"We feel like it was better back home:"Stress, Coping, and Health in a U.S. Dwelling African Immigrant Community
Background. This study examines stress and stress management from the perspective of African immigrants in southwestern Pennsylvania. Our research questions explore how participants define stress, the most common causes of stress, manifestations of stress, and common strategies for stress management. Methods. We conducted a descriptive, cross-sectional, qualitative study with 34 African immigrants. Data were collected via three focus groups. Qualitative data were audio-recorded, transcribed verbatim, and analyzed to identify common themes. Results. Five major types of stressors included: remittances, financial and job-related challenges, children, disconnected families, and unrealized expectations. Participants reported both physical and mental manifestations of stress and used both group-based and individual-focused coping strategies. Discussion. African immigrants suffer from sources of stress that are uniquely attributed to their cultural background, immigration modalities, acculturation processes, and unrealized expectations. Health care providers must be aware of these sources of stress and potential management strategies.
Health disparities, mental health, African immigrants, stress, coping strategies
Studies of United States immigration tend to focus on immigrants from Latin America, the Caribbean, and Asia. Yet, among all foreign-born migrants, the number of immigrants from the continent of Africa is now growing at the fastest rate, with over two million African immigrants estimated to be currently living in the United States.1,2 Africans in the Pittsburgh Metro Area are one of many different immigrant groups whose numbers have been increasing over the last few decades. Although exact numbers are hard to determine, the 2015 American Community Survey estimates that about 11,808 African immigrants are living in the Pittsburgh metropolitan area, which includes the [End Page 253] city of Pittsburgh and seven surrounding western Pennsylvania counties (Allegheny, Armstrong, Beaver, Butler, Fayette, Washington, and Westmoreland).1 Immigrants come from a wide range of African countries, including Ghana, Liberia, Nigeria, Cameroon, Togo, the Democratic Republic of Congo, Somalia, Kenya, Ethiopia, South Sudan, Zambia, and Zimbabwe, among others.2
While African-born immigration is growing tremendously, there has not been much attention paid to the health status, needs, or issues of these populations.3,4 Additionally, most research on health inequities and African Americans (understood here to mean people of African descent whose families have been in the United States for many generations) excludes first-generation African immigrants (i.e., those born in Africa), overlooking how their immigrant backgrounds may affect their health.
Much of the existing literature on the physical health of African immigrants focuses on the "healthy immigrant effect" in which African-born immigrants tend to be healthier than native-born African Americans across various health measures, including obesity, health behaviors and birth outcomes, allostatic load, and mortality.3,5–7 Other studies have questioned this healthy immigrant effect, for instance when focused on cardiometabolic health.8 Certain health issues such as infectious diseases and female circumcision have received more scholarly attention, while research on chronic diseases, health care access, and mental health issues is lacking.4
Regarding the mental health of African immigrants, there is a growing body of literature on pre-migration trauma and its impact on the mental health issues of refugees.9,10 Other research has examined service use, health literacy, and stigma,11,12 along with specific mental health disorders such as depression,13,14 the impact of acculturation15 and the role of perceived discrimination on poor mental health outcomes.16 However, there are a number of gaps in the scientific literature on African immigrant mental health. Most of the existing literature focuses on refugees, especially those from the Horn of Africa (Somalia and Ethiopia in particular). However, African immigrants come to the United States with a variety of immigration statuses and from a diverse array of countries. Thus, there is a need for mental health studies on African immigrants that can draw out similarities and common challenges that exist across different countries of origin and immigration statuses. Moreover, studies that explore health issues from the perspective of African immigrants themselves can capture how they understand and cope with health issues in their lives.
In a recent community-based participatory research (CBPR) study, Boise et al. found that stress was a major concern for African immigrants and refugees in Oregon, but this study's focus on stress is an exception.17 There are few studies focusing on perceptions of stress and the coping strategies of African immigrants. The present study makes a new contribution to studies of African immigrant mental health by exploring stress and stress management for a diverse group of African immigrants in the Greater Pittsburgh area and including their perspectives on definitions of stress, common stressors, physical and mental manifestations of stress, and coping strategies.
