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Push and Pull Migration Factors Influencing the Intrusive Experience and General Health of Sub-Sahara Africa Refugees Post Conflict

ProQuest Dissertations and Theses, 2011
Dissertation
Author: Cassandra E Conton
Abstract:
This study was designed to explore the relationship of push/pull migration factors, traumatic symptoms, and general health of Sub-Sahara Africans post conflict. Migration theory and the factors described therein are used to explore why some refugees from Sub- Sahara countries may fare better than others in their intrusive experience and general health post migration. To date, only a handful of studies have been dedicated exclusively to Sub-Sahara Africa refugees living in developed nations and no studies used existing migration theory to explain differences in refugee migration outcomes post conflict. Most studies of post migration factors have concentrated on variance in the refugees' personal and social resources including fluency in the host nation's language, employment, and educational status; the availability and use of interpersonal, social, or community supports; difficulties in dealing with government bureaucracies; social isolation; separation from family; and discrimination. This research explores migration factors that push (unattractive attributes of origin country) or pull (attractive attributes of receiving country) Sub-Sahara Africa refugees to migrate and posits that this cluster of factors influences the intrusive experience and general health of refugees post conflict. Further, the rich and diverse geopolitical history of Sub-Sahara Africa and affiliations with and/or support from westernized nations may serve as protective or impeding factors to successful migration outcomes. As 43 million refugees attempt to navigate the host country's culture, successful post migration outcomes of refugee populations require increased knowledge and understanding of their needs by host countries such as the United States. However, before any of this can occur, empirical research that uses existing migration theory needs to accurately identify those factors that facilitate or impede immigrant populations post migration. This study seeks to fill this void. Key Words: Sub-Sahara Africa, migration, refugee, internal displacement, forced displacement, psychological functioning, social functioning, push factors, pull factors, colonization.

v Table of Contents Part A Page Review of Literature ......................................................................................................... 13 Challenges of Refugee Research .................................................................................. 3 Theoretical Considerations ........................................................................................... 8 Push Factors ................................................................................................................ 10 Low levels of education ........................................................................................ 10 Population explosion ............................................................................................. 11 Struggle for livelihood .......................................................................................... 11 Poverty .................................................................................................................. 11 Violation of human rights ..................................................................................... 12 Political unrest ...................................................................................................... 12 Pull Factors ................................................................................................................. 13 Booming economy and financial security ............................................................. 13 Employment and job opportunities ....................................................................... 13 Favorable migration laws ...................................................................................... 13 Cultural/language similarities ............................................................................... 14 Family support ...................................................................................................... 14 Neoclassical Model of Migration................................................................................ 15 Phase/Stage Models of Migration ............................................................................... 15 Life-Events Model of Migration ................................................................................. 17 Acculturation Model of Migration .............................................................................. 19 Geopolitical Differences Among Sub-Sahara African Countries ............................... 20

vi Geopolitical and Colonization History of Sub-Sahara Africa .................................... 22 Liberia ................................................................................................................... 23 Sierra Leone .......................................................................................................... 23 Somalia ................................................................................................................. 24 Sudan..................................................................................................................... 25 Refugee Intrusive Experience and General Health Studies ........................................ 27 Sub-Sahara Africa Refugee Studies ............................................................................ 32 Risk and Protective/Buffering Migration Factors ....................................................... 34 Acculturation and Resettlement Migration Factors .................................................... 40 Refugee Families and Migration ................................................................................. 55 Use and Efficacy of Services Provided to Refugees ................................................... 61 Conclusion .................................................................................................................. 65 References ......................................................................................................................... 69 Part B Abstract .................................................................................................................. 77 Introduction ....................................................................................................................... 80 Migration Theory ........................................................................................................ 84 Geopolitical Differences among Sub-Sahara African Countries ................................ 86 Geopolitical and Colonization History of Sub-Sahara Africa .................................... 86 Push Factors Influencing Refugee Migration ............................................................. 89 Pull Factors Influencing Refugee Migration............................................................... 91 Intrusive Experience and General Health of Forced and Displaced Migrants ............ 93 Methods..................................................................................................................... 102 Recruitment ............................................................................................................... 105

