
Studies such as Onyigbuo et al. (2016) were strengthened in their exploration of pre-
35
migration help seeking behaviours and recruiting a sample of participants from
various geo-political regions of Nigeria.
It is important to note that papers not written in English were excluded from the
literature review, which presents a significant limitation, particularly as a large
number of African immigrants migrate to non-English speaking European countries
(e.g. France). This, consequently, limits the inclusion of studies completed in other
Western countries. Similarly, as most studies within this review were conducted in
the U.S, whose healthcare provision and culture differs to countries like the UK, the
impact of additional financial barriers is to be acknowledged within other countries
with similar healthcare pathways. The commonly cited barriers of awareness of
service provisions and Western conceptualisation of MH have been applied
consistently across all the host countries within this review. Whilst outside the scope
of this review, future reviews can assess the effectiveness of the alternative sources
of support for varying degrees of mental distress. Further considerations can also be
directed towards how these factors contribute to disengagement from those who have
received professional mental health support.
Clinical implications
Clinical implications and future recommendations of increasing awareness of service
provision was a relative strength in the papers that identified barriers to professional
sources of support. The current review suggests numerous strategies including
outreaching to immigrant communities, networking with faith leaders and providing
translated service leaflets as a means to improving access to services. (Saechao et
al., 2012; Piwowarczyk et al., 2014; Donnelly et al., 2011). To address the needs of
this population, health services should consider implementing community based
models to provide psychoeducation with the view to destigmatise the experience of
36
MH symptoms. With regards to help seeking, the role of MH and community
services based in Western countries is twofold. Firstly, to educate and support
immigrants from various cultural backgrounds to understand the support options
available to them, which may differ from their country of origin. Alongside this there
continues to be a need to improve the provision of culturally sensitive treatments in
mainstream services by educating clinicians on alternative models of support and
treatments utilised by these populations. Doing so could facilitate and encourage
engagement (Pumariega et al, 2005). Recognising the influence of cultural factors on
the help seeking process could lead to the development of integrative initiatives that
merge the traditional sources of support with Western treatment approaches. For
example, evidence shows that an understanding of professional counselling was
limited in some communities. Integrating these options with familiar cultural
practices i.e. through family based interventions, may assist in narrowing the gap
between professional and informal sources of support.
Although there are many overlapping factors impacting on help seeking behaviours
for African immigrants, this review highlights some marked within group
discrepancies. Of the studies identified, there is evidence of further need for research
to build on exploring the help seeking behaviours amongst subgroups within this
population, for example gender variations of help seeking behaviours.
37
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44
Part Two: Empirical Paper
Abstract
Nigeria has the sixth highest number of students from non-EU countries coming to
the UK. Not only are professional mental health services underutilised by black men,
but the acculturative stressors that typically accompany international students can
heighten the risk of experiencing mental distress. The help seeking experiences of
male Nigerian international students in the UK are a significantly under-researched
area. Interviews were conducted with eight male Nigerian international students from
a UK university, Interpretive Phenomenological analysis was used to explore how
this population makes sense of their help seeking experiences. The results identified
four themes (1) Coping strategies (2) barriers to accessing support, (3) African
identity and (4) Masculinity. Findings suggest a preference for using a combination
of independent coping strategies, with most participants considering formal
psychological support as inappropriate. Clinical implications and the limitations of
the study are discussed.
Key words: Help seeking, Nigerian, Men, International Students, Immigrants
Word count: 9896
45
Introduction
The global demand for international education is set to increase exponentially.
Secondary to the United States of America (USA), the United Kingdom (UK) is a
leading exporter of international education services (Bohm et al, 2004). Nigeria has
the sixth highest number of students from non-EU countries coming to the UK
(16,100 in 2015-2016; UK Council for International Student Affairs, 2017), the
highest number from any African country. For international students, the appeal of
UK Higher Education Institutions (HEI) includes the variety of course options,
international recognition of British qualifications, excellent provision of facilities,
prospects for post qualification progression and a simple visa application process
compared to the USA (Maringe & Carter, 2007).
The University experience is an important transitional period where the student
population are considered more vulnerable to developing mental health difficulties.
Pertinent factors include the transition of living away from home, increased
independence, academic concerns and combined financial pressure (Royal College of
Psychiatrists, 2003). These can affect both mature and younger students alike, with
younger students negotiating increased independence and older students typically
managing competing demands of family (Bradley, McLachlan, Sparks, 1990).
Research suggests that these difficulties are often amplified within the international
student population who face additional challenges of adapting to a new academic and
cultural environment. These can include being geographically separated from
familiar social networks that may provide emotional and practical support, facing
language barriers, ‘culture shock’, alienation and discrimination (Mori, 2000; Sandhu
& Asrabadi, 1994). Collectively known as acculturative stress, such challenges can
46
result in the development or exacerbation of existing physical, social and mental
health difficulties (Kadison & DiGeronimo, 2004).
Studies examining African international student populations have identified unique
difficulties in their adjustment to European and American HEIs. Puritt (1978)
interviewed sub-Saharan African students at a United States (US) university and
found that in comparison to their non-Black counterparts, these students reported
more difficulties in adapting to U.S. culture. One identified challenge included racial
discrimination. Potentially being nurtured in racially homogenous contexts, may
result in issues of race gaining increasing salience (Adeleke, 1998). Particularly
when combined with experiences of racial discrimination, this may heighten the
challenge of adjusting to a predominately White society (Winkelman, 1994; Mori,
2000).
An additional challenge experienced by African students in this study was the
cultural value conflicts (CVC). As explained by Inman, Ladany, Constantine and
Morano (2001), differences in cultural values can result in anxiety and guilt. This is
because of the cognitive conflict that can arise from differing behavioural
expectations between the host and immigrants culture. Africentric values include
collectivism (i.e. centralising priority of the group goal above individual or personal
needs) and communalism (i.e. accentuating the importance of interrelatedness of
people). These can conflict with commonly held Western values of independence
and self-reliance. As found in other immigrant student populations (Inman et al,
2001), CVC may impact on the academic and personal adjustments of African
students (Constantine, Anderson, Berkel, Cadwell & Utsey, 2005).
In recognition of these needs, HEI’s have offered counselling services, however in
addition to other mental health services, these services are less likely to be used by
47
black students (Watkins and Neighbors, 2007). There is evidence to suggest that
African men and women may seek help less frequently and in different ways to
people from other cultures, which is partially defined by their beliefs around the
origins and causes of mental illness (Patel, Simunyu & Gwanzura, 1997). Commonly
cited barriers towards professional sources of support can include an attitude of
cultural mistrust towards mental health professionals, the stigma associated with
mental ill health and the use of alternative sources of support (Saechao et al, 2012).
For example, within Nigeria, a spiritual conceptualisation of mental illness may lead
towards seeking help from spiritual leaders in the first instance (Eaton & Agomoh,
2008).
Even within cultures, there are differing patterns of help seeking across genders with
numerous studies having examined the disparity in the help seeking behaviours of
men compared to their female counterparts (Sullivan, Camic & Brown, 2015).
Research evidences that men often marginalise their own mental health needs and
that their reluctance to voluntarily seek help, including for psychological therapies,
contributes to poorer health outcomes (White, 2001). The male gender role
socialisation process and the resulting norms of acceptable emotional expression has
been presented as an explanation of this pattern of help seeking behaviour in men
both in the US and the UK (O’Brien, Hunt & Hunt, 2005; Addis & Mahalik, 2003;
Mendoza & Cummings, 2001). For example, Sullivan et al. (2015) found that men
with higher masculine ideologies, alexithymia and fear of intimacy were less inclined
to seek psychological support. Studies of Black men in the U.S, evidenced negative
attitudes towards seeking help for MH difficulties, (Neighbors & Howard, 1987;
Duncan, 2003). Watkins et al (2007) conducted a focus group with Black male
48
college students and emerging themes included the unique experience of
psychological distress compared to ethnicities due to experiences of marginalisation.
Most studies exploring black men focus on the presumed collective experience of
this ethnic group, routinely overlooking the multitude of cultural and personal
influences. Understanding the unique aspects of the lives of a specific cohort within
this ethnic group, may offer an informative understanding of the experiences of
mental health help seeking for a high risk group within this broader category of
Black men.
Rationale:
Promoting positive mental health is core to individual wellbeing. However, this is
threatened by the stressful experiences that punctuate immigrants’ transition to a new
country. For international students, there are accompanying challenges that coincide
with the experience of higher education. Although these factors are known to result
in mental health difficulties, literature highlights the limited uptake of professional
support services within the international student population. Similar patterns of help
seeking for MH within the Black male population have also been evidenced.
Arguably the triad of the immigration experience, masculine norms and the influence
of Nigerian culture could make Nigerian International Male students a higher risk
group. The researcher was unable to identify any studies solely exploring the help
seeking behaviours of Nigerian male students for mental health matters, thereby
espousing the need to explore the experiential accounts of help seeking within this
population. The research question is: What are the help seeking experiences and
coping strategies of Nigerian male international students, during periods of
psychological distress?
