A scoping review of mental health issues and concerns among immigrant and refugee youth in Canada: looking back, moving forward.
Guruge, Sepali ; Butt, Hissan
One in five Canadians is born outside the country, and a large
portion (approximately 22%) of the total immigrant population is
composed of refugee and immigrant youth (aged 15-24 years). (1) In 2012,
approximately 12% of the 234,793 immigrants admitted to Canada were
youth, and of the 23,094 refugees admitted in the same year,
approximately 21% were youth. (2) Refugee and immigrant youth often have
different migration trajectories and experiences from each other, which
may result in different mental health outcomes. Refugee youth have often
fled war or natural disasters in their home countries and may be
separated from their families or have had to depart their homes or
countries without plans about how and where they will go. They may have
lived for prolonged periods of time in refugee camps uncertain as to
when they would migrate. (3,4) These experiences, along with others
(such as torture, violence, forced labour, targeted persecution, and
forced migration) have been suggested as determinants of mental illness
among refugees. (3,5) In contrast, immigrant youth are more likely to
arrive with their families, who have often had the chance to consider
and plan their journey to the new country. (4,6,7)
Regardless of whether they come as immigrants or refugees,
newcomers face common post-migration challenges that may affect their
mental health. (8) Post-migration determinants of mental health and
illness among immigrants and refugees have been identified at various
levels: individual (e.g., age, gender, language fluency, ethnicity,
knowledge of the health care system); familial (e.g., family
(in)stability, socio-economic status, intergenerational conflict);
institutional (e.g., availability (or lack) of access to appropriate
care and services, (non)acceptance of foreign credentials); and societal
(e.g., discrimination, racism, poverty). (8-10) Although both groups may
be affected by the same post-migration determinants of mental illness,
refugees may experience these determinants in "acute and unique
ways," which may result in more mental health problems. (3) To
date, findings from different studies about mental health among
immigrant and refugee youth in Canada have not been consolidated.
Therefore, we conducted a scoping review to assess the current state of
knowledge about various aspects of mental health among immigrant and
refugee youth in Canada, identify gaps within the literature, and
provide implications for research, practice and policy.
METHOD
Various definitions of scoping reviews exist, along with various
purposes that they can serve. (11) Mays, Roberts and Popay wrote that
scoping reviews "aim to map rapidly the key concepts underpinning a
research area and the main sources and types of evidence available, and
can be undertaken as stand-alone projects in their own right especially
where an area is complex or has not been reviewed before". (12)
Arksey and O'Malley suggested four objectives for scoping reviews:
1) to examine the extent, range and nature of research activity; 2) to
determine the value of undertaking a full systematic review; 3) to
summarize and disseminate research findings;and 4) to identify research
gaps in the existing literature. (13) Our objectives were in line with
1, 3 and 4.
We applied the five-stage framework proposed by Arksey and
O'Malley for conducting scoping reviews: Stage 1: Identifying the
research question; Stage 2: Identifying the relevant studies; Stage 3:
Selecting studies; Stage 4: Charting the data; and Stage 5: Collating,
summarizing and reporting the results.
Stage 1: Identifying the research question
Our research question was: What is known from the existing
literature about mental health issues and concerns among immigrant and
refugee youth in Canada? We defined immigrant and refugee youth as those
aged 13-29 years and born outside Canada, regardless of their official
immigration status.
Stage 2: Identifying the relevant studies
With the help of an experienced librarian, we searched CINAHL,
Embase, HealthStar, Medline, PsycINFO, and Social Science Abstracts
(SSA) databases using the following combinations of keywords:
immigrant/immigration/precarious/refugee/newcomer OR culture/
cultural/multicultural/ethnocultural/minority/diversity/diverse AND
mental health/mental disease/mental illness/mental disorder/ mental
problem/depression/schizophrenia/mood disorder/anxiety/ posttraumatic
stress disorder/psychiatry/psychiatric AND Canada. Inclusion criteria
for articles were: 1) peer-reviewed; 2) focused on the Canadian context;
3) based on primary studies; 4) focused on immigrants and/or refugees;
5) published in English; and 6) published between January 1990 and
August 2013.
The databases yielded a total of 1,384 articles (CINAHL: 74,
Embase: 341, Health Star: 332, Medline: 318, PsycINFO: 247, and SSA:
72). We removed 722 duplicates from this set.
