|Year : 2014 | Volume
| Issue : 2 | Page : 233-239
Migration and mental health: An interface
HG Virupaksha, Ashok Kumar, Bergai Parthsarathy Nirmala
Department of Psychiatric Social Work, NIMHANS, Bengaluru, Karnataka, India
|Date of Web Publication||8-Jul-2014|
Bergai Parthsarathy Nirmala
Department of Psychiatric Social Work, NIMHANS, Bengaluru, Karnataka
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Migration is a universal phenomenon, which existed with the subsistence of the human beings on earth. People migrate from one place to another for several reasons, but the goal or main reason behind changing the residence would be improving their living conditions or to escape from debts and poverty. Migration is also a social phenomenon which influences human life and the environment around. Hence, migration has a great impact on any geographical area and it is known as one of the three basic components of population growth of any particular region (the other two are, mortality and fertility). Migration involves certain phases to go through; hence, it is a process. Many times, lack of preparedness, difficulties in adjusting to the new environment, the complexity of the local system, language difficulties, cultural disparities and adverse experiences would cause distress to the migrants. Moreover subsequently it has a negative impact on mental well-being of such population. Due to globalization, modernization, improved technologies and developments in all the sectors, the migration and its impact on human well-being is a contemporary issue; hence, here is an attempt to understand the migration and its impact on the mental health of the migrants based on the studies conducted around.
Keywords: Mental health, migration, process
|How to cite this article:|
Virupaksha H G, Kumar A, Nirmala BP. Migration and mental health: An interface. J Nat Sc Biol Med 2014;5:233-9
| Introduction - Understanding Migration|| |
Human migration is an ancient phenomenon that started along with the subsistence of human beings on earth. It influences human life and the environment around; hence it is known as one of the three basic components of population growth of any geographical area (the other two are mortality and fertility). Moving from one place to another for a better living conditions, food, employment, education, business etc. has been taking place since ancient days. When a person shifts his residence from one political or administrative boundary to another, it is known as "migration." Migration is a social phenomenon and can be understood as a part of society. Migration also called as a process of people adapting to a new environment which involves making decision, preparations, going through the procedure, shifting physically to another geographical area, adjusting to the local cultural needs and becoming a part of the local system. When a person goes through this process it will make a definite influence on his/her life as a whole.
Migration has been increasing largely at international level especially since the last decade. Today it is estimated that 3.1% of the world population are internationally migrated; in other words, 214 million people are known as international migrants currently. Due to socio-cultural diversity it is expected to rise further in coming days. 
The concept of migration is a broader one and different synonyms have been used for the people who migrate. It is based on the type of process involved in it and the reasons for such migration. These terms are, emigrant, immigrant, refugee (A person who is residing outside the country of his or her origin due to fear of persecution for reasons of race, religion, nationality, membership in a particular social group, or political opinion), Asylum Seeker (A person who has left his country of origin for any reason and applied for the shelter and protection in other country), internally displaced person (A person who is forced to leave his or her home/region because of unfavorable conditions such as political, social, environmental, etc. but does not cross any boundaries) etc.
| Why Do People Migrate?|| |
People migrate from one place to another place for many reasons such as, education, employment opportunities and weather issues and so on. However there are a number of theories that have been developed to understand the different factors, which influence people to leave a particular place and move to another, e.g., Ravenstein (1885) provides laws of migration as follow;
- Every migration flow generates a return or counter-migration.
- The majority of migrants moves a short distance.
- Migrants who move longer distances tend to choose big-city destinations.
- Urban residents are often less migratory than the inhabitants of rural areas.
- Families are less likely to make international moves than young adults.
- Most migrants are adults.
- Large towns grow by migration rather than natural increase.
Lee (1966) provided the "push-pull theory" which lists out the numbers of factors that push people from the place of origin and the factors which attract people to the place of destination. The push and pull factors are as follows:
Wolport (1965), provided the theory, known as "the situational approach" says that people migrate when the value of "place utility" of a location is greater than other locations; the value of "place utility" involves social, economic and other costs and benefits that the person gets in a particular location.
In the historical approach, Joseph (1988) says that migration occurs from time to time due to the pressures and counter-pressures both from the internal and external sources and due to the structural transformation of socio-economic and political setup.
Carl Marks argues that, the pauperization of the working class due to the expansion of capitalism is the major base for all forms of migrations.
Types of migration
The concept of "migration" is wider which can be classified into several types based on the characteristics and the process involved in it;
Patterns of migration
The patterns of migration have been identified as short distance migration, rural to rural migration, long distance migration, rural to urban and vice versa. In the international setting the migration patterns have been identified broadly as North American System, Western Europe System, Persian Gulf System, Asia-Pacific System and Southern Cone System. The migration happens mostly in the above patterns.