49
Method
Design
The study aims to explore the help seeking experiences and coping strategies of male
Nigerian International students during periods of psychological distress.
In line with the research question, the study used Interpretive Phenomenological
Analysis (IPA) as the methodological approach.
Interpretative Phenomenological Analysis (IPA) A qualitative
methodology was selected to enrich existing research through an in-depth
exploration of personal experiences of help seeking within a population.
Theoretically rooted in hermeneutics and phenomenology, the duality of the IPA
approach emphasises both the personal meanings that participants derive from their
experiences, and acknowledges the influence of the researchers’ interpretation
(Pietkiewicz and Smith, 2014). The phenomenological component draws on
participants’ voice of their experiences, whilst the interpretative aspect contextualises
these experiences from a psychologically informed perspective. Table 1 provides an
overview of other qualitative approaches considered and the rationale for not using
these.
Participants
Eight participants were recruited from Surrey University. The inclusion criteria
required male participants, born in Nigeria who were currently studying with an
international student status. The latter was verified through participants’ self-
disclosure. Participants interviewed had an age range between 17-35 years. The
duration of residence in this country varied between 2 months to 3 years. There was
no further criteria regarding the length of stay in the country, postgraduate versus
50
undergraduate status or age of participants. Table 2 offers participant profiles to
assist the reader in forging an in-depth connection. Identifying information has been
omitted and pseudonyms have been used where necessary to protect the identities of
the participants.
The consensus within IPA research is the use of a homogenous purposive sample
(Smith, Flowers & Larkin, 2009). With a smaller sample size, the study is able to
provide an in-depth examination of the help seeking experiences of Africans. A large
sample size can lead to a superficial understanding of the phenomenon. (Pietkiewicz
& Smith, 2014). As very few empirical literature explores the help seeking
experiences of this cohort, the idiographic nature of IPA was deemed suitable.
In addition to the recommendations for IPA sample size, time constraints within the
British Clinical Psychology doctoral program, coupled with the challenges that often
accompany the recruitment of participants from BME communities, (Rugkåsa &
Canvin, 2011) were considered to determine the number of participants for the study.
Student visas in the UK require an English language test to be completed, hence it
was assumed that all participants would understand English.
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Table 1. An Overview of considered qualitative approaches rationale for their deemed unsuitability
Qualitative Approach Summary of Approach
Grounded Theory Developed by Glaser and Strauss (1967), this method aims to develop an explanatory theory that is
grounded in the data. It relies on recruiting participants with diverse perspectives of the phenomena until
the constructed theory is fully represented by the data (Starks & Brown Trinidad, 2007).
It examines six aspects of social processes with the view to understand relationships between causes,
contexts, contingencies, consequences, covariance and conditions (Strauss & Corbin, 1998).
This approach was deemed unsuitable for this study as the development of a theory deviates from
developing a rich understanding of how this sample makes sense of their experiences.
Narrative Approaches Rooted in social constructionism, this approach focuses on the content of individuals’ stories. Narrative
analysis focuses on how respondents manage different senses of self.
This approach deviates from the proposed study as it does not aim to consider how Nigerian men make
sense of themselves within differing contexts e.g. when in Nigeria verses in the UK. Whilst the
respondents may reflect on how aspects of masculinity or being African inform their help seeking
practices, the research aim focuses on reflections of help seeking experiences.
52
Procedure
Recruitment
Historically, research has documented a low participation rate in research from Black
and Minority ethnic groups (Rugkåsa & Canvin 2011) due to the stigma typically
associated with mental health difficulties. Consequently, multiple advertising and
recruitment routes were employed. The study was advertised with posters throughout
the University campus, inviting participants to volunteer for the study. The leaflet
was carefully worded to avoid the potentially stigmatising word i.e. “mental health”
(Appendix C).
Email invitations were sent to eligible participants on behalf of the researcher
through the University recruitment and admissions manager for African students, in
addition to the University’s African Caribbean Society (ACS) and the Nigerian
Society. Additionally the researcher distributed posters by hand at the Nigerian
Society social event. To increase opportunities of coming across qualifying
participants, a spreadsheet of the courses highly subscribed by Nigerian men was
provided to the researcher by the recruitment manager, following which course
timetables were used to identify opportune times to personally distribute posters.
Those who expressed interest contacted the researcher by email and a subsequent
meeting date was arranged.
Interview
A semi-structured interview was selected as the preferred method so the researcher
could elicit detailed experiential accounts, explore the attached meanings and
personal interpretations about the topic of interest (Smith, 2011). Prior to the
interview, participants were provided with an information sheet (Appendix D)
53
outlining the purpose of the study and highlighting their right to withdraw from the
study at any time. Following an opportunity to ask questions, participants were asked
to sign a consent sheet to evidence their agreement to participate in the research
project.
Interviews were conducted in a private room in the University Library. Interviews
lasted from 50mins – 1.5hrs, using an interview schedule to offer the researcher
prompts to gather a detailed account of the area of interest (Smith, Flowers & Larkin,
2009). Interview schedules (Appendix F) were openly shared with participants at the
start of the interview. Interviews were recorded on a digital voice recorder and stored
securely until they were transcribed, following which they were deleted. To prevent
miscommunication and to facilitate transparency in the data analysis, the researcher
clarified the meaning of colloquial words and phrases during the interview.
Confidentiality was maintained by removing all identifying information and
assigning a pseudonym to each transcript.
54
Table 2: Overview of participants:
Participant number Name (Pseudonym)
Age (years) Length of time in country
T1 Jo 20 2 years (previous visits to UK)
T2 Yomi 17 2 months (no previous visits to UK)
T3 Matthew 19 3 years (previous visits in UK)
T4 Simon 19 4 years (previous visits to UK)
T5 Peter 18 2 years (no previous visits to UK)
T6 Paul 35 3 months (no previous visits to UK)
T7 Tayo 19 2 years (previous visits to UK)
T8 Charlie 21 5 years (multiple social visits)
Ethical Considerations
This research project received a favourable Ethical Opinion from the School of
Psychology Ethics Committee, Faculty of Health and Medical Sciences Ethics
Committee at the University of Surrey (Appendix B). Table 1 discusses the key
ethical considerations and how these were managed.
The Researcher
As a Black, British born female of Ghanaian heritage, the researcher acknowledged
the similarities in race with the participants. Prior to clinical training, the researcher
developed an interest in understanding the experiences of the black population within
MH services in the UK. As a Christian and second generation immigrant the
researcher was aware of the various mechanisms through which her immediate
55
network support their own mental wellbeing. Within this experience the researcher
sometimes experienced conflict between traditionally reinforced help seeking
strategies, with those endorsed by her occupation. Regular supervision and
reflections, exploring how these perceptions may influence the engagement with
research data and interviews was important. Lyons and Bike (2009) cite that racial
similarities between researchers and participants can facilitate the development of
rapport, which the researcher deemed as necessary for participants to disclose their
genuine reflections. Despite these similarities, the difference in country of origin and
gender served as a mechanism for an objective stance. To help maintain an
awareness of biases, the impact of the researcher’s background and the experience of
the interpretation of data, a separate log of personal reflections was made (see
Appendix G).
Data Analysis
Closely following the recommendations of Smith, Flowers and Larkin’s (2009)
analytic process, the transcripts were read multiple times to familiarise the researcher
with the content. The first stage comprised of a line by line analysis where the initial
identification of words or phrases were noted within the right margin. These notes
offered a brief summary of highlighted topics. The left margin was used to translate
these notes into emergent themes, ensuring a reflection of the participant’s language,
and drawing on psychological knowledge to build on the interpretation of these
accounts. This procedure was repeated for subsequent transcripts. Each theme was
listed on a post-it note, where they were categorized, and reordered into themes with
shared meanings. The emergent themes were then refined and organised into
superordinate and subordinate themes. Commonalities and differences were linked
with verbatim quotes from transcripts which best evidenced each theme. These
56
quotes were identified for reporting to enrich the narrative. This process was repeated
with each individual transcript. Patterns of themes identified across cases were
subsequently grouped into superordinate and corresponding subordinate themes.
Supervision was used to review and condense the identification of themes. Pages of
transcripts from three separate interviews were offered to peers of differing ethnic
backgrounds. They independently completed the first two stages of the analysis to
compare whether the outcome of the analysis was heavily influenced by the
researchers shared cultural experience with the participants. Figure 1 provides a
detailed account of the analytic process. The development of themes are documented
within the Appendix H.
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Table 3: Ethical Considerations
Topics for Ethical Considerations
Steps taken to address this
Consent
Right to withdraw
Confidentiality
Risk
Respondents volunteered to participant in the study by contacting the researcher via email. Following an arranged meeting, participant information sheets detailing the aims of the study, information regarding the recording and transcription of interviews were provided. Respondents were informed of who would have access to the data and how the research would be disseminated. Alongside this there was an opportunity to ask questions. Participants signed forms to express their consent.
Participants were informed of their right to withdraw from the study at any time during the interview and up to a month after the date of the interview.