Stress, coping, and health
The Centers for Disease Control and Prevention characterizes stress as the feelings that individuals develop whenever they encounter and experience life's daily challenges and conditions.18 Low levels of stress can help people develop coping skills. Alternatively, high levels of stress can cause short-term, longterm, [End Page 254] and even chronic health problems.19 Stressors can have lifelong effects on physical and mental health by establishing different patterns of vulnerability to disease across the lifespan, such as when chronic stress exposure is associated with increased risk for heart disease and diabetes.20 In addition, experiences of stress and coping become most salient when individuals are faced with major life changes, events, or challenges such as those resulting from immigration.20 Yakushko et al. and Kuo summed up common stressors of immigrants and refugees as: (a) previous experiences with violence, conflict, and trauma, and fear associated with migrants' flight; and (b) relocation, mental and physical health problems, acculturative stress, loss of social status and contact, and oppression by the host society.20,21 Due to their impact on health, knowledge of these stressors is a prerequisite to cultural competency of health care providers. Lack of cultural competence among health care providers can lead to delayed identification of conditions and initiation of treatment.22
Immigration stress and health
Immigration stress can be defined as a "multidimensional construct consisting of functionally related behaviors, attitudes, processes, and experiences."23 Migrating to a new country is considered one of the biggest stressors in life.24 During the process of adapting to and/or navigating a new culture and society, immigrants face challenges such as language barriers, cultural and ethnic differences, poor physical and psychological health, social and cultural conflicts, poverty, and unemployment.25 Research also indicates that immigration-related stress potentially correlates with adverse health outcomes.23–26 Immigrants from Somalia, Vietnam, and China living in Sweden had higher incidences of psychoses due to increased stress.24 A study with first-generation immigrants from China and Taiwan demonstrated that poor health and acculturative stress increased the risk for depression.25
Inclusion criteria for this study were: 1) individuals over the age of 18 years, 2) born in an African country, 3) able to speak and read English, and 4) self-selected for a discussion on stress and coping. Investigators collaborated with the Union of African Communities in Southwestern Pennsylvania (UAC) to advertise the study. The UAC is "an umbrella organization for all African Communities in Southwestern Pennsylvania. The union is comprised of leadership/representatives from 25 plus African Countries/communities (Immigrants, Refugees, Students, and Internationals)."27 The UAC executive team members e-mailed our study flier to the heads of various African community organizations and helped secure a venue for the focus groups which were conducted in an African café that was convenient for study participants. The purpose of the study as described on the flier was to discuss stress management and coping strategies in African immigrant communities. We also met with the UAC executive team to discuss the appropriateness and wording of some of the questions.
The purpose of this study was to explore yet unknown stressors and coping strategies among African immigrants in an inductive process for hypothesis generation. Qualitative research methodology analyzing focus group data following a grounded theory approach was determined to be the best fit for achieving these [End Page 255] objectives.28 Focus groups prove particularly useful for finding a range of opinions on a given topic.
Data were collected in August 2015 in three separate focus groups. There were 10 participants in focus group one, 14 in focus group two, and 10 in focus group three, totaling 34 participants (20 men, 14 women) from Nigeria, Liberia, South Sudan, Congo, Cameroon, Zambia, Ghana, Kenya, Angola, and Burundi (see Table 1). Each focus group lasted approximately an hour and was audio-recorded. One of the researchers, an African American female anthropologist with research experience in the Democratic Republic of Congo and among Liberian immigrants, moderated the three focus groups. A Cameroonian research assistant took notes during focus group one, while the focus group moderator took notes during groups two and three. The focus groups were conducted using a semi-structured interview guide with questions about common stressors, coping strategies, physical symptoms of stress, and a number of related issues. Questions that are the focus of this article are below (see
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In approaching the analysis of our data, we employed a grounded theory approach in which an inductive process was used to find relationships within the data. For this study, an inductive process was used as is recommended when not much is known about the phenomenon in question or if knowledge is fragmented.30,31 The recorded focus group data were transcribed verbatim and then systematically coded to find emerging themes and connections across themes. To code the data, the three [End Page 256] investigators read through the first transcript and developed a code book of labeled themes. This codebook was used to analyze subsequent transcripts. After individually coding transcripts, the investigators, as a group, reviewed all coding. Any differences and additional codes were discussed and agreed on, resulting in a final set of themes and sub-themes that emerged inductively from the data.