vii Measures ................................................................................................................... 108 Data Analysis ............................................................................................................ 117 Limitations ................................................................................................................ 118 Protection of Human Subjects .................................................................................. 118 Conclusion ................................................................................................................ 119 Results ............................................................................................................................. 121 Description of the Sample ......................................................................................... 122 Reliability of the Push and Pull Factors .................................................................... 126 Correlations of Variables of Interest ......................................................................... 127 Research Questions ................................................................................................... 128 Prediction of Wellbeing/General Health ................................................................... 128 Wellbeing/General Health Prediction: Zero Order Correlations ........................ 130 Wellbeing/General Health Prediction: Multiple Regression .............................. 131 Summary of Prediction of Wellbeing/General Health ........................................ 132 Prediction of Trauma ................................................................................................ 133 Trauma Prediction: Zero Order Correlations ...................................................... 134 Trauma Prediction: Multiple Regression ............................................................ 135 Summary of Prediction of Trauma ..................................................................... 136 Summary ................................................................................................................... 137 Discussion of Results ...................................................................................................... 138 Limitations of the Study............................................................................................ 145 Implications for Practice ........................................................................................... 146 Implications for Theory ............................................................................................ 149

viii Recommendations for Further Studies...................................................................... 150 Summary ................................................................................................................... 152 References ....................................................................................................................... 154 Appendix A. Recruitment Flow Chart ........................................................................... 162 Appendix B. Questionnaire ............................................................................................ 163 Appendix C: Zero-Order Correlations of Variables of Interest ...................................... 165

ix List of Tables Table Page 1. Factor Loadings of Push and Pull Statements from Researcher-Developed Questionnaire ...............................................................................................................113

2. Push and Pull factors on Demographic Questionnaire ................................................114 3. Variables measured by the Demographic Questionnaire .............................................115 4. Rubric to Determine Socioeconomic Status of Participants ........................................116 5. Demographic Descriptions of Samples ........................................................................122 6. Responses to Push and Pull items ................................................................................123 7. Descriptions of Computed Variables ...........................................................................124 8. Means and Standard Deviations of Demographic Characteristics ...............................125 9. Factor Loadings for Push and Pull Factors ..................................................................126 10. Reliability of Push and Pull Factors...........................................................................126 11. Variables in the Prediction of Wellbeing/General Health .........................................131 12. Variables in the Prediction of Trauma .......................................................................135

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PUSH AND PULL MIGRATION FACTORS INFLUENCING the INTRUSIVE EXPERIENCE and GENERAL HEALTH of SUB-SAHARA AFRICA REFUGEES POST CONFLICT

PART A A REVIEW of the LITERATURE by CASSANDRA E. CONTON Fielding Graduate University

xi Abstract

Push and Pull Migration Factors Influencing the Intrusive Experience and General Health of Sub-Sahara Africa Refugees Post Conflict

Review of the Literature Part A by Cassandra E. Conton This study was designed to explore the relationship of push/pull migration factors, traumatic symptoms, and general health of Sub-Sahara Africans post conflict. Migration theory and the factors described therein are used to explore why some refugees from Sub- Sahara countries may fare better than others in their intrusive experience and general health post migration. To date, only a handful of studies have been dedicated exclusively to Sub-Sahara Africa refugees living in developed nations and no studies used existing migration theory to explain differences in refugee migration outcomes post conflict. Most studies of post migration factors have concentrated on variance in the refugees’ personal and social resources including fluency in the host nation’s language, employment, and educational status; the availability and use of interpersonal, social, or community supports; difficulties in dealing with government bureaucracies; social isolation; separation from family; and discrimination. This research explores migration factors that push (unattractive attributes of origin country) or pull (attractive attributes of receiving country) Sub-Sahara Africa refugees to migrate and posits that this cluster of factors influences the intrusive experience and

xii general health of refugees post conflict. Further, the rich and diverse geopolitical history of Sub-Sahara Africa and affiliations with and/or support from westernized nations may serve as protective or impeding factors to successful migration outcomes. As 43 million refugees attempt to navigate the host country’s culture, successful post migration outcomes of refugee populations require increased knowledge and understanding of their needs by host countries such as the United States. However, before any of this can occur, empirical research that uses existing migration theory needs to accurately identify those factors that facilitate or impede immigrant populations post migration. This study seeks to fill this void.