Each participant was assigned a pseudonym and all identifying information was removed from transcripts to ensure confidentiality. The limits of confidentiality were explained (i.e. information disclosed that suggested they or another person was at immediate risk).Recordings of interviews, transcripts and consent forms were stored in a locked drawer only accessible to the researcher.
To ensure the safety of the researcher and the participants, all interviews were conducted in private rooms at the University Library. The whereabouts of the researcher was made known to other parties. Whilst some anxieties may have arisen through the discussion of participants experience, it was envisaged that the study would present minimal risk to the psychological or physical wellbeing of the participants. To mitigate this possibility, after the interview, each participant was offered a debrief sheet (Appendix E) detailing organisations they could access if the interview raised any difficult feelings for them.
Feedback for participants
At the end of the interview participants were asked if they would like feedback on the findings of the research. It was agreed the findings of the research would be disseminated as a written summary following viva, subject to any revisions. The researcher communicated the hopes to have the research available via open access in a publication journal.
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Figure 1: Steps taken by the Researcher to analyse the data
59
Credibility
Below is an outline of Yardley (2000) evaluative criteria for qualitative research and
steps taken by the present study to meet this. These four steps have been used to
review the credibility of this study (Table 4).
2
3
1
4
Initial notesThe semantic content was explored through a line by line analysis of each transcript with the aim of producing a free text analysis (Smith et al, 2009). Documented in the right hand margin, the researcher annotated the transcript focusing on the participant’s explicit meaning using by drawing on descriptive comments and considering linguistic style. Paraphrasing, summarizing, highlighting key words used and contradictions within the transcript were the primary strategies used in reviewing the data.
Repeated reading of transcripts and Reflective diary
Initial stages of IPA require the researcher to become familiar with the transcripts (Smith et al. 2009). Each transcript was initially read alongside listening to the recordings, taking note of pauses, tone etc. with the view to keeping the participant as the central focus of the analysis. This also reminded the researcher of the dynamics within the interview. A reflective diary was used to document the researchers’ initial thoughts and reflections.
Emergent ThemesThe primary aim of this step was to identify clusters of commonalities. Focusing initially on the notes in the right-hand margin, the researcher constructed concise statements/words using psychological constructs to facilitate the interpretation whilst ensuring that it captures the participant’s original meaning. These were then documented on a list on a separate document (See Appendix H for an example coded transcripts)
Clustering themes and Final ThemesUsing the list of themes the researcher looked for connections between themes. This was then checked against the participants’ initial account in the transcript to confirm that the themes reflected the meaning identified. The process was repeated for each transcript in isolation.Comparing the list of superordinate themes the 8 tables were compared to identify similarities and differences.
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Table 4: Evaluating the validity of the present study against Yardley’s criteria (Yardley, 2000)Criterion How the current study meets the criteria
Sensitivity to context
Demonstrating an understanding of relevant literature and theories. Maintaining an awareness of the power imbalance between the participant and the researcher and the social and cultural context of both.A commitment to understanding the lived experiences of the participant to uphold the true interpretation.
A literature review was completed examining the barriers to immigrant help seeking, which assisted the researcher to establish a grounding in the theories and literature within this topic area.
Purposive sampling with a homogenous group of participants as per IPA guidelines. Details of the inclusion criteria was placed on the recruitment posters and emails and distributed at the University of Surrey.
Power imbalances, whilst mindfully considered by the researcher, will inevitably remain. For example, interviewing as trainee clinical psychologist, the researcher may be positioned by the respondent as an academic with specialist knowledge in psychological processes. Furthermore, the shared similarities of ethnicity may result in a presumed shared understanding of constructs. This is explored further within the discussion section.
Commitment and rigor
A thorough consideration towards data collection, analysis and the resulting reported findings.
A non-clinical sample of 8 participants, adhering to the selection criteria, were recruited by the researcher.Each interview was complete in that no objections were made by participants to answer questions.Transcripts were transcribed by the researcher to support comprehensive engagement with the data. The researcher also has an interest in promoting awareness of issues pertaining to diversity which is presented.Following closely the guidance from Smith et al (2009), the researcher documented the analysis process and has provided sample transcripts to aid the reader in verifying the process.
Transparency and coherence
A clear description in the reporting of a study
A description of the analytic process has been detailed to facilitate transparency in the process of theme development.Alongside of this, extracts of transcripts were offered to supervisors and two peer analysts to verify the development of themes identified by the researcher. These were considered alongside of the researchers’ analysis.
Impact and importanceThis criterion emphasises the importance of research contributing to the wider understanding of the explored topic.
It is envisaged that there may be potential impact on informing counselling service provision within universities. This is discussed further in Clinical Implications.
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Results
Following the analysis of eight transcripts, the figure below visually summarises the
four identified themes. These include (1) Coping strategies (2) barriers to accessing
support, (3) African identity and (4) Masculinity. Within the “Coping Strategies”
master theme, four sub themes were identified. These included independent
strategies, religion/spirituality, social network and professional/formal services.
Analysis revealed that multiple coping strategies were often employed during periods
of psychological distress. Within the “Barriers to accessing support” master theme, a
further four subthemes were also identified. These included the sub-themes of Fear,
strength/resilience, trust and severity of difficulties. The third master theme was
“African” followed by the fourth master theme of “Masculinity”.
Figure 2: Diagram of themes
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The findings are presented within a narrative structure alongside supplementary
verbatim extracts from transcripts with a focus on the nuances between participants’
experiences. Some minor alterations have been made to the quotes to improve the
readability. Ellipses (…) will indicate the omission of a few words to facilitate
brevity and clarity.
The following summary outlines the challenges typically reported by participants to
contextualise the experiences that have initiated help seeking behaviours. All
participants recognised challenges and stressors that they experienced during their
time studying in the UK. All but one participant reported experiencing multiple
difficulties/stressors concurrently. Sources of stress included finances, university
work demands, adjustment difficulties including feeling homesick, difficulties with
language and social isolation.
One of the common challenges reported amongst participants was the difficulty in
managing finances or meeting daily living expenses. The cost of international fees
relative to the home student fees increased the impact of financial worries for many
of the participants. The knowledge of this large financial investment and the
sacrifices made by others on their behalf, served as a reminder that this was a
privilege afforded to them at great cost.
All participants described their experience of the course as “difficult”, “challenging”
or “stressful”. It appeared that the challenge was in managing the expectations of
others in addition to the expectations participants placed on themselves. The
standards from loved ones typically centred on academic achievements, which
mirrored the students’ own expectations of achievement. Notably there was a distinct
notion that a pass would not suffice as a successful achievement. Consequently,
expectations were to attain the highest possible grade.
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For some transitioning to a different country proved trying as it represented
considerable change to their responsibilities, routines and separation from their
familiar social network. The “reality” of living at university and in a new country,
coupled with taking responsibility for their actions, independently contributed to the
difficulty of transitioning between cultures.
For those who had not been in the UK previously, despite being proficient in the
English language, reported how difficulties in understanding accents often impacted
on their studies. By extension, this too resulted in a reduction in the willingness and
confidence of participants to integrate with non-Nigerian students. Some participants
reported experiencing social isolation and homesickness, which proved particularly
difficult for those with no pre-existing social networks within the University.
As a consequence of the challenges, increasing distress was marked by changes in
physical health, thoughts and behaviours. Physical symptoms included losing weight,
loss of concentration and changes in sleep pattern. Outside of this, changes in
thoughts, particularly increasing worries and thoughts of giving up were also
identified as a sign of increasing distress. Some participants did not explicitly
identify the link between thoughts changing and increasing distress, but reflected on
the changes in their self-talk. These thoughts were described as atypical to the
normal patterns of thinking. A reduction in free time for socialising was also reported
alongside having a build-up of academic work.
Coping Strategies
The first superordinate theme was coping, within which, the various coping strategies
used are explored. Participants delineated an array of resources to assist them in
overcoming or tolerating the distress that often accompanied the challenges reported.
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This theme comprises of the reported experience of utilising informal support,
namely through social networks, faith/spirituality and independent resources. Formal
support comprised of the use of professional services such as accommodation
services and the local wellbeing centre. The use of multiple strategies was commonly
reported.
Independent
Independent coping strategies were endorsed by all participants. To manage the
demands there was an emphasis on relying on oneself. Whilst some favoured a
suppressive coping strategy, others adopted a more practical and proactive approach.
Suppressive strategies included avoiding thinking about problems by distracting
themselves with other physical activities (e.g. sports or sleep). In contrast, the
application of proactive approaches in managing their difficulties was typically used
to relieve stress caused by finances, social isolation or academic work.
For example, whilst there were no reports of the participants being advised to take up
paid jobs, to manage financial demands and relieve the financial pressure on parents,
some participants proactively sought paid work. Simon’s experience captured this:
if I’m not working that puts a lot more stress on her and if she can’t do it that
puts a lot more stress on my dad and considering he’s in Nigeria with the
exchange rate and stuff you don’t want to have to make him transfer you
money every month to pay for accommodation so I feel like the only person
who can really handle that and take the burden off them is me. Simon, T4,
48-51
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Reassurance through self-talk was another coping strategy used to alleviate periods
of distress. The use of comforting statements either denying or minimising the
difficulty was typically used as a quick way of bolstering perseverance.