Reasons for immigration
Reasons for immigration included civil war (10), family reunification (7), education (12), political persecution (1), winning the diversity lottery(1), coming as musicians (3) and seeking better financial opportunities (1) (several participants chose multiple reasons for migrating).
. SEMI–STRUCTURED GUIDE FOR FOCUS GROUPS
1. Tell us what country you are from and the date you moved to the United States.
2. In a sentence or two, tell us why you came to the United States.
3. This project is about dealing with the effects of stress. How do you define stress, in your own words?
4. What kinds of things stress you out the most/most often? (What are your most common stressors?)
5. How does your body feel when you are stressed out? (Are there physical symptoms of stress?)
Participants defined stress from both physical ("something that keeps your adrenaline moving") and mental ("stress is anything that is overwhelming and that you cannot deal with") perspectives.
"Everyone who is not successful in your family is your responsibility:" Remittances and reciprocity
Remittances were identified as a major stressor because their families in their countries of origin expect help. This financial pressure forces many of the study participants to work multiple jobs to provide for themselves and to support family members overseas. Articulating the high level of frustration with family, one participant said:
There is another thing makes me stress, sending when you know that you have to work hard to send money back home, you are to work way hard to pay your bills and save some other money, it's like you working twice, to save money for them and for yourself too; our lives evolving between here and there, our lives here in America and Africa.
Another participant concurred:
… a lot of people back home are depending on you while you are in the U.S. They assume you have a job, you got money. So you got cousins and aunties, uncles and brothers and sisters that you have to pay their tuition back home. You gotta send [End Page 257] money every time you get paid. So that's very stressful. You have to deal with stuff in the U.S. You gotta pay bills… but you also have to worry about how you are going to feed the mouths of them back home, they are depending on you.
Although some felt they were being exploited by family in Africa, others expressed a moral obligation to help: "I think because our culture as Africans we are communal. So here it's more individual so you still feel obligated to help people back home because we are a communal society… So we have that attachment to family and relatives and everybody else you know."
Sending money is culturally consistent with values and belief systems that support reciprocity:
Actually the reason why we stress level of us Africans… culturally the way you grow up it's almost like they put that like you have to help the family, that you go to school you do this. This is why they are helping you then you can help everybody else. Everyone who is not successful in your family is your responsibility… . Someone dies or someone is about to go to the hospital they ask them for money they are thinking of you. And sometimes it's not just the family members, it's friends, the cousin, the neighbor will know that you live in America and so they get your number you done. So that particular part make you feel like an obligation…
"All you do is work, work, work:" Financial challenges and job-related stressors
Many of the participants reported stressors related to overwork, job dissatisfaction, and financial challenges. One participant emphasized stress from multiple jobs and working to the point of exhaustion:
… most Africans that live in the U.S, if you think about it, they have multiple jobs, two, three jobs and the reason for that is to also help their family members back home and that alone will… stress you out because all you do is work, work, work, you, you don't have enough sleep, you know, you don't go out to socialize, you don't have the time because you have to go to work. That alone is a drain on the body… you are tired… you are stressed right there.
Financial challenges as stressors emerged as a theme across the focus groups. One participant explained how aspects of U.S. life were monetized in ways they were not back home:
… life here is very, very different from home, you know. Like here everything is bills, bills, bills, which is not, we are not used to that at home, like even if here let's say you have… your house, you still pay some bills, some taxes, it's never ending, unlike home, once you build your house it's yours.
"You are almost on edge every day:" Stress related to children
Participants reported stress related to raising children that was exacerbated by differences in U.S. culture versus culture in the parents' country of origin. Parents reported differences in disciplinary methods and in educational and social expectations for their children. Children's adaptation to the United States was also a significant source of stress for parents. [End Page 258]
Parents reported children's behavior constantly changing as they attempted to embrace their dual cultures. Parents also feared that children were involved in drugs, and for the girls, talking with strangers on the phone. Parents felt ill-equipped to handle the changes caused by generational and cultural differences.