[FIGURE 1 OMITTED]
Stage 3: Selecting studies
We assessed the abstracts of the remaining 662 articles to confirm
that: they were based on primary data, they had a mean/median age
between the specified age range of 13-29, and at least 50% of study
participants were born outside Canada. The latter criterion was
determined easily if the articles explicitly used terms such as
'refugee(s)' and/or 'immigrant(s)' to identify the
participants. If these criteria were not clear from the abstracts,
articles were retrieved and read. A total of 44 full articles were read
and 17 of these met the inclusion criteria and were included in this
scoping review (see Figure 1).
Stage 4: Charting the data
The 17 articles were charted in Microsoft Excel 2011 using the
following headings: Author/s; Name of journal; Year of publication;
Title; Aim of the study; Focus area; Study method; Study design;
Ethnicity; Age; Immigration status; Gender; Sample size; Study setting;
Data collection; Data analysis; Major findings; Limitations; and
Implications for research, practice, and policy. Table 1 displays the
charted data (with the exception of the findings, limitations and
implications).
Stage 5: Collating, summarizing and reporting the data
Based on the content of the articles included in the scoping
review, we devised the following categories of focus and placed each
article in the appropriate category: determinants of mental health;
rates of mental symptoms/illness; and program evaluation/intervention.
Common themes across articles were identified, and when possible,
articles were compared.
The next sections present the findings.
Characteristics of the studies included
In the 17 articles selected for analysis, sample sizes ranged from
10-281. Eleven (65%) studies were conducted in Quebec and five (29%) in
Ontario. One study was conducted in both Quebec and Ontario. All studies
were carried out in major metropolises. In terms of study design, 15
(88%) studies were cross-sectional and 2 (12%) were longitudinal. Three
(18%) were qualitative and the remaining 14 (82%) used mixed methods.
Age ranges of study populations fell within our definition of youth
(13-29 years of age) in 2 of the 17 studies (12%). Nine (53%) studies
were labeled as 'mixed,' which included children (<12
years) and youth, or youth and adults (>29 years), or children, youth
and adults, and the mean or median age of the study sample was between
13 and 29 years. The remaining six studies (35%) did not mention the age
range of participants, but were included in our review because the mean
or median age of their study populations were between 13 and 29 years.
Eight (47%) studies included refugee youth and three (18%) included
both immigrant and refugee youth. The remaining six studies (23%) did
not clearly state the official immigration status of the study
participants. However, these studies did provide information about their
birthplaces. In terms of gender, one (6%) study focused on young women;
one (6%) on young men; and the other 15 (88%) articles included young
men and women. The studies captured ethnicity in different ways: many
used categories such as 'country of origin,' 'country of
birth,' or 'continent of birth' instead of ethnicity. Six
(43%) studies included only one ethnic group (e.g., ref. 21). Eleven
(65%) studies focused on more than one ethnicity (e.g., ref. 22). A few
ethnic groups were common across a number of articles. For example,
Cambodian youth were discussed in five articles, Central American in
three, Caribbean in three, Somali in two, and Filipino in two.
Summary of study findings
Three themes emerged from the articles: determinants of mental
health were discussed in nine articles, rates of mental illness in four,
and program evaluation/intervention in two. Two articles discussed both
determinants of mental health and rates of mental illness. Mental health
problems discussed in the articles included but were not limited to
emotional and conduct problems (n = 4), depression (n = 3), self-esteem
(n = 2), stress (n = 1), anxiety (n = 1), and conduct disorders (n = 1).
Determinants of mental health included both pre- and post-migration
determinants. Pre-migration determinants included pre-migration
experiences, culture and trauma. Pre-migration experiences and culture
appeared to provide youth of various ethnocultural backgrounds and
genders with coping mechanisms in Canada. For example, one study
reported that Somali refugee youth were relatively "protected"
through the collective meaning of separation embedded in their
"nomadic" culture. (21) Two types of pre-migration trauma,
personal and collective, and their effects on cultural adaptation and
mental health were discussed. For example, one study reported that
Somali refugees' experiences of pre-migration collective trauma
(exposure to warfare, ethnic discrimination, stay in a refugee camp)
were not related to depressive symptoms, although these experiences were
associated with poorer adaptation. However, personal trauma (serious
accident, death of a loved one, assault from a familiar other, etc.) was
associated with depressive symptoms among Somali refugee youth. (15) A
study with Cambodian youth (24) contested the negative relation between
collective trauma and adaptation, but confirmed that the relation
between collective trauma and mental health may not necessarily be
negative: Cambodian families exposed to political violence prior to
migration reported positive 'social adjustment' and fewer
mental health symptoms. (24) In another study, (19) however, immigrant
and refugee youth who had experienced collective and/or personal trauma
self-reported greater emotional problems. The latter study involved
youth participants from a range of countries of origin. Post-migration
determinants included the number of years since immigration to Canada
(negatively related to depression), (17) in- and out-group conflict
(positively related to depression), (17) discrimination (associated with
increase in stress symptoms), (18) family environment (associated with
externalization), (25) and family structure (associated with
internalization). (25) The Youth Self Report (YSR) was used to measure
internalizing and externalizing symptoms, and the Family Environment
Scale (FES) was used to measure family environment, specifically
cohesion and conflict. (25)
Rates of mental illness appeared to vary by gender, ethnicity, and
immigration status. According to one study, (30) female refugee
adolescents (from a range of countries of origin) had higher rates of
psychopathology than their male refugee counterparts. Another study (18)
reported that Chinese female youth had lower self-esteem than their
Chinese male counterparts after experiencing discrimination. In one
study, Central American refugee youth reportedly had fewer emotional and
behavioural problems compared with both Cambodian and Quebecois youth.
