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| ARTICLE |
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| Year : 2019 | Volume
: 17
| Issue : 2 | Page : 174-180 |
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Emotional distress among Rohingya refugees in Malaysia
Stacey A Shaw1, Hamid Karim2, Noelle Bellows3, Veena Pillai4
1 PhD, MSW, School of Social Work, Brigham Young University, Provo, Utah, USA
2 Research Assistant for School of Social Work, Brigham Young University, Malaysia
3 MSW, Research Assistant for School of Social Work, Brigham Young University, Provo, Utah, USA
4 MBBS, Dhi Consulting, Kuala Lumpur, Malaysia
| Date of Submission | 12-Apr-2019 |
| Date of Decision | 03-Sep-2019 |
| Date of Acceptance | 03-Sep-2019 |
| Date of Web Publication | 29-Nov-2019 |
Correspondence Address:
Stacey A Shaw
2175 JFSB, Brigham Young University, Provo, UT 84602
USA
 Source of Support: None, Conflict of Interest: None  | 4 |
DOI: 10.4103/INTV.INTV_8_19
Malaysia hosts over 175,000 refugees or asylum seekers who are registered with the United Nations High Commissioner for Refugees, over half of whom are ethnically Rohingya. Economic, social and health challenges are common among refugees residing in countries of asylum such as Malaysia with limited legal rights and uncertainty regarding the future. This study examined emotional distress among a sample of 115 Rohingya refugees living in urban areas within Malaysia. We utilised both quantitative and qualitative methods to assess psychosocial wellbeing. After measuring emotional distress with the Refugee Health Screener-15, we examined socio-demographic and environmental characteristics associated with distress scores. We then examined open-ended responses to qualitative questions regarding perceptions of difficulties refugees experience in Malaysia as well as perspectives on needed assistance. Findings indicated that emotional distress was widespread among this sample. Age was associated with higher rates of distress, while gender, time in Malaysia, employment and other measured factors were not associated with distress. Qualitative themes emphasised challenges with income, documentation and concerns regarding global conflict. Findings point to the need for services that address economic needs as well as reducing distress, in addition to policy challenges that will enable stability and security for Rohingya refugees.
Keywords: asylum seeker, forced migration, Malaysia, mental health, refugee, Rohingya, wellbeing
How to cite this article:
Shaw SA, Karim H, Bellows N, Pillai V. Emotional distress among Rohingya refugees in Malaysia. Intervention 2019;17:174-80 |
| Introduction | |  |
As a major sending country for permanent resettlement, Malaysia hosts a large community of Rohingya refugees. Although Malaysia is not a signatory to the 1951 Refugee Convention (UNHCR, 2015), the country is the fifth top submission country for refugee resettlement globally, with 3285 cases submitted and 2631 persons departed for resettlement (UNHCR, 2018). In Malaysia, as of 2019, over 175,000 people were registered with United Nations High Commissioner for Refugees (UNHCR) as refugees and asylum seekers (UNHCR, 2019). Most (152,220) originated from Myanmar, including 95,110 Rohingya (UNHCR, 2019). Due to persecution faced in Myanmar over the proceeding decades, Rohingya refugees have resided in Malaysia for many years (Letchamanan, 2013; Yesmin, 2016). Temporary residence in a country of first asylum involves significant economic and social challenges. Refugees from Myanmar who live in Malaysia have cited difficulties securing safety, employment and housing, as well as social and health supports (Azis, 2014; Buscher & Heller, 2010; Smith, 2012; Tay et al., 2018). Working without legal rights or protection, refugees in Malaysia are at risk of experiencing harassment, extortion and non-payment of wages (Smith, 2012). Additionally, women working in informal settings report experiencing gender-based violence, detention and fears of arrest (Women’s Commission for Refugee Women and Children, 2008). These challenges, while common to refugees in other countries of first asylum (Doocy, Lyles, Akhu-Zaheya, Burton, & Burnham, 2016; UNHCR, 2015), create an environment of uncertainty and prolonged stress.