… our youth… our children mostly because they are dealing with cultural shock and cultural change you don't know in the morning when they wake up what culture they will pick, you almost on edge every day… even the food they are eating at home compare to what they are eating either with their friends they are feeling some type of something…
Another participant expressed similar worries about children:
… when they come home you think like when they are with you are they following the rules back home or they mostly picking up the attitude and behavior outside of the house with their American friends or the other Africans or whatever culture that they getting and then automatically issues such as drugs issues such as, um, you know for young ladies being so much on the phones and talking to different strangers, it gets scary…
One of the children-related stressors included bullying. One participant stated that for Somali children, "American kids were picking on them because of the way they are dressed to the way they talk, so they even had to put them on separate buses." Stress arose for some because their children fail to practice their religion as Muslims and are distracted from their studies by time spent reaching out to American children.
African immigrant parents are stressed by the incompatibilities between African and American cultures, and the impact of this discordance on their children: "… we all want our kids to adapt American culture but I don't think we… stress enough for them to keep the African culture too… We ask them to be like American kids it's like we are confusing them."
"How to put my family together:" Disconnected families
Migrating to a foreign country puts a lot of stress on families as they struggle to integrate. Some felt their families were falling apart in the U.S.: "That only thing that stress me in the whole country, since I been here… I will talk about my family first. My sisters, brother, that really stress me, how we in the country, we living separate minded… I'd rather have my family all the time… not feeling connected at all… The next thing that hurt is how to put my own kids together… every day I try to find a way so we can live together and become and get used to each other very well… the stress I am really going through is how to put my family together."
Another participant expressed the transnational nature of pressures from family when he said, "The main problem I've got that's causing stress is like family issues both in London and back home." The inability to establish cohesive family relationships caused stress for some of the participants. In addition to their nuclear families as stressors, others shared how losing touch with their extended families in their countries of origin was also a source of stress. [End Page 259]
… I am here don't have connection there in Africa over there. I don't know who died, who living, so that making me so stressed… I am looking to get that communication back… that communication I was with my family, my wife, my daughters so it's cut off… and I really worry about those things I left back home.
"We feel like it was better back home:" Unrealized expectations
The United States is perceived by many as a country of great wealth and abundant opportunity. Thus, many immigrants expect abundant job opportunities and easier social mobility, leading to a better socioeconomic status than they could have realized in their home countries. Participants identified a mismatch between the expectations they had of life in the U.S. before migration and the reality they faced once they arrived. Participants expected life in the U.S. to be easier, with greater support to achieve goals. One participant said:
… you come here expecting to… prove yourself and get… to a higher level but then when you come here they want you to go start on the same level, so it's like almost like going back, everything you have done back home is a waste of time…
Another participant expressed the same sentiment:
… the expectation that we came with what we thought so different to that of what we saying because some of us were in Africa before coming this place we go to be having a better life than what we use to live and I think sometimes as much as we are here, we feel like it was better back home…
Manifestations of stress
When asked to describe stress, participants reported both physical and mental manifestations of stress. Physical manifestations of stress included: lack of appetite, fatigue, high blood pressure, increased body temperature, migraines and headaches, difficulty sleeping, fainting spells, vision problems, panic attacks, dizziness, and stress aggravating existing health conditions. Psychological manifestations of stress included: memory loss, emotional distress, loss of interest, blacking out, depression, nervousness, irritability, anger, and excessive crying. One participant captured both physical and psychological manifestations of stress: "… You worry a lot, you are overwhelmed, you, you know, you cannot eat, you are losing weight, depressed, all that stuff…"
Common coping strategies
The coping strategies can be divided into two categories: interpersonal strategies and individual strategies. The most common interpersonal strategy was talking with family or friends. One participant described "… talking to people to cool you down." Other interpersonal strategies included: going out, going to church, and going to the doctor. Individual coping strategies varied more widely. Individual strategies that appeared across all focus groups included walking, listening to music, watching television, and alcohol consumption (a strategy only mentioned by male participants). Other individual strategies mentioned by multiple participants included sleeping, exercising, praying, dancing, reading the Bible, cleaning the house, and focusing on what makes you happy. [End Page 260]
Sources of stress
Participants reported five major sources of stress: remittances, financial and job-related challenges, children, disconnected families, and unrealized expectations. The pressure to send remittances played a major role in stress for African immigrants, leading to overwork and working in menial jobs, which many saw as unsatisfactory. World Bank data show that African immigrants in the United States sent more than 8.35 billion dollars to Africa in 2014.33 Moreover, remittances are a large percentage of the gross domestic product (GDP) for many African countries such as Liberia (31.2%) and Ghana (13.2%), which is not the case for other countries with many immigrants in the United States such as Mexico (2.3%) and India (3.3%).34 Overall, remittances as discussed by the focus group participants are complex and continue to put unnecessary, unmanageable, and unrealistic financial pressure upon African immigrants. In addition, some feel that sending money to their countries of origin encourages and perpetuates dependence. Remittances are one of the major stressors that participants cannot readily resolve. Nevertheless, most participants stated they would continue to send remittances because they felt a moral obligation to do so. One stressor that was not as common in this study but which has appeared in other studies of Black immigrants was that of racism.35 Two participants in focus group one explicitly discussed experiences with racism, but this theme did not appear across all three focus groups, which is why it was not reported as one of the major stressors in this study.