Key Words: Sub-Sahara Africa, migration, refugee, internal displacement, forced displacement, psychological functioning, social functioning, push factors, pull factors, colonization.

Review of Literature Since the mid-1970s, post migration mental health status and social functioning of refugees has become the subject of substantial and mounting research interest (Begic & McDonald, 2006; Fazel, Wheeler, & Danesh, 2005; Gerritsen et al., 2006; Lustig et al., 2003; Porter & Haslam, 2001, 2005). Interest in the topic by world health organizations and researchers has soared as more than 1% of the world’s population has been forced into migration across national borders by the rising frequency of civil wars (Ajdukovic & Ajdukovic, 1998; Fazel et al., 2005). Civil wars target and eventually affect cultural, ethnic, and religious factions. Although civil conflicts are pandemic, virtually all of these wars have occurred within the conflicted regions of East Asia, the Middle East, the former Yugoslavia, and Sub-Sahara Africa (Porter & Haslam, 2005; Sinnerbrink, Silove, Field, Steel, & Manicavasgar, 1979). Of these, 5 African countries rank in the top 10 nations generating refugee flow, with Sub-Sahara countries reporting disproportionately higher rates of displaced refugees (U.S. Committee for Refugees and Immigrants, 2002). From these 10 nations, 908,810 Sub-Sahara Africa refugees are residing in the United States and 50,785 of these reside in the Atlanta, Georgia metropolis (World Health Organization, 2006). Conflicting literature exists as to whether the migration process generates positive or negative outcomes for forced migrants. Positive outcomes include safety from violence, an increase in educational and job opportunities, and increased exposure to cultural/ethnic diversity. Negative outcomes include the loss of highly skilled people, resentment of the refugees within receiving communities, an inability to access resources in the host country, language barriers, substandard housing, and noncompetitive earnings

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(Lee, 1966; United Nations High Commission for Refugees, 2005). However, there is a consensus that migration is an integral part of human existence, is life altering, and the factors motivating the move are complex and intertwined. Estimates of the total number of refugees worldwide vary with differences in defining criteria. Citing United Nations sources, Porter and Haslam (2005) reported that at the end of 2004, there were roughly 43 million refugees, asylum seekers, internally displaced persons, and stateless persons around the world. Concurrently, Fazel et al. (2005) provided estimates in the range of 11 million to 13 million that was later confirmed by Alix-Garcia and Saah (2008). These figures do not take into account former refugees who have been granted permanent residence by the governments of the host countries to which they have relocated. Regardless of the inclusion criteria used, more than 1% of the world’s populace is comprised of people who have undergone forcible displacement across national borders (Fazel et al., 2005). Most externally displaced refugees currently live within developing countries and typically in neighboring nations. Rather than being absorbed into the host society, they are usually housed in specialized camps operating under the auspices of nongovernmental international relief agencies with an expectation for their eventual repatriation (Fazel et al., 2005). As Thapa, Van Ommeren, Sharma, de Jong, and Hauff (2003) observed, there has been very little research conducted with these groups. Both practical and ethical considerations have restricted the study of psychopathology in these settings. Consequently, virtually all published studies on refugee mental health and social functioning have been carried out in the developed nations, including the United States and Canada, Western Europe, Australia, and New Zealand.