Emotional distress and mental health challenges are common among refugee communities due to the stressors associated with forced migration from one’s country of origin as well the difficulties of residing in transitory countries of first asylum (Hunt, 2002; Low, Kok, & Lee, 2014). Prior to migration, exposure to war, violence and political persecution can cause trauma (Alemi, James, Siddiq, & Montgomery, 2015; Almqvist & Brandell-Forsberg, 1997; Keller et al., 2006; Momartin, Silove, Manicavasagar, & Steel, 2004; Thabet, Abed, & Vostanis, 2004). While gaining a level of relief and safety within a country of first asylum, forced migrants often experience social isolation, discrimination, poverty, violence, privacy violations and stress regarding means of survival (Afifi, Afifi, Merrill, & Nimah, 2016; Hutson, Shannon, & Long, 2016; Kim, 2016; Low et al., 2014; Miller & Rasmussen, 2010; Thomas, Roberts, Luitel, Upadhaya, & Tol, 2011). Refugees in Malaysia exhibit high levels of mental and emotional distress, and few report receiving mental health treatment (Kok, Lee, & Low, 2017; Low et al., 2014; Shaw, Pillai & Ward, 2018; Smith, 2012; Tay et al., 2018; Zarkesh, Baranovich, & Shoup, 2017).
With the aim of informing understanding about Rohingya refugees in Malaysia, this study quantitatively examines emotional distress (N = 115). We also qualitatively assess the perspectives of a subset of Rohingya participants regarding their experiences and challenges as forced migrants residing in Malaysia. Findings from both qualitative and quantitative methods allow for an in-depth understanding of the challenges faced by this sample of Rohingya refugees in Malaysia.
| Methods | | |
Data were obtained from two intervention research projects conducted with refugees and asylum seekers from multiple ethnic backgrounds residing in Malaysia, the first focused on parenting supports and the second on mental wellbeing. Data were collected during 2017 and 2018.
For each project, participants were recruited through community centres and networks by a Rohingya research team member with experience in service provision and training in research methods. Information was shared at a Rohingya community school located in the greater Kuala Lumpur area. Participants also learned about the projects through word of mouth from other participants and community leaders. To be eligible to participate, one needed to be eighteen years of age or older and be a Rohingya refugee or asylum seeker residing in Malaysia. Additionally, participants had to express interest in participating in an intervention related to wellbeing or parenting. To be eligible for participation in the parenting project, participants also had to have a child under eighteen years of age.
After learning about the study and providing informed consent, participants completed a brief assessment. Administered verbally, assessments were conducted in Rohingya, Burmese or English according to the participant’s choice, with nearly all participants completing the interviews in Rohingya. Interviews were conducted primarily in the community school location, as well as at other places of a participant’s choice such as one’s home. Interviews were conducted privately, where responses could not be overheard. Participants in the parenting intervention were also asked a series of qualitative questions regarding their experiences as refugees living in Malaysia. Ethical approval for both studies was obtained from a local ethics review board as well as from the Institutional Review Board of Brigham Young University in the United States.
Measures
Socio-demographic characteristics assessed included age, gender, ethnicity, education and questions regarding family composition. Three questions, ‘Where were you born?’, ‘Before coming to Malaysia, where did you live?’ and ‘What is your nationality?’, were asked to assess whether a participant was ethnically Rohingya. To assess marital status, we asked whether participants were married, single, widowed or divorced. The latter three categories were combined into ‘unmarried’. If married, we also asked whether a participant’s spouse lived with him/her in Malaysia. After enquiring whether a participant had children, we asked how many children he/she had. Participants’ responses to the question ‘How much education have you received?’ were combined into categories of no formal schooling, primary school and secondary school or more.
To assess environmental factors, we asked participants to describe the length of time they had lived in Malaysia, employment status, food security and homelessness. The amount of time participants had spent in Malaysia was assessed by asking, ‘How long have you lived in Malaysia?’ and the responses were coded into the number of months in country since immigration. Employment status was assessed through asking whether participants worked full time, part time, were unemployed or other. Any employment was combined to signify that the participant was employed. To examine food insecurity, we asked, ‘In the past ninety days, have you always had enough money for food?’ If participants reported ‘no’, they were designated as experiencing food insecurity. Similarly, when asked, ‘In the past ninety days, have you always had a regular place to sleep?’, a ‘no’ response was designated as experiencing homelessness.