(23) However, another study (20) found no significant difference in
self-reported psychiatric symptoms between Central American and
Cambodian adolescents. Canadian-born youth were reported in one study to
have lower rates of psychopathology in comparison with their refugee
youth counterparts. (30) Another study reported that Canadian-born youth
had higher rates of emotional and behavioural problems and were more
likely to engage in risky behaviours compared with Central American and
Cambodian refugee youth. (23) These findings were substantiated by
another study in which Caribbean and Filipino youth reported fewer
behavioural problems than their Canadian-born provincial counterparts.
(27)
Two articles discussed a program and an intervention designed for
immigrant and refugee adolescents in schools. The first evaluated a
9-week school drama therapy program (26) and the second evaluated an
intervention involving a 12-week series of workshops integrating drama
and language awareness. (29) Both of these studies reported
post-program/intervention reductions in impairment related to emotional
and behavioural symptoms among participants compared with comparison
groups. For the 9-week drama therapy program, performance in mathematics
increased significantly compared with the comparison group, although
there was no reported improvement in self-esteem or emotional and
behavioural symptoms. This program also appeared to be associated with
"a decrease in impairment in girls, while the program appeared to
prevent an increase in impairment in boys." (26)
DISCUSSION
The findings presented above should be interpreted with caution for
several reasons related primarily to the methods used in the original
studies. First, studies often used non-representative and small samples,
which did not permit inferences to be made about youth from the
particular ethnic group or across groups. Second, all the studies took
place in Ontario and/or Quebec, and one research team conducted 10 of
the 11 Quebec-based studies. The findings cannot, therefore, be
generalized to immigrant and refugee populations across Canada. Third,
only a few mental illnesses were examined across the studies. Depression
was mentioned in three studies but in different contexts, without much
basis to draw comparisons between particular groups of youth. Fourth,
although the studies generally reported gender differences, it was
difficult to identify the challenges faced specifically by female and
male youth because these were not explicitly discussed. Fifth, although
there were a few common ethnic groups across articles, the focus areas
of these articles did not necessarily converge, making it difficult to
draw conclusions about the status of a specific ethnic group. For
example, the five articles that included Cambodian youth covered three
separate themes. Finally, no studies explicitly compared the rates of
mental illness among immigrant and refugee youth, thus preventing
comparisons and conclusions regarding their mental health.
Pre-migration trauma appeared as a complex factor for the
post-migration mental health of refugee youth. The relationship between
pre-migration collective trauma and cultural adaptation in the
'host' country appeared to conflict: Somali refugees who had
experienced collective trauma prior to migration (e.g., through civil
war), had 'poorer cultural adaptation', (15) whereas Cambodian
refugee youth, after exposure to political violence in their home
country, reported positive 'social adjustment'. (24) The
relationship between collective trauma and mental health was also not
clear, as some findings suggest collective trauma could act as a
protective factor. To determine whether trauma is a risk or protective
factor in refugee youth mental health, it would be necessary to consider
not only the intensity and duration of trauma, but the age at which the
trauma is experienced. Even when the trauma is experienced as
collective, the intensity of its effects may vary among and between
groups of youth. It is also important to note that the two articles that
examined this relationship had relatively small samples (57 and 169),
and (as noted above) focused on only two ethnic groups (one on Cambodian
youth and one on Somali youth). More research with larger sample sizes
and more ethnic groups is needed to further clarify these findings.