In India the patterns of migration have been changed due to social-cultural, economic, political and legal factors. As the result of industrialization and economic development people started to migrate in large numbers; it is usually from villages to towns, from towns to other towns/cities and to other countries also. The patterns of migration in India can be seen in terms of short distance, medium and long distance migration. Wherein short distance migration women have largely migrated because of the tradition of exogamy, it is even more predominant among the population of lower socio-economic status. Rural to rural migration has been decreasing and rural to urban and urban to urban migrations have been increasing, where medium and long distance migrations take place and here both sexes seem to be equal. 
The process of migration has a definite influence on health, social, economic, cultural, religious and political aspects of human life and the region. Since the beginning the people have been studying the impact of migration on different aspects of the human life and among these, impact on the mental health of the migrants is one important area which has been attracting the people as well.
When individuals migrate from one place to another place, the process involves a series of factors, such as preparations and fulfilling all procedures, reaching the destination, adjusting to the new culture and society, compromising with their beliefs and practices, accommodation, assimilation etc., this process may not be favorable to everyone. There are some special groups such as women, children, elderly, lesbian, gay, bisexual and transgender individuals, etc. who are more prone to certain mental health issues during the migration process.
| Migration and Mental Health: An Interface|| |
Migration-health and lifestyle
In the year of 1932 Odergaard conducted a research to know migration and its connection with mental health of migrants. He found that the people who migrated (Norwegian emigrants to Minnesota, USA) had genetically predisposed psychosis and later they developed Schizophrenia. He pointed out that when people are vulnerable to mental illnesses, they are more prone to develop disorders in subsequent to migration. It shows that migration becomes a precipitating factor for mental illnesses due to the various barriers that people come across in the migration process and in the post migration period. 
The children who migrated from developing countries (e.g. of Maya) to developed countries (USA), though they had good physical growth and health, they became overweight and obese and developed an unhealthy life-style compared with local children. It shows that when the pattern of migration involves the migration from developing countries to developed countries, people will find it difficult to continue their healthy life-style and prone to adopt an unhealthy life-style due to the complex factors that the migration process involves. This pattern of migration may negatively affect the health of the migrants.  The migrant adolescents have reported worse mental health symptoms and highly engaged in risk behaviors compared with the native Israel counterparts, it was even significantly higher when compared with the second generation migrant adolescents. 
More often the migrants of developed countries who migrated from developing and middle income countries are recognized as, high risk group for human immunodeficiency virus/ acquired immunodeficiency syndrome (HIV/AIDS). This indicates the phenomenon may be because of the social exclusion, discrimination, cultural and language barriers in offering and accessing the health and other services at the place of destination. It shows the complexities of migration; the people who migrate from developing countries to developed countries are hesitating to access the needed services including health services. And more often the services are not inclusive because of which social and health related issues are more prevalent among migrants. 
Self-esteem and coping strategies
Self-esteem is understood as a general attitude toward the worth or value of oneself and it refers to the individual's evaluation of the discrepancy between the self-image and ideal self.  A large discrepancy between the self-image and ideal self will result in low self-esteem. , Self-esteem is basically social in nature and develops along with the interaction with the society around; for students the peer group, teachers have great influence on its development.  The re-evaluation and modifications happen in self-esteem during the transition periods such as migration.  The research studies have proved that the self-esteem influences the overall functioning of the individual; inevitably the girl children who enrolled at primary school after internal migration (in Turkey) found to come across a number of challenges after coming to a new school environment. These hurdles are seen mainly in terms of adjusting to the new system, language barrier, poor socio-economic background, peer relationship, discrimination and bullying from others. These factors found to be having a negative impact directly and indirectly on these children where their academic performance, attendance were very poor compared to local children. The respondents (children) reported moments often having self-doubts, thinking that the local counterparts have been right always more prosperous and successful, whereas they remain backward perpetually contributing to feelings of inadequacy and difference and poor self-image. Further they became victims of bullying by the local children and they developed feelings of anxious, helplessness, sometimes suicidal thoughts by self-degrading and self-blame.  The study attempt to highlights the negative patterns of coping styles of the children in the post migration phase.
Impact on people left behind
When compared the health status and life-style of the older population of Thailand, the older people whose at least one child had migrated from the family had very poor physical and mental health status including exposed to chronic diseases, had poor perceived health and very poor help seeking behavior and accessing to available services compared with those whose child or children have not migrated. 
In south-east-Asian countries, the children whose parents were migrated to other countries, found to be less happy, less enjoyable, poor academic performance and poor resilience compared with children of non-migrant families. It shows that migration of parents has a negative impact on children's social life and health. 