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Mollica and McDonald (2002) Bhugra (2002), Elliott (2002), and Cortes (2004) reported that not only have very high prevalence rates for psychiatric disorders been reported among refugees resettled in developed countries, there is also ample evidence that “untreated wounds of war do not just go away. Beyond immediate and acute suffering, traumatic events and major life losses experienced prior to relocation continue to impair the post migration general health and functioning of refugees. Both narrative reviews (Eisenman, Gelberg, Liu & Shapiro, 2003; Begic & McDonald, 2006) and meta- analyses (Fazel et al., 2005; Porter & Haslam, 2001, 2005) have found elevated rates of psychopathology among refugees from diverse countries; most notably inordinately high rates of chronic stress and depressive disorders. Challenges of Refugee Research Within developed countries, research among refugees is fraught with obstacles. Prospective study populations are often physically, linguistically, and culturally inaccessible (Porter & Haslam, 2005). Even when refugees’ resettlements are carried out as part of an organized effort and they are provided with services at reception centers, the refugees tend to disperse over time. Many prospective subjects appear to be averse to participation in medical, psychiatric, and social science research (Simick, Beiser, & Mawani, 2003). This is understandable given the mistrust many felt and continue to feel about government-run and/or political organizations. An even larger problem revolves around the derivation of reliable generalizations. As Lustig et al. (2003) have observed, “New refugee arrivals (to the United States) are extremely diverse, with the largest place of origin today being Africa, a continent with overlapping national and tribal boundaries” (p. 5). Findings from studies using refugees

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from a particular nation or ethnic group may not be generalized to members of another nationality or ethnic group. As emerging dynamic models of the refugee experience suggest, even within a homogeneous sample, basic data such as mental disorder prevalence rate or employment status are likely to vary according to the duration of time between resettlement and measurement. Although scores of research studies on refugee psychopathology have been carried out, “The relevant epidemiological evidence is generally sparse, scattered and apparently conflicting, and its interpretation has been complicated by the use of different sampling and assessment methods” (Fazel et al., 2005, p. 1309). Indeed, what is most striking about the field of refugee mental health studies is the remarkable wide range of findings reported. Gerritsen et al. (2006) lamented, “For depression, posttraumatic stress disorder, and anxiety symptoms, there is a huge range of prevalence reported in population-based studies focusing on adult refugees living in Western countries” (p. 24). Moreover, because refugees from particular conflict situations have relocated in waves, those national and ethnic groups that have arrived most recently have not been investigated to the same extent as long-established groups. Commenting upon this uneven coverage, Hsu, Davis, Hansen one year later in 2004 added their voice to Lustig et al. (2003) who remarked that “Additional research is needed with refugee groups, such as Africans, for which there is little information” (p. 30). Aside from the paucity of data on many newlyarriving refugee groups and the problematical reliability of reported findings, the validity of the current approach to the study of war refugees has come under sharp criticism of late (Jaranson, Martin, &

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Ekblad, 2000). The basic thrust of this criticism is that the current focus on individual psychopathology, grounded in premigration experiences (notably exposure to war trauma and personal losses), is too narrow (Silove, Sinnerbrink, Field, Manicavasagar, & Steel, 1997). Among others, Scheinfeld (1993), Arroyo and Eth (1985), and Wetters (2001) have asserted that researchers who have approached refugee mental health based on western psychiatric categories have paid “scant attention to the social, political, and economic factors that play a pivotal role in refugees’ experience” (p. 1709). From Wetters perspective, they have grossly overlooked their subjects’ own interpretations of the distress they have experienced and how it can best be treated. The widespread use of posttraumatic stress disorder (PTSD) and major depressive disorder (MDD) diagnostic screening instruments in refugee mental health studies has evoked substantial criticism on technical, normative, and conceptual grounds. Ichikawa, Nakahara, and Wakai (2006) conducted a pilot study with Afghan refugees to determine the reliability of cut-off points on mental health status assessment devices measuring PTSD and MDD. Fifty-five subjects voluntarily participated in this study using instruments commonly used in refugee mental health research. The Hopkins Symptoms Checklist-25 and the Harvard Trauma Questionnaire were used. The researchers used the cut-off point method to diagnose the subjects with MDD or PTSD, which resulted in overestimation of mental health problems. About 38% of the diagnosed cases for PTSD and MDD were actually false positives. It was speculated that the over-estimations “might be caused by cross-cultural differences in their response to the symptoms” (Ichikawa, Nakahara, and Wakai, 2006, p. 249). These researchers ultimately recognized that caution is necessary in the application of scale cut-off points determined in one