I just kept saying ‘I’m not stressed’, ‘I could deal with it’, ‘it doesn’t
matter’… I guess, watching a lot of movies growing up, the hero always going “I
can do anything”, me believing I could do anything, well, with God helping me, I
just figured I can hack it. I just, its hard now obviously because I just started and I’m
not used to taking on too many things, or as much as I did in second year, so I was
like, just keep going J, you can do it, at some point you’re going to be able to, you
know, juggle everything. Jo, T1: 137-144
Religious/Spiritual
Participants asserted that faith and religion occupied an important position in their
lives. There were reports of varying levels of involvement with regards to private
devotional activities (e.g. reading the bible, watching sermons and prayer) and
attending religious gatherings (e.g. church or mosque). All but one participant made
reference to using this as a tool to yield comfort from the stressors of university life.
Prominent in Paul’s narrative, he described how his understanding of Islam helped
him obtain solace even in the face of being homeless upon arriving at the University.
Everything that will happen to you, even before you were given birth it has
been written and the life of book that this thing will happen to you and that
belief that ideology is what keep me going. Paul, T6:426-429.
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Embracing the understanding that his difficulties as part of a divine plan alleviated
Paul from the burden of feeling solely responsible, thereby assisting him in coping
with the undesirable circumstances. By extension of this he described the difficulties
as transient, stating, “this is not permanent”. In a different vein, whilst clearly a
valued tool, Yomi described the use of prayers as a rehearsed strategy.
I don’t know if it does anything for me…I think you’re supposed to pray so
God hears you…but I can’t go to bed if I don’t do a quick prayer. It’s weird.
(Charlie, T8: 237 – 241)
The use of religious texts such as the Quran and the Bible also provided reassurance.
Although Simon stated he did not believe in the traditional philosophy of his church,
he still used his interpretation of religious texts and sermons as a guide to shape his
decisions
Social Network
There was a consensus amongst all participants of the importance of social networks.
The social network within this theme comprises of friends, classmates and family
members. Within these groups the participants held varying opinions around the
suitability of these systems.
Friendship groups were considered an effective source of support for most of the
participants. Typically, support was sought from long standing, established
relationships that were either classmates or friendships formed through socialising at
University social events.
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thanks to friends and the people who are around me and the kind of people I
associate myself and establish myself with it’s definitely been a lot easier
(Simon, T4: 89-91)
Whilst some made conscious efforts to expansively extend their social network to
include home students, others focused on maintaining friendships primarily within
the circle of Nigerian International students. For the latter the rationale in eliciting
support from only fellow Nigerian International students was the perception that
those with similar experiences would be best placed in providing relevant advice.
Only two participants considered the shared likenesses in their experiences amongst
other international students. Within this, Tayo explicitly emphasised only
considering support from peers with cultures who they perceived as similar to their
own Nigerian culture.
I know stereotypically that, with regards to Asians, the parents also put some
stress on them, so from that basis they will also understand what I’m going
through (Tayo, T7: 462-465)
The preference for similarity extended past cultural similarities to shared
experiences. It appeared that in accessing support from those they considered like
themselves, this may have served as a reminder of their own potential to overcome
similar challenges. The collectivist values around providing support to peers is
reciprocated, as demonstrated by Jo who spoke about advising a Nigerian friend
who, like him, expressed that they were homesick.
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Friendships were also used as a bridge to access connections with other people who
were deemed as more knowledgeable or through the recommendations of suitable
services. This was typically used with practical challenges such as academic or
financial difficulties.
Although the value of utilising social support was acknowledged, for some
participants the support was not always explicitly requested.
because the friends I made, I met, I made quite a lot of diligent friends in our
course so I, erm, I almost missed so many deadlines, but they reminded me,
so that’s why im saying if it wasn’t for them. I guess with the deadlines as
well, I probably could have missed a lot of deadlines, if not for the friends I
made here, and getting my test results back and everything. So yea, that
really helped. I didn’t ask them directly how do you guys, like, how it works
here, but just being around them I was able to understand like, you know
their learning processes. (Jo,T1:186-191)
For those who used their family typically considered them as their primary source of
support. The family unit, primarily parents, were deemed as a reliable network who
had their best interests at heart. Having established longer relationships with family
members gave reassurance that the advice given would be helpful, as Yomi describes
in his rationale in speaking with his father.
I was just listening because he usually gives good advice ‘cause he’s usually
a wise guy I was just trying to take everything on board. (Charlie, T8: 181-
182)
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For Paul and Tayo, sharing any difficulties with their parents would result in the
autonomy of making a decision being taken from them.
I mean if my parents were aware they will say okay just quit and there’s
nothing I could do then because we obey our parents (Paul, T6: 143-144)
Obeying parents’ requests was deemed as a sign of respect towards them. In Paul’s
case, however, this resulted in him choosing to not share information particularly if
the plan to resolve the challenges were contrary to what his parents may have
advised. Some participants refrained from using parents as their support network for
fear of burdening them or anticipating that their concerns would be diminished as
trivial. Indeed, not all members of family were automatically deemed as suitable
sources of support to confide in, as demonstrated here in Simon’s reflection:
I feel like blood makes you related but it doesn’t make you family (Simon,
T4:498)
Some participants reflected on the difficulties of discussing concerns with family
back home, which primarily centred around the assumption that this would be
burdensome and cause additional worry for the family.
Professional/formal services
Professional services included the Wellbeing Centre, which offers a counselling
provision. Most participants were aware of this service provision but only Tayo had
previous experience with seeking support through this service. Some participants
stated they were open to using the service although during periods of stress did not.
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Reasons for not using professional counselling services included a limited
understanding and confidence in the effectiveness of the support provisions offered,
as explained here by Charlie.
I know it must help but the science of it I guess I don’t know it so I’m not
100% behind it (Charlie, T8:376-377)
For most participants’ attitudes towards professional counselling services
demonstrated a rejection in the participant’s willingness to using such services.
Honestly, well I don’t know, I’ve not actually tried to contact, use the centre
of wellbeing before so I won’t like to say, but I just don’t, I will not go to
them (Tayo, T7:294-295)
Even if I was having a panic attack I wouldn’t go to the wellbeing centre (Jo,
T1:523)
The rationale for this is discussed further in the African and Masculinity theme.
Even with those who expressed an openness to using the service, they often
emphasised their strength and the unlikeness of having to use professional
counselling services. Tayo’s experience of considering support is explored within the
“Barriers to accessing support” theme.
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The structure of the professional service provision also served as a practical barrier to
this source of support being utilised for some, namely the accessibility of formal
services, such as the wellbeing centre. Tayo, the only participant to have attended the
wellbeing centre, explained that his expectation of immediate or timely support
during a time of need seemed impractical given the referral process of the service.
I have to wait like a month before I can get a chance to speak to someone.
And when I get there I will just go there to complain about my life. It just doesn’t
seem practical (Tayo, T7: 301-303)
Multiple Strategies
Participants commonly reported using multiple strategies in response to the
challenges they faced. For most participant’s multiple help seeking strategies were
either used in succession if the difficulty remained unresolved, whilst for others the
use of a particular strategy often directed them to additional sources of support. The
latter was particularly evident when prayer was used as the initial coping strategy.
Prayer was rarely used in isolation, as was the case for Yomi;
on top of praying I still need to talk to someone (Yomi, T2: 104-105)
For some its value as a coping strategy was framed in the provision of short term
comfort whilst additionally compelling them to establish dynamic partnerships with
other people in their social network to help them problem solve. Jo, who described
that guidance from a higher being would direct him to the appropriate individual or
services to seek additional support from, is an example of this:
72
as much as I prayed I felt like what I understood from like reading the bible
and things I’ve learnt is, erm, God can speak through different people (Jo, T1
478-480)
In a similar way, if independent coping strategies failed to resolve the challenges,
typically an alternative source of support was sought.
Barriers to accessing support
A combination of both systemic and individual level barriers was prevalent.
Systemic level barriers comprised of the accessibility of services, whilst some
individual barriers identified included denial, normalizing difficulties, conflicts with
personal values alongside philosophies around strength and resilience. Typically, the
reported barriers often prompted participants to depend on alternative support
strategies, such as independent coping. For those who stated there were no obstacles,
they rationalised using strategies congruent to their level of need.
Fear
The decisions around who not to seek support from was at times perpetuated by a
fear of appearing inferior to others or being mocked. Consequently, this reinforces
emotional self-control as a chief value. For some the risk of being labelled as unable
to cope or weak emphasised the need to find safer ways of resolving their difficulties
as demonstrated here by Yomi and Tayo:
I don’t want anyone to feel bad for me. I don’t like feeling inferior. (Tayo,
T7: 360-361)
73
nobody definitely wants to be mocked, so to avoid that you would avoid
expressing some emotions. (Yomi, T2: 425-426)
This fear partly stemmed from the anticipation that disclosing feelings of distress or
homesickness would either be dismissed as trivial or perceived as evidence of
weakness and an inability to cope. Consequently, this typically compelled the use of
independent coping strategies. Here Yomi explains that ‘homesick’ is not
acknowledged as a difficulty.