We used the Refugee Health Screener-15 (RHS-15), with validated versions available in English and Burmese, to assess emotional distress. RHS-15 questions were developed to assess somatic manifestations of depression, anxiety and trauma (Hollifield et al., 2013). The RHS-15 is an empirically developed tool specific to refugees which has demonstrated high sensitivity (0.81–0.95) and specificity (0.86–0.89) among refugee communities in the United States (Hollifield et al., 2013). The tool has also been found to be reliable and valid when utilised among refugee communities elsewhere (Bosson et al., 2017; Kaltenbach, Härdtner, Hermenau, Schauer, & Elbert, 2017). Items 1–14 are measured on a 5-point scale ranging from 0 (not at all) to 4 (extremely). The last item (15) includes a general distress thermometer with a 10-point scale ranging from 0 (no distress) to 10 (extreme distress). Participants screened positive for experiencing emotional distress if the total score from items 1–14 is greater than or equal to 12 or if the rating of the distress thermometer is greater than or equal to 5.
Qualitative questions
Participants individually answered a number of open-ended questions as part of an assessment interview: ‘What do you like best about living in Malaysia?’ ‘What is most difficult about living in Malaysia?’ ‘What type of services or assistance do refugees living in Malaysia need most?’ ‘What are your plans for the future?’ ‘What do you think about what’s happening in the world right now?’ ‘What should people from other countries do to help refugees?’
Data analysis
For quantitative findings, we used descriptive statistics, including independent sample t-tests and chi-square tests of association to compare subgroups within the sample. We also used general linear modelling to examine associations between emotional distress (dependent variable) and demographic and contextual factors.
For qualitative findings, open-ended responses were audio-recorded. As Rohingya has no written language, the researcher translated recorded responses directly into written English. Responses were then coded in NVivo version 12 by a research team member who was blinded to the hypothesised relationship between distress and environmental stressors, after which inductive thematic analysis was used to identify key themes that emerged from the data.
Sample
In total, 115 Rohingya participants completed quantitative assessments − 83 individuals from the parenting project and 32 from the mental health–focused project. For the few participants who were in both projects, only the initial assessment the participant completed was included. Comparing participant characteristics across the two projects demonstrated that those who participated in the parenting project were more likely to have children, be female, be married and live with their spouse, while those in the mental health intervention were more likely to experience food insecurity and be employed. No differences were observed in relation to emotional distress, age, education, number of children or time in Malaysia. While recognizing the two projects attracted participants with slightly different characteristics, the similar recruitment and assessment methods used across the two projects allow for the larger, combined sample we use throughout this analysis. Of the 115 total participants, 67 completed a qualitative assessment. The qualitative sample included those who participated in the parenting project and who were available to answer a series of open-ended questions.
Among the sample of 115 Rohingya participants, the average age was 31 and 73% of the sample was female. Most (81%) were married, including 89% who lived with their spouse in Malaysia. Nearly all participants (97%) had children − on average three children per family. While the average time spent in Malaysia was seventy-four months (six years), the median (and mode) number of months was forty-eight (four years). Six participants reported living in Malaysia for more than thirteen years. Two thirds of participants (67%) were unemployed and 58% had no formal education. Most participants (94%) experienced food insecurity but few (6%) experienced homelessness in the ninety days prior to the assessment.
Among the sub-sample of sixty-seven people who participated in a qualitative interview, the average age of participants was 29. Most of the qualitative participants were female (91%) and all of them had children [see [Table 1]. On average, those who completed qualitative interviews were more likely to be younger, female, married, have children, not experience homelessness and be unemployed. There were no significant differences in participants’ number of children, education, whether their spouse was with them in Malaysia, time spent in Malaysia, food insecurity or emotional distress. Although some differences existed among those who completed qualitative interviews and those who did not, levels of emotional distress were similar across all participants and qualitative findings from this large sub-sample give an indication of challenges likely experienced by other Rohingya participants in the combined sample.
| Findings | | |
Nearly all participants (97%) screened positive for experiencing emotional distress, with an average score of 34 on the first fourteen items of the RHS-15, demonstrating high levels of distress.