The importance of engaging families in addressing the mental health
and illness concerns of immigrant and refugee youth was highlighted in a
number of articles. One study (20) recommended the involvement of
multiple informants, especially from the family, to bring in multiple
perspectives about the mental health of their children. The school was
commonly identified as an important site to address the needs of
immigrant and refugee youth, and the two programs/interventions that
appeared to offer innovative approaches to address the mental health
needs of immigrant and refugee youth were both located in schools. The
12-week intervention was designed to help youth cope with adversity, and
the 9-week program was designed to prevent emotional and behavioural
problems and to improve school performance. Evaluation of the program
revealed a differential impact based on gender, which should be taken
into account when designing future programs. One article suggested
traditional methods for dealing with assimilation in the new country,
such as family therapy. (25) One article recommended reaching out to
refugee youth, especially during their turbulent first year of arrival
in Canada. (30) One article recommended using self-reported
questionnaires in schools to assess symptoms quickly. (19) Overall,
considerably more research is needed to evaluate various aspects of such
interventions and programs to clarify which components of which
intervention could be of long-term benefit, to which groups of youth, at
which period of post-migration, in which settings.
Limitations
One key limitation of our scoping review was the exclusion of grey
literature, which can include important research conducted by community
organizations. Second, our literature search did not include a
comprehensive search of social science databases, which could have
yielded additional articles on the topic. Third, we did not search for
articles on addictions--which are often perceived as part of the mental
health, illness, and disorder continuum. Fourth, we followed the
suggestion of Arksey and O'Malley (2005) and did not assess the
quality of studies included (which could be done in a systematic
review). Despite these limitations, this scoping review makes valuable
contributions to the existing body of literature about immigrants and
refugee youth and their mental health, by identifying research gaps and
providing recommendations/ implications for research, practice and
policy.
Implications for research, practice and policy
The small number of articles (n = 17) published over a 23-year
period demonstrates the paucity of research focused on mental health
among immigrant and refugee youth in Canada. Substantially more research
is needed on this topic. In particular, more research is needed to
assess the prevalence rates and pre- and post-migration factors to
explain variability in symptoms, and to gain a holistic picture of the
mental health of refugee and immigrant youth. More research is also
needed to assess the use of mental health services among youth of both
genders and of various ethnic groups, immigration status, and length of
stay in Canada. Potential subject areas for future study include trauma,
resilience, and protection among refugee youth, further clarification of
the determinants of mental health, pathways to care, and the dynamics
within immigrant and refugee families (e.g., parent-child relations) and
between the family and the socio-economic environment. Future research
could also explore the reasons for potential variability in specific
mental illnesses by gender and immigrant groups. Many of the articles
stressed the need for longitudinal research to explore specific mental
health issues among individuals and subpopulations over time, as well as
the need for gender-based analyses to identify different styles of
coping across genders and ethnic groups.
The articles revealed several implications for practice, such as
the importance of family involvement and school settings as points of
care. Both of the programs/interventions were based in schools, and
drama therapy programs and workshops appear to be promising, although
more research is required to evaluate their effectiveness in the medium
and long term. Reaching out to refugee youth, especially during their
first year of arrival in Canada, may be helpful. Health care
professionals should work across health, social, and settlement sectors
to address the various determinants of mental health and provide more
effective services based on how these have differential effects on
various youth groups.
The articles also revealed some implications for policy. Policies
need to be developed with an awareness of the importance of and need for
intersectoral collaboration to reduce structural discrimination and
racism, which negatively affect immigrant and refugee youth. Policies
should also include multisectoral and context-specific mental health
promotion programs: different sectors need to work together to address
mental health issues among immigrant and refugee youth, particularly at
the time of arrival, to assess their health status and refer them to the
appropriate services. This kind of pre-emptive action may help prevent
the costs of treatments associated with the management of full-blown
mental illnesses, and benefit youth, their families, and society.
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* Those references included in the scoping review are identified
with an asterisk.
Received: May 15, 2014
Accepted: November 1, 2014
Sepali Guruge, RN, PhD, [1] Hissan Butt, BA (Hons) [2]
Author Affiliations
[1.] Associate Professor, Daphne Cockwell School of Nursing,
Ryerson University, Toronto, ON
[2.] Research Assistant, Division of Urology, The Hospital for Sick
Children, Toronto, ON
Correspondence: Sepali Guruge, PhD, Daphne Cockwell School of
Nursing, Ryerson University, 350 Victoria Street, Toronto, ON M5B 2K3,
Tel: 416-979-5000, ext. 4964, E-mail: sguruge@ryerson.ca
Acknowledgements: This study was supported by a grant from the
Ministry of Health and Long-Term Care (Grant # 06662). The first author
also acknowledges financial support for her work from the Institute of
Gender and Health of Canadian Institutes of Health Research in the form
of a New Investigator Award.