They wouldn’t really be expecting me to feel homesick because I’m meant to
be tougher than T2:569-570 Yomi
Loyalty to collectivist values also served as a deterrent to disclosing difficulties for
fear of placing the burden on loved ones.
Strength /resilience
For some men, expectations of strength and resilience in the face of adversity also
acted as a deterrent in utilising social networks and services for support.
I feel like you’re just expected to handle it however way you can (Jo, T1:
354-356
Upholding these expectations appear to supplement their own expectations of
resilience.
I’m the kind of person that I have a very strong mind. What I mean by that I
hardly get the - of course I get depressed but I don’t allow that to overwhelm me
(Paul, T6:501-503)
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Transitioning to an individualist culture, for some, was associated with heightened
responsibility in addressing problems on their own.
no one here really cares that’s the thing so your basically on your own
(Peter, T5:327)
Trust
Central to the decision to access support was the creditability and trustworthiness of
individuals. For example, within friendship networks, there was the notion of “good
friends” verses bad friends. While participants could socialise with both groups,
making wise choices around who to seek support from was dependent on which
category these friends fell in. ‘Bad’ friends were deemed unsuitable for a variety of
reasons including a lack of trust and concerns of being judged.
Paul explained that trust was important because it ensures confidentiality. For Simon
trust was built through building a relationship.
someone might even go somewhere gossiping. So I mean I just don’t like it.
(Paul, T6:338-339)
I don’t really know them and with that being said I don’t really trust them.
Whereas with the people I hang around with there’s a certain level of trust
im giving to by us being friends. (Simon, T4:529-532)
Severity of difficulties
75
Participants who stated they would consider support services explained that they
never previously explored such options because their difficulties were not of a nature
or degree that would warrant seeking support.
yea it would be difficult, really difficult. like It needs to be like, its really
getting bad and that feeling is taking over my life…like I would look like
really depressed and I would look like I really like, I’m really carrying like
some really heavy emotion…when people start to like ask you what’s
wrong…Like when people actually notice it. When you can’t bottle it no more
and people actually notice it and people keep asking you what’s wrong, stuff
like that, you know that you really really need to get it off your shoulders.
(Yomi, T2:450-461)
African identity
Except for two, all participants identified being African or Black as an important
influence on their decisions around help seeking. For some, the underutilisation of
formal support help seeking strategies was couched within their expectations of how
an African should deal with difficulties. Within this theme, the impact of their
personal and world view of being African and its impact on help seeking practices is
also explored. Further to this, the theme also considers participants expectations or
experience of help seeking in Nigeria.
Amongst those who considered being African or Black as a significant component,
they often drew a distinction between themselves and other students by ethnicity,
often typifying Westerners as less resilient to stressful circumstances.
76
the people here are very fragile with certain situations. (Jo, T1:668)
Yomi proposed that the expectation of resilience was a result of the lack of
professional support back home in comparison to the UK.
here they stress and make more like a big deal, there are like actual experts.
Like there are actual experts that deal with, they specialise on things like that.
Whereas back there I don’t think I’ve heard of one. So your, its more of like, back in
Nigeria them expecting you to like, you should be able to deal with some things. I
mean you should be able to deal with somethings more than here, where there is
help for it or way out of it.(Yomi, T2: 616-623)
Jo and Paul emphasised that there was a perception of strength that they felt society
held about people from Africa, thereby influencing their own understanding of
expectations about appropriate help seeking behaviour.
It’s just because we are a bit strong, you know that is what people will keep
telling you that Africans they are strong, you know they have a strong blood. (Paul,
T6:929-931)
I don’t think they[British people] would expect you to erm maybe speak
about it. Maybe just my personal perception. Its not something I really thought about
but I wont expect them to expect me to be like, “oh this is what’s going on”. Pour
your heart out, that’s emotional… they would want to help you but I guess they will
be more, they will be surprised if you erm, open up to them, but they will expect you
to be able to handle it yourself (Jo, T1:616-620)
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Consequently, decisions on what difficulties were deemed as suitable to seek help for
was influenced by their desire to maintain cultural stereotypes of resilience and
strength. Whilst there were expectations around Black people being resilient, for Jo
this did not negate the impact of difficult circumstances, but rather had more
influence on how difficulties should be resolved.
I guess there’s also, another mentality that black people are not meant to be
that stressed. Like, we’re stressed but we still don’t need to be talking to people
about that. (Jo, T1: 350-351)
I can’t imagine a black guy going to the wellbeing centre (Jo, T1:564)
Here Jo describes that whilst the cultural expectation is to be resilient, the reality is
that stress is experienced, even in circumstances where this may occur, masking
difficulties behind the veil of strength and not showing your distress remains more
important. Alongside this runs the knowledge that the appropriate outlets for support
for black men are not within professional talking services.
Tayo similarly talked about the expectations of strength stemming from cultural
expectations of men within the Nigerian culture.
I learn these examples from erm, my environment, the media, where I grow
up but I would say mostly the culture in Nigeria. It says the man is the head
of the home, men are meant to, are seen as providers and someone that’s
meant to be a provider that meant to be doing all that and getting money is
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meant to be someone that’s strong minded you know, not easily erm, if things
don’t go well, not easily dismay. Not easily, doesn’t give up easily, those kind
of things (Tayo,T7:66-70)
Charlie describes how mainstream portrayals of black men may exemplify the
expectations regarding help seeking
All those rap guys are not going to seek help…it’s not cool…There is a sort
of, giving up kind of thing (Charlie, T8: 385-387)
Jo was unable to fathom the idea of seeking support from such services. Reasons for
this are in part to protect how Nigerian students were viewed by British people. Jo
stated:
Well, I guess first there is the ego, this, you don’t want them to particularly
look down on you as a Nigerian student… if I found someone who was receptive
enough to want to help out and listen, … but in Nigeria it would be easy because I
grew up there so I could just easily approach anyone.” (Jo,T1:199-208)
For others, the decisions to seek help were influenced by their experience of help
seeking back home. Matthew and Paul spoke of how they felt less inclined to ask for
support in their home country. This was often couched within the context of others
focusing on their own needs primarily, often leaving little opportunity to support one
another. Here Matthew describes why he felt it was more difficult for him to ask for
support with his coursework in Nigeria
79
in Nigeria in your presence you get people struggling to do things and stuff.
People will be like “I’m doing mine why are you bothering me”. So like its a lot
difficult asking for people, help back home (Matthew, T3: 194-196)
In addition to self-preservation, Matthew later explains that he considers the main
drivers for this behaviour as “competition”. Whilst he acknowledged the
competitiveness amongst his peers in the UK he reported that this was heightened
back home.
if I’m having the same module with you and I’m having problems with it and
maybe you’ve done yours, you wouldn’t, at times they don’t feel like helping because
they feel like if they help me I might do better than they did. (Matthew, T3: 183-186)
Masculinity
The theme of masculinity appeared to be rooted in relationships to self and with
family. In relationships to self, participants valued perseverance and resilience. The
use of words such as “strong” and “determined” were typically drawn on when
discussing the worldview of men. This theme explores how participants developed
their expectations of masculine behaviour and the impact of this on their decision in
negotiating which sources of help should be utilised.
Families were central to the participants construct of masculinity. For some this was
realised through their acknowledgement that the responsibilities of men were shaped
by their families. For Yomi he determined what was an appropriate expression of
emotion for men through observing male role models in his life.
80
they will bottle them like, my dad will tell me like I’ve never seen my dad cry
so you look up to different people and it kind of like changes your concept of a man
(Yomi, T2: 442-443)
In a similar vein Tayo’s described the expectations of men, emphasising qualities of
strength and resilience:
supposed to be determined, strong, you know strong willed in the things we
do and even when times get hard. The man is the head of the home, men are meant to
be someone that’s strong minded you know, if things don’t go well, not easily
dismay. Not easily, doesn’t give up easily(…) (Tayo, T7:63-66)
Tayo explained that even outside of the immediate family, men within the wider
community often took responsibility teaching and holding younger men accountable
to maintaining these standards.
all the men around us will put us straight and say “ay, you’re a guy you have
to firm it. You cannot keep complaining. Yea all the guys around there especially the
seniors, the teachers (Tayo, T7: 77-78)
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Discussion
Research evidences that the international student population face additional
challenges which can impact on their mental wellbeing. Despite this they are less
likely to utilise professional psychological support services (Royal College of
Psychiatrists, 2003). Patterns of underutilising professional MH services have been
found generally in men (Sullivan et al, 2015), and African immigrant populations
(Saechao et al 2012). As the Nigerian international student population continues to
grow in U.K. HEI’s, this trend provides an important context for the justification for
this study. This study provides an experiential account of the help seeking behaviours
and coping strategies for an at-risk population; Nigerian Male International students.
An Interpretive Phenomenological Analysis was selected as it afforded an
opportunity to capture the lived experiences and processes involved in help seeking
decision.