Studies conducted in India
In the cross-sectional survey of people living in Sangam Vihar, New Delhi, the slum residents where majority of them is migrated from other states of India, found to be most at risk for mental illnesses. Poor social support, relationship problems with other members of the family, increased worry about health, easily getting angry and irritated, lack of satisfaction about the living condition etc. are the major findings from the survey which indicate the poor psycho-social health status of the internally migrated population. 
The majority of migratory quarry workers is mostly exhibiting varieties of somatic and neurotic symptoms for a long period of time. They have a poor awareness about their mental health as well as have a very poor help seeking behavior. 
The refugee children from Sri Lanka, who are staying in residential school in Bangalore, have come across a number of high stressful life events; some of them have witnessed the violence, some of them have lost their parents. The children are exhibiting adjustmental problems with the environment, low self-esteem and emotional problems. They have high psychological and social distress, which indicates a poor mental health status of the refugee children. 
The psychiatric morbidity was more (predominantly depression, post-traumatic stress disorder and generalized anxiety disorders) among Kashmiri migrants (33.66%), who were staying in Muthi camp at Jammu, compared with non-migrants (26%). The major observation of the study is that, there is a need for improving the socio-economic status of migrants and providing them effective psychiatric services. 
The occurrence rate of psychiatric disorders among migrated refugee population (who came to India after partition) of Lucknow was 9.6% compared with non-migrant local population, which was 4.2%. The psychiatric patients (majority was suffering from psychoneuroses, depression and enuresis) among the migrated group were been suffering for >10 years and mostly belong to older aged group. 
Migration positively associated with the wellbeing of migrants
Migration is found to be the factor for improvements in social and mental health status of migrants, who migrated to New Zealand form Tonga when compared with the native population; it is truer especially among women and the group who had a lower mental health status in their country of origin before the migration. There are factors which improved the mental health of migrants in place of destination that include, living as permanent residents for longer periods (<3 years), good employment opportunities, joining family members and/or community members who are already in the destination place, accessing better public services such as health care and being subject to less cultural restrictions. 
The prevalence of mental health issues among the migrant population is shown in the table;
| Responding to mental health issues of migrants|| |
The research studies from different parts of the world reveal that migration is a complex process which affects the people differently. Most often it is associated with stressful events, barriers and challenges because of which the psycho-social issues and other health issues are more prevalent among the migrants compared with the native population. In responding to this, several research studies have tried to draw some approaches and suggested preventive, promotive and curative strategies. And lots of efforts have also been taken at local, national and international levels by the governments, organizations and individuals.
Interventions at the global level
The International Organization for migration has come into force on 1951, headquarters in Geneva, Switzerland. Since then it has been involved in formulating and implementing varieties of activities and programs to help the migrant population. Some of them are:
- Resettlement and repatriation services of refugees
- Assisted voluntary return and reintegration program
- Counter trafficking services
- Immigration and visa support service
- Recruitment and employment facilities
- Migration training program
- Migration health assessments and travel assistance service
- Health promotion
- Migration health assistance to crisis-affected population and so on.
The above programs are aimed at trying to make the migration process easier and less complicated and responding and assisting those who are negatively affected from the migration.
Administrative level interventions
There are many countries have started services for migrants such as trans-cultural mental health units in Paris, Bordeaux, Strasbourg etc., units for victims of torture and forced exile started by Paris, Marseille, Lyon etc., The global forum on migration and development, regional consultative processes on migration, improvements in the protection of migrants' rights by International Labor Organization and so on programs have started world-wide in order to reduce the psychological and social distress among migrants.
Limitations of the interventions
However in spite of the availability of services to migrants the accessibility of the available services from the migrants is very poor. It shows there are many barriers, which are blocking them in accessing such services. These barriers are mainly such as, cultural and linguistic barriers, belief in non-medical interventions, the necessity of producing legal documents and fulfilling the eligibility criteria for accessing health care services and poor help seeking behavior. It is very important to address these hurdles in order to address the psycho-social and health issues of the migrants.
