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

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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unpublished) are fully identified as such within the work and attributed to their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

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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.

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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

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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.

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Part One: Literature Review

A review of the evidence on factors impacting on mental health help seeking for

African immigrants in Western Societies

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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.

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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

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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

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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

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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.

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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,

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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,

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all contributing sources were listed below to ease the organisation of the reported

findings.

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Figure 1. PRISM Diagram

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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

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(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

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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

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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)

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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

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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.

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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

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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.

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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

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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

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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

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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.

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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)

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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.

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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

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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

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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

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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:

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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)

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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

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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.

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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

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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.

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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

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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

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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: n.nsiah@surrey.ac.uk

Supervised by: Dr Linda MorisonAddress: University of SurreyContact: l.morison@surrey.ac.uk

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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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