Conflict of Interest: None to declare.
Table 1. Charted data
No. Author Sample information Research design
information
1 Hyman et al. Ethnicity or Method: Qualitative
2000 (14) country/continent Design: Cross-
of birth/ origin: sectional
South-east Asian Collection:
Age: Range = 10-24; Interviews, focus
mean/median = * groups
Immigration status: Analysis:
Refugees Qualitative
Gender: M & F analysis
Sample size: 52
Location: Ontario
2 Jorden et al. Ethnicity or Method: Mixed
2009 (15) country/continent Design: Cross-
of birth/origin: sectional
Somali Collection:
Age: Range = 18-62; Questionnaires,
mean = 29 interviews
Immigration status: Analysis: Multiple
Refugees regression
Gender: M & F analysis;
Sample size: 169 qualitative
Location: Ontario analysis
3 Khanlou et al. Ethnicity or Method: Qualitative
2006 (16) country/continent Design: Cross-
of birth/origin: sectional
Korea, China, Collection:
Russia, Taiwan, Interviews, focus
Macao groups
Age: Range = n/a; Analysis:
Mean = 17 Qualitative
Immigration status: analysis
n/a; 100% of sample
born outside Canada
Gender: F
Sample size: 10
Location: Ontario
4 Lay et al. Ethnicity or Method: Mixed
1998 (17) country/continent Design: Cross-
of birth/origin: sectional
Vietnamese Collection:
Age: Range: 19-34; Questionnaires
median 22 Analysis: Multiple
Immigration status: regression
Immigrants and analysis
refugees
Gender: M & F
Sample size: 60
Location: Ontario
5 Pak et al. Ethnicity or Method: Mixed
1991 (18) country/continent Design: Cross-
of birth/origin: sectional
Chinese Collection:
Age: Range = n/a: Questionnaires
26% 18-19 years; Analysis: Variance
68% early 20s and covariance
Immigration status: analyses using
n/a; 88% of sample general linear
born outside Canada model procedure
Gender: M & F
Sample size: 90
Location: Ontario
6 Persson et al. Ethnicity or Method: Mixed
2012 (19) country/continent Design: Cross-
of birth/ origin: sectional data
Asia, Latin America, from a
Africa, Europe, longitudinal study
North America Collection:
Age: Range = 12-18; Questionnaires
mean = 15.5 Analysis: Multiple
Immigration status: linear regression
Immigrants and
refugees
Gender: M & F
Sample size: 111
Location: Quebec
7 Rousseau etal. Ethnicity or Method: Mixed
199820 country/continent of Design: Cross-
birth/ origin: sectional
Central American and Collection:
Cambodian Interviews
Age: Range: = 12-16;
mean = 14 Analysis:
Immigration status: Comparisons of
Refugees means and Spearman
Gender: M & F correlation
Sample size: 158 coefficients
adolescents of a
total sample of 281.
The remaining sample
consisted of
children 8-12.
Location: Quebec
8 Rousseau et. Ethnicity or Method: Qualitative
al. 1998 (21) country/continent of Design: Cross-
birth/ origin: sectional
Somali Collection:
Age: Range = 1 3-18; Interviews
mean = n/a Analysis: n/a
Immigration status: (qualitative
Refugees ethnographic
Gender: M analysis?)
