D.Litt et Phil. / For over a decade, from the late 1970's to October 1992, a war raged in Mozambique that resulted in what has been described as, one of the "most terrible genocides in the history of Africa". Over 4 million people were displaced during this war. Conservative estimates put the number of Mozambicans who sought refuge in South Africa at 250 000. This study examines the trauma created by the war, and its psycho-social outcomes, from the perspective of women refugees who came to settle in villages in the Nkomazi region of Mpumalanga province, in South Africa. Posttraumatic stress disorder, the concept which dominates research in the field of trauma studies, was based on research with male war veterans in western industrial societies. Recently a body of work has emerged which questions the validity of applying posttraumatic stress disorder to contexts of massive social conflict, and its utility in cross cultural contexts. This body of work suggests that an understanding of extreme trauma and its outcomes requires careful consideration of the social and cultural dimensions of trauma. The inclusion of a cultural formulation in the latest edition of the Diagnostic and Statistical Manual for Mental Disorder, DSM-IV, reinforces a growing acknowledgement amongst mental health researchers of the influence of culture on mental health and disorder. The gaps in research on African women survivors of war and the lack of standardised assessment tools, makes this an exploratory study which uses qualitative research methods. Unstructured interviews were conducted with 30 Mozambican women refugees to explore their experiences and definitions of trauma, the psycho-social outcomes of the trauma, and coping and survival in the aftermath of the war. The magnitude of the trauma evident in the research findings called for a conceptual definition which reflects multiple risks and the interdependence of social and individual trauma. Thematic analysis and qualitative coding of the interview data revealed clinically well defined posttraumatic stress disorder symptoms and locally specific discourses of suffering framed by cultural beliefs, social practices and historical experiences. Their testimony and observations in the field, revealed that the survivors demonstrated a capacity to survive and reconstruct their lives. Their coping strategies and survival tactics were fundamentally shaped by socio-historical experiences and the limits and possibilities contained in the recovery environment. The results of this study suggest an approach to examining the complex relationship between trauma and its consequences, which abstracts neither trauma nor its victims from cultural and social-historical contexts.

Globally, an estimated one in four women have experienced intimate partner violence (IPV) in their lifetimes. IPV has enormous physical, mental, and social consequences across ecological levels of human experience. These consequences extend to the children of adult women survivors of IPV and are worsened by intersecting experiences of racism, classism, sexism, and xenophobia. Service systems purporting to help, such as child protective services (CPS) and health service systems, can either create additional harm for women and their children or offer services that women may have difficulty accessing due to cost, isolation, and other factors. These harms can be especially pronounced among (a) Black women who have used drugs, who have children, and who are in community supervision programs (CSPs) in the U.S. and (b) Syrian refugee women with children living outside camps in Jordan. These populations of women face particular challenges getting basic needs met while navigating safety for themselves and their children – both due to IPV and from systems themselves (e.g., risk of losing custody of their children, sociocultural risk of interference in family life). Yet, limited research exists on the relationship between experiencing IPV and service involvement within these two populations. The following dissertation aims to address these research gaps in three papers, using descriptive and bivariate data as well as logistic regression analyses of E-WORTH and Women ASPIRE studies, as informed by ecological theory. The first paper (E-WORTH), guided by ecological theory, aims to determine the prevalence of and test hypothesized associations between psychological, physical, and sexual IPV and CPS involvement among Black women who have used drugs, who ever had children, and who are in CSPs in New York City (N=247). I hypothesized that women who ever had children, were in CSPs, and had ever experienced psychological, physical, and/or sexual IPV by male partners would have higher odds of being involved with CPS in their lifetime than women who ever had children, were in CSPs, and had not experienced IPV by male partners. Using self-reported data from Black women who have used drugs and were recruited from CSPs in New York City, I found that 70.85% of women who ever had children and who were in CSPs reported ever experiencing psychological IPV by a male partner, 70.04% reported ever experiencing physical IPV by a male partner, 48.58% reported ever experiencing sexual IPV by a male partner, and 40.89% reported ever experiencing psychological, physical, and sexual IPV by a male partner. Further, I found that 55.87% of women reported ever having had an open case with CPS. Multivariable logistic regression analyses revealed that women who had experienced lifetime sexual IPV had significantly higher odds of ever being involved with CPS than women in the study who had never experienced sexual IPV (OR: 1.81; 95% CI: 1.09, 3.01). Similarly, women who experienced multiple forms of IPV (psychological, physical, and sexual) also had significantly higher odds of being involved with CPS (OR: 1.81; 95% CI: 1.07, 3.04). However, these associations did not hold in adjusted models. Paper 2 (Women ASPIRE) aims to (1) compare the prevalence of mental health symptomology (anxiety, depression, and PTSD) among Syrian refugee women with children under age 18 living outside camps in Jordan who have and who have not experienced physical and/or sexual IPV in the past year; and (2) examine the relationship between IPV and mental health symptomology among Syrian refugee women with children living outside camps in Jordan. Based on ecological theory as my conceptual framework, I hypothesized that Syrian refugee women with children who had experienced IPV in the past year would have significantly higher odds of meeting screening criteria for anxiety, depression, and PTSD as compared to Syrian refugee women with children who had not experienced IPV in the past year. I found high rates of IPV, anxiety, depression, and PTSD among women in the sample (N=412). Furthermore, using multivariable logistic regression models from the Women ASPIRE dataset, I found that women with children who had experienced physical and/or sexual IPV in the past year had significantly higher odds of meeting screening criteria for all three mental health conditions – anxiety (aOR: 3.68, CI: 2.28-5.94, p<0.001), depression (aOR: 3.03, CI: 1.83-4.99, p<0.001), and PTSD (aOR: 6.94, CI: 3.75-12.84, p<0.001) – than women with children who had not experienced IPV in the past year. Despite these findings, at least one-fifth of women with children reported an unmet need for mental health or protective services, and less than one-third of women were aware of the availability of these services in their local communities. The third paper (Women ASPIRE) aims to (a) examine the prevalence of physical and sexual IPV among health service-seeking Syrian refugee women with children in non-camp settings in Jordan and (b) compare the differences in health service use between women with children who had and who had not experienced IPV (N=412). Informed by experiences across levels of ecological theory, I hypothesized that women with children who had ever experienced IPV would have lower odds of using each type of health service (i.e., general, specialist, reproductive, mental health, and emergency health services) – and would have higher odds of using limited numbers of services – than women with children who had never experienced IPV. I tested my hypothesis using binary logistic regression models and an independent samples t-test. I found that nearly 60% of Syrian refugee women with children living outside camps in Jordan had ever experienced physical and/or sexual IPV by their current or most recent husband. Contrary to my hypotheses, I found that women with children who had ever experienced IPV had over three times the odds of using mental health services and were significantly more likely to use a greater variety of health services (including mental health services) than women who had not experienced IPV (aOR: 3.10, 95% CI: 1.92-5.00, p<0.001; mean 3.26 vs. 2.84 types of services respectively, t [410] = 03.71, p<0.001). Findings affirm that IPV is a serious public health issue among the affected populations and that access to needed services remains crucial to affected populations. Results fill gaps in existing literature by confirming that women with children in each study population have high odds of system involvement, particularly with CPS and mental health service systems, thereby offering social workers within those systems opportunities to intervene effectively. Thus, this dissertation can help social work practitioners and clinicians offer more responsive, accessible, and relevant services to clients within the study populations. Policymakers and administrators can fund development and testing of interventions across multiple ecological levels to promote the safety, health, and well-being of women and their children. Researchers can build on these findings through quantitative and qualitative studies on intervention effectiveness and accessibility among women engaged with system.