Four master themes were identified from the transcripts (1) Coping strategies (2)
Barriers to accessing support, (3) African identity and (4) Masculinity. The emerging
themes highlight the rich combination of influencing factors, with findings
supporting the constructs generally identified in African Immigrant help seeking
behaviours.
The students’ perspective on academic success unanimously underscored the primary
source of distress. Expectations of scholastic success both from the self and parents
resulted in an unnegotiable desire to achieve. This resulted in anxiety and stress
whenever the possibility of attaining this goal was threatened. The impact of stress
on a student’s academic performance has been extensively investigated and shows
that those who are unfamiliar with how to manage this may become depressed (Alao,
2003). Similarly, strong identification with values of achievement have been found to
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impact on negative mental health outcomes within African immigrant populations
(Idemudia, 2011).
Whilst these difficulties are similarly experienced within home student populations,
the unique challenges for the international students centred on the financial concerns
that occurred as a result of paying international fees. For most, this was further
compounded by the recognition of the sacrifices made by loved ones to facilitate this
prestigious experience. Even for Paul who attained a scholarship, the decision to
further his education required the sacrifice of temporarily stepping away from his
financial duties as a father and a husband. Other challenges identified included
difficulties adjusting to a new environment, feeling homesick, difficulties with
language and social isolation. The impact of these stressors were identified through
physical health complaints, e.g. “lack of sleep”, although for some there was an
awareness of changes in typical thinking patterns. Presenting with somatic symptoms
is common within BME populations (Shaw, Creed, Tomenson, Riste and
Cruickshank, 1999). Even within this none of the participants sought physical health
assistance support.
Recognising the occurrence of these difficulties gave rise to the exploration of the
help seeking pathways utilised by this sample. Whilst some participants openly
acknowledged their symptoms of distress, none identified the need for professional
support through the University counselling service. In managing these difficulties,
analysis revealed most preferred to utilise independent coping strategies to resolve
these difficulties. Spirituality, positive reframing through self-talk, distraction and
problem solving were found to be the coping mechanism employed during periods of
stress. It was clear from the narratives that participants considered these strategies
83
effective. In Mincey, Alfonso, Hackney and Luque (2015) study of masculinity and
coping in black undergraduate students, similar coping strategies were also found.
Drawing on spiritual coping strategies was unanimously identified. These included
prayer, attendance to religious gatherings and the reading of religious texts. Across
both Christians and Muslims advocated that these practices afforded a connection to
a trusted higher power who provided resilience and the necessary resources to endure
challenges. For some this provided comfort in the knowledge that the challenge was
transient. Holmes and Hardin (2009) found that spirituality can work positively in
preventing participants from being overwhelmed by their experiences, thereby
possibly decreasing the need to access professional mental health services.
Those who did not subscribe to all aspects of their faith continued to acknowledge
the comfort that these practices provided, and instead utilised faith as a habitual
strategy. It is important to note that using spiritual methods of coping did not
necessarily endorse managing difficulties independently, but in some cases directed
the decision to seek additional support from the social network. Often used in
addition to or instead of spiritual resources, participants relied on suppressive coping
strategies which were characterised by the avoidance of threatening information.
Suppressive strategies included distraction versus proactive strategies i.e. problem
solving.
Secondary to independent coping strategies, the students reported using their social
support network. Within collectivist societies such as Nigeria, greater emphasis is
placed on norms of social connectedness. Influenced by these principals, research
evidences that individuals from collectivist cultures are inclined to accept influence
from external sources (e.g. family and friends) (Cheng, Cheung, Chio & Chan,
2013). Effective social support has been evidenced to mute stressful experiences and
84
enhance wellbeing. However, this study showed that this is not necessarily a linear
process as the decision on who to solicit and receive support from appeared to
depend on the nature of the relationships and the anticipated response.
Research examining the taxonomy of social support identified three primary
categories: Information support; Instrumental support and Emotional support
(Taylor, Sherman, Kim, Jarcho, Takagi & Dunagan, 2004). Information support
entails the provision of advice to make sense of stressful circumstances with the view
to identifying strategies. Instrumental support provides tangible resources for
example in the form of financial support or services, whereas emotional support
offers warmth and reassurance. Participants reported utilising primarily information
and instrumental social support, which lends more to the problem solving strategies
typically employed.
For the students in this study, the decision to solicit social support was conditional to
trustworthy and reliable sources being identified within the network. This was often
negotiated by approaching those who have previously demonstrated credibility in
dealing with past challenges. For unknown individuals within the network, support
was elicited in a covert manner (i.e. not talking directly about difficulties or masking
challenges in humour or “banter”). Central to the characteristics of those identified as
suitable to access social support from included being proactive in checking on the
individuals’ wellbeing and were deemed knowledgeable. Mojaverian and Kim
(2013) explored the effectiveness of both solicited and unsolicited social support and
found that unsolicited support reinforced a sense of social belonging, which within
the context of this study, may mitigate against the threats of disclosure of personal
struggles. This fear partly stemmed from the anticipation that disclosing feelings of
85
distress or homesickness would either be dismissed as trivial or perceived as
evidence of weakness and an inability to cope. Consequently, this typically
compelled the use of independent coping strategies.
In the absence of this, the study found there was an increasing reliance on
independent coping strategies, which were often most accessible. The decision to not
seek social support was at times perpetuated by a fear of appearing inferior to others
or being mocked. Interwoven in this was the desire to portray characteristics
typically associated with masculinity. Some participants referred to male role models
back home who shaped their understanding of appropriate expressions of distress,
typically regarding “talking” as a method associated with females. Echoing both UK
and US research findings that suggest gender role socialisation impacts on the help
seeking behaviours (e.g. O’Brien et al, 2005), this consequently, reinforces emotional
self-control as a chief value. It also emphasises how masculine concepts defined
acceptable responses to mental health difficulties and the corresponding coping
mechanism.
Embroiled within this was the value often held in adhering to collectivist principals
which deterred the disclosure of difficulties for fear of placing the burden on loved
ones. Such notions are likely to reinforce high self-concealment which conflicts with
the structure of formal support services. These findings present a balanced
consideration of the overly optimistic view of the role of social networks commonly
documented in literature (Maundeni, 2001).
Within social networks there appeared to be a preference to rely more so on other
Nigerian international students. Research posits that international students form
distinct categories of friendships (Bochner, McLeod & Lin, 1977), with co-national
86
friendships evidenced to diminish the distress typically experienced when
transitioning between cultures and offering emotional support. (Maundeni, 2001).
Arguably the dependence on primarily co-national friendships may inhibit the
sharing of alternative help seeking behaviours. However, these friendships may be
inhibited by the participants’ perception of their proficiency of the English language.
For some this was coupled further with the assumption of ethnic prejudices, which
may encourage more self-concealment.
Most participants strongly rejected even the possibility of seeking support from the
local Wellbeing centre and engaging with talking therapy services. Research reports
some reasons include differing conceptualisations of the causes of mental distress
and a lack of familiarity with traditionally promoted counselling services
(Constantine, Anderson, Berkel, Caldwell & Utsey, 2005). Within this study the
disapproval towards this was couched within limited understanding of the service
provision, with the presumption that it would not benefit them. Within the context of
the provision of health services, in comparison to Europe, a community study in
Nigeria showed lower levels of public knowledge and negative attitudes towards
mental health regardless of age, gender and education (Gureje, Lasebikan, Ephraim-
Oluwanuga, Olley & Kola, 2005). With regards to this study the perception that
therapy is simply an opportunity to “complain” may also conflict with the preferred
proactive resolutions. Some participants alluded to the belief that professional talking
services were not a provision targeted towards Black communities. This is a belief
which could be considered within the context of their own experience of the limited
availability of this provision back home.
87
Of those who expressed openness to using this form of support, despite their
disclosure of significant challenges, they dismissed the reported instances as
distressing enough to utilise professional therapeutic support. Whilst this
demonstrates a level of openness to considering therapy, it raises concerns about
whether the implementation of sanctioned coping strategies may result in help only
being sought when more significant mental health difficulties are experienced. This
may limit the opportunity to address mental health at an earlier stage, thereby
increasing the possibility of crisis intervention, a pattern currently seen in the
engagement of Black men within mental health services (Bhui & Bhugra, 2002).
This research supports the findings of beliefs about coping and resilience affect the
individuals’ perception of the severity of the symptoms.
Constructs of resilience and strength were central to the participants’ perception of
their own and societal expectations of being African. Pride in being African appeared
to perpetuate the desire to uphold and demonstrate values of resilience, to both non-
Africans and Africans alike. For some, there appeared to be a concerted effort to
differentiate from the perceptions of “fragile-ness” held about the British
communities. This could be considered through the perspective of Africentric values,
whereby collectivism though prioritising a united group narrative of “strength”, may
motivate a desire to uphold the behavioural expectations of their culture. For those in
this study, this sense of pride served both a detrimental and protective function as on
one hand it discouraged help seeking, whilst the values of emotional restraint and
beliefs about resilience empowered some to not feel “overwhelmed”. Kibour (2001)
and Mossakoswki (2003) report that a stronger ethnic identity serves as a protective
factor against poor mental health. Conversely, the same value of communalism did
88
not always translate to a willingness to share difficulties with other students from
similar backgrounds to their own.