Examining sample characteristics by gender, bivariate analysis demonstrate that men were more likely to be employed, with 86% of male participants and 14% of female participants working (p<.001). Most participants of both genders were married, including 70% of male and 86% of female participants. Additionally, most of them lived with their spouse in Malaysia, including 67% of male and 96% of female participants (p<.001).
Results of the regression analysis indicated that on average, increased age was associated with higher levels of emotional distress (B = 0.35, 95% CI = 0.03, 0.66, p<.05) [see [Table 2]. Other indicators measured, including gender, family and factors related to the environmental context in Malaysia, were not significantly associated with emotional distress scores. | Table 2 General linear model examining associations with emotional distress
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In the qualitative responses (n = 67), themes emerged related to household and community stressors, including income, documentation and conflict. These themes will be addressed in more detail in the following sections.
Income
Insufficient income was most often noted as the central difficulty about living in Malaysia. Thirty-two participants described having insufficient income; for example, a 41-year-old female described, ‘[it is] difficult for income, not enough [money to live] with income’. Additionally, twenty-five participants said paying rental costs is a major difficulty. For example, a female who had been in Malaysia for three years described, ‘[it is] very difficult [to pay] for home, if [one] cannot pay rental, [they] have to get out from [the] house’. When asked about services needed in Malaysia, twenty-two participants emphasised income or money. For example, an 18-year-old female noted, ‘[we] need money to stay [in] Malaysia’. When participants described the types of assistance refugees need, 20 pointed to money. A married female with one child described, ‘it is better to help refugees [with] money’.
Housing was also a major focus, reflecting an income-related concern. When asked about services and help needed, twenty-two participants described housing as a major need and nineteen noted the importance of helping refugees through providing housing assistance. As a 26-year old female noted, ‘[we] need house to stay in Malaysia’. Similarly, a female who had been in Malaysia for three years described, ‘it [is] better if [people provide] help for hous[ing] to refugees’. Beyond income and housing, fourteen participants described that refugees need help with food.
Documentation of legal status
In addition to challenges with economic wellbeing, participants emphasised the need for legal documentation. When asked about the difficulties of living in Malaysia, eighteen participants pointed to the reality that they cannot work and eleven described not being documented. A female participant who had been in Malaysia for six years said, ‘[it is] difficult for work and difficult [to] stay without [an identification] card’. When describing services needed in Malaysia, thirty-three participants mentioned the need for assistance with legal status through UNHCR. For example, a 44-year-old female described, ‘[we] need legal documents like (IC) [Identity card], if we have IC Malaysia we can buy house and car for that identification card is very important to living in Malaysia’. When describing help that refugees need, fifteen participants mentioned legal status. For example, a 36-year-old male participant said, ‘status [is] very important for refugees’.Conflict
When discussing thoughts on what is happening in the world right now, thirty-six participants mentioned that the world involves violence and a lack of peace. For example, an employed female participant who had been in Malaysia for six years said, ‘[the] world has no peace. Also [there is] no peace in our country’. Another participant, a 23-year-old female said, ‘the world has only violence’. More specifically, twelve participants described that there is no peace for their particular ethnic group within their home country. For example, a male who had been in Malaysia for four years said, ‘there is no peace in Myanmar for Muslims’. Similarly, a female participant described, ‘in my country for Rohingya [are] facing very [serious] problems’. A female participant with three children described, ‘I [start] cry[ing] when [I] hear about [our] country. We need the peace [within] our country because our parents [are] living there’. Another female participant noted that there is peace for others, stating, ‘my country has no peace but other countries have peace’. When pointing to help that refugees need, thirteen participants emphasised the need for Myanmar regain peace.
While a few participants noted positive things about living in Malaysia, for example that they cannot be tortured or killed, they have free movement and more peace, that Malaysia is a Muslim country or simply ‘everything’, the focus among most participants on stressors related to income, housing, documentation and security highlights the many challenges that influence day-to-day life among Rohingya refugees in Malaysia.
| Discussion | | |
Study findings add to the limited understanding of Rohingya refugee experiences in Malaysia (Tay et al., 2018). Quantitative findings alongside the consistency of issues discussed in the qualitative interviews point to general themes of distress that were common among this sample. As observed in other research highlighting the difficulties common to refugee communities in Malaysia (Buscher & Heller, 2010; Smith, 2012; Women’s Commission for Refugee Women and Children, 2008), this study demonstrates that emotional distress was high among this sample of Rohingya refugees in Malaysia. These high rates were similar to those observed among non-Rohingya refugees also residing in Malaysia (Shaw, Pillai, & Ward, 2018). Other research conducted among Rohingya refugees in Malaysia suggests that fewer (20%) participants experienced symptoms associated with depression or posttraumatic stress disorder (PTSD) (Tay et al., 2018). Qualitative findings highlight major challenges to wellbeing, which include financial pressures and housing, concerns regarding legal documentation and conflict.