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cultural group to another. It was suggested that an alternate method of using algorithms could have improved the mental health classification accuracy. Both methods (usage of cut-off points and algorithms) assess for symptoms; however, the sole use of cut-off points tends to overestimate psychopathology. Similarly, Durieux-Paillard, Whitaker-Clinch, Bovier, and Eytan (2006) discussed the difficulties of attempting to adapt standardized screening instruments for MDD and PTSD for culturally and ethnically different refugee populations. They questioned the reliability of assessments using standard diagnostic protocols, asserting that existing devices are “too culturally reductive” for use with non-western subjects (Durieux-Pallard et al., 2006, p. 593) and therefore caution must be heightened in the use of instruments that have been normed with a cultural group that may be different from the population of interest. In their study of Bosnian refugees resettled in Norway, Lie, Laake, and Lavik (2001) measured symptoms of PTSD. The researchers explained that, “The symptoms observed after exposure to multiple traumas are heterogeneous and complex and the diagnosis of PTSD may be too simple to diagnose the disturbances of people after multiple traumas” (Lie et al., 2001, p. 278). False diagnoses due to errant cut-off points, cultural disparities in the expression or manifestation of symptoms, and exposure to multiple traumas across time may help to explain radically diverse findings for psychiatric disorder prevalence rates that have been reported in the refugee mental health literature. Summerfield (1999) has been a salient critic of the assumptions behind psychological trauma programs with refugees in war-affected areas. Summerfield has characterized the use of psychiatric diagnostic categories as a manifestation of the

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medicalization of suffering and argued that this represents the imposition of a western worldview upon non-western individuals who do not share the same values as their benefactors. Elaborating on Summerfield’s position, Gozdziak (2004) observed that western medical treatment models are grounded in the value system of humanistic psychology, with a strong emphasis upon self-assertion and individual autonomy. By contrast, many of the non-western cultures into which refugees have been socialized value “interdependence and deference to authority in social relationships” (Gozdziak, 2004, p. 206). What may seem to be pathological passivity or withdrawal may in fact be normal behavior within a refugee’s culture of origin. Lastly, from the findings of the study of Bosnian refugees who have resettled in Norway, Lie et al. (2001) concluded that, “Too much focus on PTSD as a diagnosis may lead to possible underestimating of the complexity of maladjustment as well as the resiliency of refugees” (p. 292). On this last count, researchers have reported a high current prevalence of diagnosed PTSD within refugee samples that nevertheless exhibit social functioning that is equal or superior to that of matched host country non-refugee groups (Beiser & Hou, 2001; Rousseau & Drapeau, 2003). For some refugees, the purported presence of a major psychiatric disorder has not significantly impaired their capacity to adjust to living in a foreign land and adjusting to a culture that is significantly different from their own. Similarly, Eisenbruch, de Jong, and van de Put (2004) declared that “bringing order out of the chaos” (p. 128) of refugee studies would require jettisoning an exclusive focus on psychopathology as the source of all of the difficulties that refugees encounter.

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Theoretical Considerations Despite decades of empirical study, there is no comprehensive model of how pre- and/or postmigration experience may affect mental health and social functioning outcomes among refugees. The underdevelopment of theory is partially an artifact of the unique characteristics of refugees, who differ from both conventional immigrants and from individuals who have suffered alternative types of trauma and loss (Hsu, Davis, & Hansen, 2004). An extensive body of literature on migration and the many factors that can facilitate or impede the process exists (Bauer & Zimmermann, 1995; Kritz, 1983; Kritz, Lim, & Zoltnik, 1992; Massey, 1993; Portes & Borocz, 1989). Though migration theory emanated among economists who were primarily concerned about the movement of people from one locality to another, the complexity of the topic has researchers and academicians across disciplines investigating how migration affects individuals, communities, infrastructures, and resources. Bijak, Kupiszewska, Kupiszewski, Saczuk, and Kicinger (2006) noted that understanding the many complexities of migration involves the skills of varied disciplines, from political science to sociology and psychology. Considering that a migrant can be a slave, or job/education seeker, or a refugee, no single theory can provide a comprehensive explanation for the process of migration. Ravenstein (1889), an English geographer, has been credited for one of the earliest works in migration research. Curious about the movements of people, Ravenstein conceptualized migration as the movements people make across space within and between countries. His theory posited that migration is determined by the presence of attracting (pull) factors at a destination and repelling (push) factors at the place of origin