For some participants, the decision to delay help seeking was attributed to
perceptions of masculine norms of emotional control and self-reliance. Research
corroborates similar experiences within male populations within the UK (Sullivan,
Camic and Brown, 2015). Hinged on the values of family centeredness and by
extension protecting the family, the decision to not burden loved ones justified the
use of self-regulation strategies. The use of independent coping strategies was
reinforced by other males within the community who often berated any expression of
“complaining” or “weakness”. However, this was not always explicitly stated, as
some participants referred to witnessing male role models (e.g. fathers) not being
emotionally expressive. Berger, Levant, McMillan, Kelleher and Sellers (2005)
found that higher levels of traditional masculine ideologies instilled through
socialisation, were associated with more negative attitudes towards help seeking.
However, not all participants considered their perceptions of masculinity to be a
prominent factor in their decision to seek help, and rather attributed their preferences
to personal characteristics.
Limitations
Qualitative research does not propose that findings can be generalised to the wider
population, however an exploration of the experiences of this population can help
inform the practices of university support services. Whilst attempts were made to
bracket the researchers’ biases it is important to acknowledge that the similarity in
the ethnic background of the researcher may have resulted in respondents’ accounts
89
being shaped by the assumption of culturally appropriate narratives. However, these
cultural similarities may have also enriched the process of eliciting information to
identify a range of themes that may otherwise remain undisclosed. However, whilst
research documents some fundamental cultural similarities amongst students from
the continent of Africa (Essandoh, 1995), there remains challenges in generalising
the findings given the inherent differences in diversity between tribes, economic
class and faith within Nigeria.
A potentially veiled challenge may be speaking frankly about the perceptions of
professional psychological support services within the context of being interviewed
by a trainee clinical psychologist. A further weakness of this study stems from data
being collected from one University which may diminish the transferability of these
findings to other learning institutions which may have varying models of
psychological support available. It is possible that self-concealment coupled with
social desirability may have impacted on the information provided by the
participants, or even in who expressed an interest in participating in the study.
90
Clinical Implications
The findings of this study echo previous research on the help seeking behaviours of minority
groups in its assertion that it is important to identify culturally ascribed methods of providing
psychological support. Several pertinent questions have emerged from this study, primarily
how the current counselling and support provisions within universities can be best adapted to
the help seeking frameworks adopted by Nigerian male international students. It is important
to consider ways in which traditional help seeking pathways can be shaped to help encourage
flexibility in beliefs on when and what help can be sought.
The preference to use multiple coping strategies highlights the various avenues through
which practical interventions can be shaped. This also places emphasis on the need for
collaborative interventions between professional, spiritual and community support networks.
For example, training faith leaders in mental health first aid will equip them in identify signs
of psychological distress that would benefit from additional professional support. Similarly
training mental health professionals in the understanding of the role of spirituality as part of
the recovery journey can assist in the development of holistic treatment interventions. As
identified within the findings, there is a need to challenge the perception that professional
services are not a provision for students of African descent. Regular involvement of male
service users and staff of similar ethnic backgrounds can serve as accessible role models who
advocate the use of professional support services. Similarly, stigma around mental health can
be challenged by normalising discussions about mental wellbeing through creative arts
programs with student unions.
Conclusion
91
This study provides an idiosyncratic exploration of the help seeking processes, of a
population who have several mental health risk factors; male, international students and
African. In its focus on Nigerian men, this study also contributes to the exploration of within
group variances in help seeking behaviours of African men. The findings echo help seeking
constructs typically reported in studies exploring help seeking practices across BME
communities. In particular, it highlights the preference for the use of non-professional sources
of support and offers an alternative perspective on the idea that support through relatives is
unanimously practiced by people of African descent. This highlights the need for further
exploration through a phenomenological perspective, on a subgroup that can often be
perceived as homogenous. Further exploration of how relationships to help seeking are
shaped and influenced by cultural upbringing, perceptions of masculinity and migration from
different countries across the continent of Africa, may offer additional understanding into the
mechanisms that can foster positive mental health outcomes.
92
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List of Appendices
Appendix A: Guidelines for Authors
Appendix B: Evidence of Ethical approval
Appendix C: Recruitment Email and Poster
Appendix D: Participant Information Sheet
Appendix E: Consent Forms, Debrief Sheet
Appendix F: Interview Schedule
Appendix G: Reflective diary sample
Appendix H: Example of coded extracts and development of themes
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Appendix A: Guidelines for author would have appeared here.
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Appendix B: Evidence of Ethical approval
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Appendix C: Recruitment Email and Poster
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Appendix D: Participant Information Sheet
PROJECT TITLE The experience of male Nigerian international university students.
IntroductionMy name is Nancy Nsiah and I am a Trainee Clinical Psychologist at the university of Surrey. As part of my training I am completing a research project exploring the experiences of male Nigerian International students at university. I would like to invite you to take part in a research project. The following study is supervised Dr Linda Morison from the School of Psychology, University of Surrey and Dr Luke Sullivan a practicing Clinical psychologist. Before you decide please take the time to read the following information carefully so that you know what you will be asked to do.
What is the purpose of the study?I am interested in exploring what factors makes the transition of being a student in Nigeria to a UK university easier or more challenging for Nigerian Male International students.
Why have I been invited to take part in the study?You have been invited to take part in the study you are a male Nigerian international student.
Do I have to take part?Participation in this study is entirely voluntary and will not have any negative consequences. If you would like any further information after reading this information sheet you can contact me on the email listed below. If you agree to participate you can withdraw your consent at any time up to one month following the interview.
What will I have to do?Once you have read this information sheet we will arrange to meet on the University Campus to complete the interview. At this time you will be asked to sign the consent form if you are happy to participate in this study. You will be asked to discuss your experience of studying in the UK, including aspects that have made the experience easier or more difficult. The interview will be recorded and will last approximately an hour.
Are there any downsides of taking part?Some can find that discussing their experience can bring up difficult feelings. If you would like to access some support following this interview you can contact any of the services listed on the debrief sheet.
What are the possible benefits of taking part?Whilst it is unlikely that you will benefit directly, this study provides an opportunity for you to talk about your experiences, which many find can be a helpful process.It is hoped that the outcome of the study will further our understanding of international students experience to coming to a university in the UK. Consequently this could have implications on the ways in which services support international students in the future.
What if there is a problem?
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If you have any complaint or concern about any aspect of the way you have been dealt with during the study then you can contact my supervisor. The contact details have been listed at the end of this sheet.
Will my taking part in the study be kept confidential?Yes. All of the information you give will be anonymised so that those reading reports from the research will not know who has contributed to it.Data will be stored securely in accordance with the Data Protection Act 1998.In the unlikely event that you feel you may be a risk to yourself or others I would have to disclose this to an appropriate authority. This would usually be discussed with you first.
Who has reviewed the project?The study has been reviewed and received a Favourable Ethical Opinion from the Faculty of Health and Medical Sciences Ethics Committee at the University of Surrey.
Thank you for taking the time to read this Information Sheet.
Research being conducted by:Name: Nancy NsiahAddress: University of Surrey Contact: [email protected]
Supervised by: Dr Linda MorisonAddress: University of SurreyContact: [email protected]
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Appendix E: Consent Forms
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Appendix F: Interview Schedule
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Interview Schedule
Section 1: Gathering initial information: age, course of study, how long in
country, etc in order to put participant at ease.
Section 2: Main body of research
Part I: Adjusting to University
1. Who do you usually spend time with since you’ve been at university?
Prompt: Other Nigerians/Africans, mixture, spend a lot of time alone etc
2. How have you been finding studying at Surrey?
Prompt: Has anything been especially challenging/exciting? Any difficulties
(work/personal/emotional)? Ever felt lonely/stressed/under pressure?
Part II: Challenges and sources of support
3. What do you usually do when things feel difficult? (Ask about specific
instances of difficulties mentioned)
Prompt: Try and deal with it alone? Talk to friends/pastor/tutor/centre for
wellbeing/Other sources of support etc
4. What makes it more challenging to seek support?
5. Do you think being a Nigerian man in a British university influences this?
Prompt: In what way? Why? How? What would other Nigerians expect?
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6. Do you think dealing with personal/emotional difficulties is regarded differently here to at
home?
Prompt: In what way? How?
7. Would your answers have been different if you were being interviewed by someone of the
same gender or different race?
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Appendix G: Reflective diary extracts
Reflections on Interviewing
“I wonder whether some participants would have raised religion as a coping strategy if this
was not offered as a prompt. Part of me thinks they may not have felt this was an appropriate
topic to raise because I was a psychologist and British. Another part of me feels that my
introducing this idea gave them permission to freely express this.”
Analysing Paul’s Transcripts
“I was struck by Paul’s experience of being homeless. His determination to keep going
regardless of the circumstances, I reflected on what I would have done in this situation.