Recommendations for stress management
The stress experienced by members of the African immigrant community can be addressed by health care providers and in community settings including faith-based organizations and community-based agencies. Health care providers should understand the sources of stress experienced by this community and include questions about these community-specific stressors in their assessments and treatment recommendations. Based on discussions with participants, we hypothesize that it is unlikely that members of the African immigrant population would report stress-related feelings of depression. It is also highly unlikely that they would accept treatment if diagnosed with clinical depression secondary to the stress of life experiences.36
We also recommend development of a culturally-appropriate stress reduction intervention since focus group participants reported a willingness to participate in group community-based interventions. Because over 96% of sub-Saharan Africans are reported to have some religious affiliation, including among other religions 62.9% who are Christians and 30.2% who are Muslims, it would be appropriate to add a faith-based component to the intervention.36 The potential stress reduction intervention should also include counseling on how to cope with the demands of family members in the country of origin, rights as employees and renters, and parenting bi-cultural children. While most of the recommended intervention involves counseling, we propose the addition of a physical component. Because dance and music are so integral to the African experience,37 the physical component of the stress reduction intervention program should include dance and music.
In addition, many African immigrants belong to community associations with [End Page 261] members from their country of origin.38 These community associations typically meet on a monthly basis. Hence, we also recommend integrating an intervention into existing community gatherings, as that is the most successful means to ensure sustained attendance for a community-based stress reduction intervention.
Research limitations and implications for future research
While to our knowledge this is the first study that explores stress and coping in a diverse sample of African immigrants from across the continent of Africa, there are several limitations to this study. First, because of the small sample size, the results cannot be generalized to the larger population of African immigrants in the United States. Second, due to the focus group setting, it is possible that some participants may have been reluctant to discuss personal circumstances or certain behaviors related to stress in front of other group members. In future studies, individual interviews might be recommended to reduce inhibition. Third, while 10 African countries were represented, immigrants from other countries who are also present in southwestern Pennsylvania (such as Ethiopia, Somalia, Zimbabwe, and Togo) were not represented.
To capture particular trends in common stressors, the somatization of stress, and coping strategies, larger studies must be conducted with a more diverse population of African immigrants and refugees. Future research should also examine substance abuse as a coping strategy and mental health disorders as related to stress. Moreover, while our study provides qualitative descriptions of stress and coping strategies, there is a need for biological measures of stress (such as with cortisol), to examine how common stressors for African immigrants can get "under the skin."
YOLANDA COVINGTON-WARD is an Associate Professor in the Department of Africana Studies at the University of Pittsburgh in Pittsburgh, PA. KAFULI AGBEMENU is an Assistant Professor in the Department of Family, Community, & Health Systems Sciences, School of Nursing, at the State University of New York at Buffalo in Buffalo, NY. ANNAMORE MATAMBANADZO is the Founder and Executive Director of Advance African Development, Inc., a Region III Master Trainer for Community Health Workers, and Consultant.