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(Bijak et al., 2006). Contemporary migration theories have bloomed from Ravenstein’s efforts, culminating in variations on his conclusions. The developmental concept of migration that has dominated and perhaps defined international migration through the 1970s, further clarified that migration must be long term and permanent (Skeldon, 1990). As Skeldon elaborated, the developmental concept of migration maintained that every society is located at certain stages of development and will transform from traditional to modern societies or from a lower level of development to a higher level of development. Migrating populations thus move from less-developed societies to more advanced ones. Hence, the perception that the underlying cause of international migration is the underdevelopment of sending societies. Underdevelopment may include a cluster of push and pull factors that push people to leave their countries of origin and pull them to receiving countries. Lee (1966) reformulated Ravenstein’s (1889) theory, giving particular emphasis to push factors and outlined how intervening variables such as human capital or motivation may significantly influence the migration process. Similar to Ravenstein, Lee posited that the decision to migrate is influenced by push and pull factors. Push factors include violence from political unrest, threats to personal safety, poverty and social insecurity, struggle for livelihood, and low levels of education. Pull factors encompass the more personal dreams of self-improvement, a booming economy and security, job opportunities, favorable migration laws, unification with family, pursuit of better socioeconomic possibilities, and education. However, in the face of war-induced violence, all migrants would comfortably fall in the category of being pushed (to refugee camps or to family members). Lee posited that variables such as political barriers and

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having dependent familial relations could impede or even prevent migration. Lee also pointed out that the migration process is selective because factors such as age, gender, and social class affect how persons respond to push/pull migration factors and these conditions shape the refugee’s ability to overcome obstacles. Furthermore, personal factors such as a person’s education, knowledge of a potential receiving country’s culture and systems, and family ties can also facilitate or impede migration. Since this dissertation focused on why some refugees fare better than others, it seemed reasonable to use a theory of migration that explores the effects of motivating migration factors (i.e., push versus pull factors) and how they shape the migration process and affect the intrusive experience and general health of post conflict refugees from Sub-Sahara Africa. Push Factors A variety of push factors motivated Sub-Sahara Africans to migrate elsewhere. These factors were generally survival strategies in the face of threats to life and personal safety. Chief of these are social and political problems. Low levels of education. The political conflicts in Sub-Sahara regions are usually concentrated in provincial towns where the number of uneducated and poorly educated is high when compared to capital cities and their surrounding towns. Access to media, reading material, and technology is often limited. In addition, 60% of the Sub-Sahara Africa doctors trained in the 1980s and about 60,000 highly skilled workers fled Africa contributing to the brain drain of Sub-Sahara Africa (Berry, Kim, Minde, and Moks, 1987; Harris, 2002). These numbers mean that there are less well-educated, trained people to provide apprenticeships and internships and to serve as mentors to the

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upcoming generation. Furthermore, women are often confined to traditional cultural roles compounding exponentially their access to, and support of, educational opportunities. Population explosion. A high fertility rate and an inability to access birth control has been the primary culprit of frequent births. On average, women in Sub-Sahara Africa give birth to six (live) children. This includes many provincial women, especially women living in polygamous unions (Adepoju, 1995; Silove, 2004). The decrease in the mortality rate (life expectancy at birth was 3 years less than in it was 10 years ago) contributes to a high population growth and overcrowding in big cities. Internal conflicts have resulted in people migrating to larger towns, sometimes in search of employment and other forms of livelihood. Struggle for livelihood. In rural areas, farming and fishing is predominately how families earn a living. Access to land, good soil, and favorable weather makes farming and fishing possible. It becomes a struggle when the yields are discouragingly insufficient. Poor crops and the overharvesting of fishing waters motivate mass migrations to urban areas where looming underemployment and high employment rate soars. Once in the city, migrants come to realize that they are poorly prepared for gainful employment and the struggle for livelihood is perpetuated. Frustrated and unable to feed and clothe their families, migrants are easily swayed to join in the chaos of violence. Reports indicate that this was the case in Sub-Sahara Africa (Adepoju, 1995). Poverty. Many African countries are at the very bottom of the 2007 Human Development Index. Sierra Leone is the lowest ranked country on the Human Development Index and seventh lowest on the Human Poverty Index. When asked to