Honestly, I would have considered these circumstances unnecessary to endure and opted to
inform my social network so I could feel validated in my decision to give up. This instantly
left me questioning whether I would be considered as “weak” given the more salient
challenges others faced in their daily lives. This dissonance was with my African side. My
British side allowed me to be more compassionate towards having to potentially make that
decision. My African side reminded me of the sacrifices my parents made when they first
came to London and all the opportunities I may not have had if they had “given up”.
It reminded me of a “by any means necessary” and “take it on the chin” mentality that
draws strength from these invisible sources. It reminded of a Kwame Nkrumah (The first
African president of Ghana) quote “forwards ever, backwards never”- which, to me offers
encouragement and faith of better times to come. “
Appendix H: Example of coded transcripts (T2 and T3)
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Table 5. Example of Theme development: Transcript 6
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Identified Themes Extract from transcript 6 Line by line analysis (initial)
Coping Strategies (Master
Theme)
Religion (Subordinate
theme)
“sometimes I just feel like
staying in the prayer room, take
the Quran and recite, Maybe
with that which I know of course
I have, ermmm I will have some
benefits from reading or reciting
it and then that also come and be
a solution to my problem . yeah
when things are going wrong
when you noticed some change
in situations the Quran and will
always, I will quote a part, will
always say you should, there is a
word we say in Arabic, sabar,
patience is one of the key things
in life and I don’t always, and
again you’ll be patient and don’t
blame yourself because
everything has been destined to
happen to you and there’s
nothing you can do about that.
Prayer
Reading/reciting religious texts
Helps to solve difficulties/coping
Use faith when difficulties arise
patience
Predestined
No practical action can help
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Table 5. Example of Theme development: Transcript 6
Identified Themes Extract from transcript T7: 275-277
Line by line analysis (initial)
Barriers to accessing
support (Master Theme)
Severity of difficulties
(Subordinate theme)
Coping strategies (master
because when I (pause) tried it
the first time, I just, I just, I just
said “ok let me see what this was
about”. Told me that I should
sign, I should fill in the form and
I should write, I saw depression,
I saw anxiety, I saw lots of like
(pause), lots of like serious erm,
mental erm, I won’t say issues
but like things that are, things
that I don’t think it’s not that
level. And when I, yea so they
told me I have to come in like 30
days or something because its
filled up already. Just, so, I don’t
force myself, ok, I’m signing up
for this, I have to wait like a
month before I can get a chance
to speak to someone. And eerm,
when I get there I will just go
there to complain about my life.
It just doesn’t seem practical.
Something I wouldn’t do. I’d
Centre of well being
Depression is “deep”
They are different from me
experience
Perceptions of severity /seriousness different for him compared to others
Waiting / lack of immediate access to support
Talking is “complaining”
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theme)
Independent
Social network
(subordinate theme)
just probably just firm it and call
my parents than sign up then
come to wait so long, that I will
even probably, even after the
last 30 days I’ll probably be fine
“firm it”/ be strong
call parents/social support is immediate
problems wont last longself talk “ill probably be fine”
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Summary of clinical experience
Adult Mental Health Placement
My first placement was based within a community mental health recovery service, working
with adults ranging from 18-65 years of age. Working within a multidisciplinary team, the
placement afforded me the opportunity to assess, formulate and offer interventions to clients
with a range of presentations including Psychosis, Bi-polar disorder, Depression and Panic
disorder. The primary model of intervention was CBT. Some outcome measures used
included PHQ-9, GAD-7 and session by session feedback rating scales. I co-facilitated a
coping skills group, offering psychoeducation to service users on a range of topics including
Sleep hygiene, managing stress and wellbeing and coping with difficult emotions drawing on
Dialectical behavioural therapy techniques.
Memory Assessment Service (Older Adults)
During my second placement I undertook neuropsychological assessments including the
WAIS-IV,WMS-IV and Graded Naming Test. The resulting findings were considered
alongside clinical interviews and screening assessments with clients and carers, to ascertain
the nature of their memory difficulties. Within this placement, I also co-facilitated a Living
Well with Dementia (LWWD) group, aimed to improve the quality of life of those living with
a diagnosis of dementia. This offered me the opportunity to consider a social model of
dementia, which varied from the neurobiological perspective I gained through the assessment
pathway.
I worked therapeutically with older adults with vascular dementia, anxiety and depression
using CBT and systemic models. I also offered consultation to a local care home in-reach
team, supporting them to explore how challenges within care homes may be considered
within a psychological framework.
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Learning Disability
My third placement was within a community learning disability team. The primary theraputic
model within this placement was Positive Behavioural Support (PBS) and adapted Cognitive
Behavioural Therapy. This placement exercised my creativity by encouraging me to consider
novel ways of facilitating engagement and adapting CBT methods to suit client needs.
Alongside this I had the opportunity to work both directly and indirectly with clients. This
required varying methods of assessment including observations and clinical interviews with
support staff, to ascertain the needs of clients who had difficulties with limited
communication.
I undertook further neuropsychological assessments for dementia using the
Neuropsychological Assessment of Dementia in adults with Intellectual Disabilities (NAID).
Additionally, the WAIS-IV was used to assess for impairment of intellectual functioning,
alongside the Adaptive Behaviour Assessment System (ABAS) to assess adaptive and social
functioning. I routinely worked alongside other agencies including social workers and
learning disability nurses.
I administered therapeutic interventions for service users presenting with behaviours that
challenge, suspected dementia, sexuality assessments and anxiety
Eating Disorders: Specialist placement
I completed my specialist placement across an inpatient and outpatient eating disorder
service. Within this placement, I worked alongside a multidisciplinary team to ensure that the
psychological and physical wellbeing of the patients were attended to. I predominately used
the CBT-E (Enhanced CBT for eating disorders) model, alongside drawing on some
Dialectical Behavioural Therapy (DBT) to support a client with emerging Personality
disorders.
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Within this placement, I co-facilitated an excessive exercise group alongside another trainee,
exploring maintaining factors and alternative strategies using a CBT excessive exercise
model.
Consultation was offered to inpatients to ascertain which form of psychological therapy
would be best suit their identified needs. Clients were often subjected to detention under the
mental health act to facilitate their treatment. Traditional models of therapeutic interventions
were challenging to implement as a result of the physical state (e.g. considering impact of
starvation). This, subsequently, required a strong working relationships with others within the
MDT to manage risk. I presented on the topic of therapeutic weighing to support a wider
MDT reflection.
CYP-IAPT, Child and Adolescent Mental Health Team (CAMHS)
My Child and Adolescent placement was based within a local CAMHS and Single Point of
Access (SPA) team. I assisted in service development projects including the development of
referral pathways with non-statutory agencies. Similarly, I designed service user consultation
sessions to obtain feedback on the proposed psychoeducation groups, thereby supporting the
team to gain insight into the initiatives from a service user perspective.
Neuropsychological assessments including the WISC-IV were completed within this
placement. Several routine outcome measures were incorporated into the assessment and
review of difficulties, including goal based outcomes and the RCADS and Strength and
difficulties questionnaire (SDQ). I worked alongside many professionals including family
therapists, SENCO’s and psychiatrists, to provide a holistic care package. Drawing on
systemic approaches, I participated in reflecting teams as part of complex case discussions
within the team. I worked with children and their families with varying presentations
including Post-traumatic stress disorder, separation anxiety and social anxiety.
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PSYCHD CLINICAL PROGAMMETABLE OF ASSESSMENTS COMPLETED DURING TRAINING
Year I AssessmentsASSESSMENT TITLE
WAIS WAIS Interpretation (online assessment)Practice Report of Clinical Activity
A woman in her early thirties referred by her care coordinator for assessment and intervention of anxiety and stress management
Audio Recording of Clinical Activity with Critical Appraisal
Audio recording of Clinical activity with Critical Appraisal: Miss Smith session five recording (anonymous name)
Report of Clinical Activity N=1
A woman in her mid 30’s, referred by her GP for assessment and intervention of on-going symptoms of anxiety and panic.
Major Research Project Literature Survey
A literature survey of black men and their help seeking behaviour for mental health
Major Research Project Proposal
How do male African international Higher Education students manage differing cultural expectations regarding help seeking for psychological distress?
Service-Related Project An evaluation of ethnicity profiles of applicants to a clinical psychology doctorate
Year II AssessmentsASSESSMENT TITLE
Report of Clinical Activity/Report of Clinical Activity – Formal Assessment
Assessment and diagnosis of intellectual disabilities of a right-handed man in his late 50’s.
PPLD Process Account A reflection on the Personal and professional learning discussion group
Presentation of Clinical Activity
The assessment and post diagnostic psychosocial intervention of a woman in her late 70’s with Alzheimer’s disease.
Year III Assessments ASSESSMENT TITLE
Major Research Project Literature Review
A review of the evidence on factors impacting on mental health help seeking for African immigrants in Western Societies
Major Research Project Empirical Paper
An Interpretive Phenomenological Analysis of the help seeking behaviours and coping strategies of male Nigerian international students
Final Reflective Account On becoming a clinical psychologist: A retrospective, developmental, reflective account of the experience of training.
Report of Clinical The assessment and treatment of woman in her early
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Activity/Report of Clinical Activity – Formal Assessment
20's with a diagnosis of Bulimia Nervosa.
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