Sample size: 10
Study setting/
location: Ontario
and Quebec
9 Rousseau et al. Ethnicity or Method: Mixed
200022 country/continent of Design: Cross-
birth/origin: sectional
Central American and Collection:
Cambodian Interviews
Age: Range = n/a; Analysis: Difference
mean = 14 between mean
Immigration status: scores and
Refugees percentage using
Gender: M & F confidence
Sample size: 152 intervals,
Location: Quebec correlation
analyses, Spearman
rank correlation
coefficient
10 Rousseau et al. Ethnicity or Method: Mixed
2000 (23) country/continent of Design: Cross-
birth/ origin: sectional
Central American, Collection:
Cambodian. Interviews and
Age: Range = n/a; questionnaire
mean = 15 Analysis: Means,
Immigration status: confidence
n/a; all Central intervals,
American and multiple
Cambodian youth born regression
outside Canada
Gender: M & F
Sample size: 158 of
225 Central American
and Cambodian youth
Location: Quebec
11 Rousseau et al. Ethnicity or Method: Mixed
2003 (24) country/continent of Study design:
birth/ origin: Longitudinal
Cambodian Collection:
Age: Range = n/a; Interviews
mean at baseline = Analysis:
14 Generalized linear
Immigration status: models, Spearman
Refugees correlation
Gender: M & F coefficient, means
Sample size: 57 comparisons, odds
Location: Quebec ratios
12 Rousseau et al. Ethnicity or Method: Mixed
2004 (25) country/continent of Design: Longitudinal
birth/ origin: Collection:
Cambodian Interviews
Age: Range = n/a; Analysis: Paired
mean at baseline = t-tests, multiple
14 linear regression
Immigration status: analyses
Refugees
Gender: M & F
Sample size: 67
Location: Quebec
13 Rousseau et al. Ethnicity or Method: Mixed
2007 (26) country/continent of Design: Cross-
birth/ origin: Asia, sectional
Eastern Europe, Collection:
South America, Questionnaires
Middle East and Analysis: Univariate
Africa generalized linear
Age: Range = 12-18; models
mean = 15
Immigration status:
Refugees and
immigrants
Gender: M & F
Sample size: 123
Location: Quebec
14 Rousseau et al. Ethnicity or Method: Mixed
2008 (27) country/continent of Design: Cross-
birth/ origin: sectional
Caribbean & Filipino Collection:
(and Quebecois) Interviews
Age: Range = 12-19;
mean: 15
Immigration status: Analysis:
n/a; 63% born Descriptive
outside of Canada statistics;
Gender: M & F t-tests and
Sample size: 252 of chi-tests
319 Caribbean-
Canadian and
Filipino-Canadian
youth
Location: Quebec
15 Rousseau et al. Ethnicity or Method: Mixed
200928 country/continent of Design: Cross-
birth/ origin: sectional
Caribbean and Collection:
Filipino Interviews, focus
Age: Range 12-19; groups with youth
mean 15 Analysis:
Immigration status: Qualitative
n/a; 61% born analyses; Pearson
outside of Canada correlations and
Gender: M & F t-tests,
Sample size: 254 correlations,
Location: Quebec hierarchical
multiple
regression
16 Rousseau et al. Ethnicity or Method: Mixed
2012 (29) country/continent of Design: Cross-
birth/ origin: sectional
Africa, Latin Collection:
America and Interviews
Caribbean, Asia, Data analysis:
Other Chi-square,
Age: 12-18; mean: 15 t-test, paired
Immigration status: t-test;
Immigrant and qualitative
refugees analysis of
Gender: M & F participant
Sample size: 55 observation
Location: Quebec
17 Tousignant et Ethnicity or Method: Mixed
al. 199930 country/continent of Design: Cross-
birth/ origin: Over sectional
35 countries Data collection:
Age: 13-19; mean: 16 Interviews at
Immigration status: home, university,
Refugees or community
Gender: M & F centre in multiple
Sample size: 203 languages
Location: Quebec Data analysis:
Chi- squared test
with Yates
correction
No. Author Focus area
information
1 Hyman et al. Determinants of
2000 (14) mental health
2 Jorden et al. Determinants of
2009 (15) mental health
3 Khanlou et al. Determinants of
2006 (16) mental health
4 Lay et al. Determinants of
1998 (17) mental health
5 Pak et al. Determinants of
1991 (18) mental health and
rates of mental
symptoms/illnes
6 Persson et al. Determinants of
2012 (19) mental health
7 Rousseau etal. Rates of mental
199820 symptoms/illness
8 Rousseau et. Determinants of
al. 1998 (21) mental health
9 Rousseau et al. Determinants of
200022 mental health
10 Rousseau et al. Rates of mental
2000 (23) symptoms/illness
11 Rousseau et al. Determinants of
2003 (24) mental health; Rates
of mental symptoms/
illness
12 Rousseau et al. Determinants of
2004 (25) mental health
13 Rousseau et al. Program evaluation
2007 (26)
14 Rousseau et al. Rates of mental
2008 (27) symptoms/illness
15 Rousseau et al. Determinants of
200928 mental health
16 Rousseau et al. Interventions
2012 (29)
17 Tousignant et Rates of mental
al. 199930 illness
* Mean age for individual interviews = 16; age range for 3 focus
groups = 13-24.