Suggestions - interventions at clinical setting
Some of the suggestions drawn in order to tackle the above said hurdles are, using cultural formulation while dealing with psycho-social issues of migrants, building therapeutic alliance and trust, making services inclusive and accessible, good quality interpreter services, appropriate training for clinicians and interpreters, improving health literacy, developing participatory and collaborative partnerships with the migrant populations, achieving cultural competence etc. ,
Migration process has specific stresses in its each phase on migrants; the specific psychological distress is influenced by the nature of the migration experience that the person undergoes. The communication difficulties due to language and cultural differences, adverse experiences before, during and after migration, traditional beliefs, coping patterns, socio-economic status of the family, non-favorable familial dynamics are the major challenges for migrants; hence people may not expect or prepared enough for these unexpected hurdles. When migrants identified with psychological distress or approach for help, the clinicians need to be trained and equipped enough to address these issues. They have to inquire systematically-the whole process of migration, social, vocational and family aspects of functioning, cultural background, socio-economic status, comparing pre-migration to post migration status etc. These will help in understanding and identifying the problems in adapting to the new society. The clinicians should take assistance of trained interpreters and culture brokers; they may also meet the other family members for thorough information and should make use of the existing community organizations of the particular ethnicity. These strategies will help the clinicians to identify the stressor or the problem, formulate the appropriate intervention/treatment strategy, prevent the psycho-social distresses and promote the psycho-social wellbeing of the migrants. 
Community based interventions
Some of the research studies have tried to respond to the tribulations of the migrants through drawing the interventions at community level. One of the research studies states that, "there is a need for change in delivering services to the migrant population in distress; the cottage-based-model found to be more effective than traditional health care delivery to the geriatric long-term care residents during the migration. The consumers, their family members and the staffs have felt that the model is more helpful in improving the health status, social activities of the consumers." 
The community based intervention which involves "community mobilization" and "comprehensive voluntary counseling and testing services" among migrated rural community of Shanghai has proved a significant improvements in the promotion of voluntary HIV counseling and testing (VCT) acceptance and utilization, knowledge about HIV/AIDS, positive attitude towards HIV positive individuals and condom use compared with the traditional VCT services. 
Along with the policies, practices and resettlement opportunities, the existence of ethno-cultural organizations and religious institutions are highly important in supporting the migrants in the process of adaptation in legal, religious and social aspects. These ethnic communities and religious organizations welcome the migrants, provide the sense of belonging and try to reduce the impact of migration losses, isolation and discrimination as well. ,, Hence it is very important to the local bodies or the administrations to recognize, support and developing networking among the existing communities and religious organizations in order to mobilize the psycho-social support and the necessary resources for the migrant population especially who are in distress. 
Group based interventions
The "self-help group (SHG)" and "Cognitive Behaviour Therapy" group interventions were found to be partially useful among the migrated women who were diagnosed with recurrent depressive disorder. During the group intervention sessions, family affairs and difficulties in pertaining to their husbands and children need for social networks, dealing with loneliness, being unable to meet with the demands of the day to day life, were the main issues discussed as the members preferred. The group interventions found to be useful in symptom reduction, increased amount of mutual trust among the members, acquiring problem solving skills and regaining their strengths. Most of the members also expressed their will to continue the group meetings informally during the follow-up. However the respondents were disappointed about the way the therapy was offered and the results suggest, culture sensitive treatment by ethnic, same-gendered professional on individual based is more useful.  Along with SHG and cognitive behavioral therapy the 'psychodrama, psychotherapy, eye-movement-desensitization and reprocessing forms of group interventions have been provided for the migrant populations who are suffering from mental health problems such as depression, post-traumatic stress disorder and so on and they have proved to be helpful to some extent in reducing the symptoms and improving the functionality. ,,
The above studies try to prove the efficacy of different strategies and strongly suggest the need for formulating a variety of/combination of interventions such as, administrative, legislative, group and community based intervention in responding successfully to mental health or psycho-social issues of migrant population. The intervention strategies have to be formulated at the individual level, local level, community level, policy level and national or international level; the local and international organizations, governments and the individuals, every one's efforts are crucial here. The inclusion of services and mutual respect of cultural aspects is vital as well.
| Conclusion|| |
Migration is a contemporary, complex phenomenon in which the main intention behind is betterment or escaping from the non-favorable factors. Hence migration need not to be stressful all the time, but when there is no proper preparation and no social support, complexities present, barriers and differences involved, there will be definite distress; no matter whether it is international or internal migration. The research studies have shown that, most of the time migration is a vulnerable factor to develop Mental Health complications. Due to the insecurity feelings and non-availability of their own community members, the distress would turn into mental health consequences or other forms of health complications. The studies also pointed out that the local and international efforts to responding to these problems are inadequate and deficient. There is an immense need of making avail, accessible and affordable of the public and health services. Making the services inclusive, culture specific and culture free, providing necessary training for the personnel, making use of culture brokers and trained interpreters should happen in all the levels. Providing the information about migration, preparing the migrants, ensuring the necessary health and public services will help in preventing expected psychological distress and promoting mental health well-being among migrants. There is a wide scope for research studies to investigate further to have in-depth understanding of the pattern of mental health problems and formulating more effective intervention strategies in preventing the distress and promoting the psycho-social well-being of the migrants.
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