The voices and experiences of immigrant and refugee women in Canada have been conspicuously absent from policy issues, programme planning, and mental health literature. However, more immigrant and refugee women than men, from traditional cultures, are considered to have mental health needs, because of risk factors such as stress at the time of migration, and because of Canadian policies and programmes which disadvantage them. This study explores from the consumers perspective the reasons for disparate mental health service utilization between South Asian and Latin American women in Vancouver. Using a cross-sectional, exploratory, case study approach, and a feminist perspective, ten South Asian and ten Latin American women who have used mental health services were interviewed in depth. Sixty percent of the participants were survivors of violence and torture. Five Latin American women were survivors of pre-migration catastrophic stress. Their mental health needs were characterised by traumatic experiences, grieving and depression. Except for the three who were married, they had no traditional support networks. In contrast with the South Asian group they appeared to have less shame and covert behaviour. Mental illness, considered a ‘house secret’, carries great stigma in the South Asian community, and has serious ramifications for the immediate as well as the extended family. Among South Asian participants seven had been subjected to wife battering, and four of their spouses had a substance abuse problem. Their mental health needs were also triggered by traumatic experiences, grieving and depression. The more established South Asian women had extended family living in Vancouver, yet social support was still lacking. Having ‘no one to turn to’ was a pervasive theme across both groups of women; their experiences characterised by loss. Analysis of data exploring the decision to use services illustrates stages in a process of recovery from experienced violence. Post migration domestic violence and pre-migration violence have devastating, life-shattering consequences which require culturally sensitive interventions by social workers and other health care professionals. An obligatory stage in the clinical intervention process is to explore the issue of violence. Finally, policy decisions which impact upon women from ethnocultural communities in Canada must embrace a philosophy which considers well-trained, culturally-sensitive, linguistically—competent workers a priority.

The voices and experiences of immigrant and refugee women in Canada have been conspicuously absent from policy issues, programme planning, and mental health literature. However, more immigrant and refugee women than men, from traditional cultures, are considered to have mental health needs, because of risk factors such as stress at the time of migration, and because of Canadian policies and programmes which disadvantage them. This study explores from the consumers perspective the reasons for disparate mental health service utilization between South Asian and Latin American women in Vancouver. Using a cross-sectional, exploratory, case study approach, and a feminist perspective, ten South Asian and ten Latin American women who have used mental health services were interviewed in depth. Sixty percent of the participants were survivors of violence and torture. Five Latin American women were survivors of pre-migration catastrophic stress. Their mental health needs were characterised by traumatic experiences, grieving and depression. Except for the three who were married, they had no traditional support networks. In contrast with the South Asian group they appeared to have less shame and covert behaviour. Mental illness, considered a ‘house secret’, carries great stigma in the South Asian community, and has serious ramifications for the immediate as well as the extended family. Among South Asian participants seven had been subjected to wife battering, and four of their spouses had a substance abuse problem. Their mental health needs were also triggered by traumatic experiences, grieving and depression. The more established South Asian women had extended family living in Vancouver, yet social support was still lacking. Having ‘no one to turn to’ was a pervasive theme across both groups of women; their experiences characterised by loss. Analysis of data exploring the decision to use services illustrates stages in a process of recovery from experienced violence. Post migration domestic violence and pre-migration violence have devastating, life-shattering consequences which require culturally sensitive interventions by social workers and other health care professionals. An obligatory stage in the clinical intervention process is to explore the issue of violence. Finally, policy decisions which impact upon women from ethnocultural communities in Canada must embrace a philosophy which considers well-trained, culturally-sensitive, linguistically—competent workers a priority. / Arts, Faculty of / Social Work, School of / Graduate