While the context of Rohingya refugees in Malaysia is unique, some findings are similar to what has been observed among other refugee populations. The finding that age was associated with higher levels of distress is consistent with other research among communities of refugees and asylum seekers (Porter & Haslam, 2005), suggesting that people’s ability to cope with the difficulties of displacement may decline as they get older. Additional research is needed to examine the relationship between gender and distress among Rohingya refugees. Gender has been associated with distress among refugee populations elsewhere (Hollander, Bruce, Burström, & Ekblad, 2011; Porter & Haslam, 2005), although research among Burmese refugees (Rohingya as well as other ethnic groups) resettling to Australia found that gender was not associated with PTSD, depression or anxiety (Schweitzer, Brough, Vromans, & Asic-Kobe, 2011). Research among Rohingya refugees in Bangladesh found that being female was associated with increased PTSD and depressive symptoms (Riley, Varner, Ventevogel, Taimur Hasan, & Welton-Mitchell, 2017). The lack of significance in this study in regards to gender as well as contextual factors such as economic opportunities or education, which have been identified as being significantly associated with mental wellbeing in other studies (Porter & Haslam, 2005; Riley et al., 2017; Silove, Sinnerbrink, Field, Manicavasagar, & Steel, 1997), may be related to the lack of variability and statistical power in this non-random sample. The sample was relatively homogeneous, where most participants had similar experiences with education and economic vulnerability, as characterised by the near universal experience of food insecurity alongside relatively low levels of homelessness.
Limitations
The generalisation of study findings on Rohingya refugees in Malaysia is limited as the study sample was recruited through community networks, potentially oversampling participants who were more likely to frequent community centres and reside in certain neighbourhoods within Kuala Lumpur. Additionally, as we recruited participants for intervention research projects, we oversampled those interested and available to participate in receiving programmatic supports, specifically oversampling women who were less likely to be working in the formal employment sector and had increased availability to participate. As one project included only those with children, we also oversampled those with children. Additionally, the environmental factors we assessed were limited in scope. Future research could examine complex constructs such as food insecurity in more detail. Research is needed to examine the relationships between distress and other social and environmental factors. Beyond the limitations associated with recruiting a non-random sample, other potential explanations for the high rates of distress observed include limitations in both quantitative and qualitative assessment procedures, particularly related to the lack of valid measurement tools available in Rohingya. Despite these limitations, the use of both quantitative and qualitative assessment methods allows for increased understanding of emotional distress as well as the challenges experienced by a sample of Rohingya refugees residing in Malaysia.
| Conclusion | | |
High levels of emotional distress observed among this sample of Rohingya refugees in Malaysia point to the need for responsive programming and policy solutions. As most demographic and contextual factors were not significantly associated with distress levels, it appears that distress is common for community members regardless of gender, employment status or time spent in the country. The emphasis of participants on difficulties with economic survival and concerns about global conflict highlight key factors that influence distress and mental wellbeing. Health and social services that provide basic economic and social supports are needed, including efforts to ensure that households are able to secure adequate food. Concerns with legal documentation point to the need for added programmatic supports that will enable access to and navigation of refugee status and resettlement application processes. The scope of protracted situations such as those experienced by Rohingya refugees in Malaysia calls for comprehensive policy solutions. Options such as addressing and resolving conflict in Myanmar, providing permanent asylum or other opportunities to build a secure future in Malaysia or accessing opportunities for permanent resettlement to third countries are sorely needed. In the absence of such solutions, improving living conditions through granting opportunities for legal work, health access and education has the potential to enhance life quality and reduce emotional distress among Rohingya and other refugees residing in Malaysia.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
[34]
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[Table 1], [Table 2]
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