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evaluate their past financial situations, refugees report not having enough money to meet their basic needs. Kritz (1983) discussed how many poor people are dependent upon local moneylenders and shopkeepers for credit in emergencies and during lean times. The cycle of borrowing and repaying lenders from already insufficient income results in a cycle of poverty (Boyd, 1989; Datta, 2006; & El-Hinnawi, 1985). Violation of human rights. The United Nations General Assembly adopted the Universal Declaration of Human Rights in 1948. It asserts and protects the inherent dignity of all members of the human family. All members have equal and inalienable rights to life, liberty, security, health, education, food, clothing, housing, livelihood, and self-determination. The Declaration agrees that nothing shall justify domination of one people over another. Countries in Sub-Sahara Africa are among the most glaring examples of the violation of human rights. Ravaged by wars, the countries’ intellectual and professional classes leave in masses, while those left behind suffer repressive, personal rule, not allowing for the development of any autonomous political or social institutions. Ethnic groups not in power are purged, forced into exile, killed, tortured, imprisoned, or simply disappear. Political unrest. The political history of most African countries has been turbulent since the end of colonialism. For many Sub-Sahara African countries, instability is caused by weak democratic nations, unrestrained and rampant violence, multiple military coups, and rebel or guerrilla war (Koroma, 1996; Tolin & Foa, 2006). In the decade-long civil wars in some Sub-Sahara countries in the 1990s, conflicts became notorious because of particular brutalities including abductions, hacking off

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limbs of uncounted civilians, the use of child soldiers, systematic rape, and high rate of other sexual violence. Pull Factors Pull factors refers to factors which influence refugees to seek residence in a given country or region. Despite the fact they are fleeing violence or persecution, they may have a degree of control over where they go in search of opportunities identified in this section. Booming economy and financial security. Compared to Sub-Sahara Africa, the United States is perceived as the land of opportunities because of her industries, infrastructure, and economic stature, which are attractive features to all refugees. The vast majority of migrants who leave for developing or western countries are motivated by their desire to better their material conditions. The bulk of the research on cross-border migration has focused on wage differentials, opportunities for upward socioeconomic mobility, and other factors that pull migrants away from their countries of origin to circumstances that are more favorable in other countries (Hsu et al., 2004). Employment and job opportunities. Refugees are pulled into other countries for better employment opportunities. People who look across borders for improvement of their situation include both professionals and nonprofessionals. Chirot and Reid (1997) emphasized that refugees tend to be among the more innovative and better-educated members of any population. Armed with a legal temporary status, these refugees are able to gain employment, though at much lower wages. Favorable migration laws. The economic and political state of the countries in Sub-Sahara Africa that were engulfed by atrocious internal wars signaled some people to

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pack up and migrate to the West. The United States, like other western countries, welcomed many refugees with provisions in the immigration laws that favor temporary and permanent residency. The Immigration and Naturalization Services willingly provided temporary legal status to refugees from Sub-Sahara Africa, though most failed to avail themselves of this service for fear of being sent (Immigration and Refugee Services, 2003). Cultural/language similarities. It is common for refugees to plan their migration to a country with some similarities. Consequently, refugees from Anglophone Africa seek reception from English-speaking countries like the United States, England, and Canada; while those from Francophone Africa migrate to countries like France and Las Palmas. In a similar light, refugees who planned their migration acknowledge that they had information about the country of destination, including information about the homo- ethnic climate, unlike migrants who were pushed out often with no knowledge of their destination (Gould & White, 1974). Family support. The presence of a kin is a decisive factor in choosing the country of refuge, because established family members offer the newly arrived refugee a built-in support system. Taylor (1986) and Hsu et al. (2004) identified that people with interconnected family and friendship ties make early decisions to migrate, and Boyd (1989) later affirmed that the same phenomenon is responsible for population flow between borders. Family members can assist in finding employment and introducing a migrant to the new culture.

Full document contains 178 pages
Abstract: This study was designed to explore the relationship of push/pull migration factors, traumatic symptoms, and general health of Sub-Sahara Africans post conflict. Migration theory and the factors described therein are used to explore why some refugees from Sub- Sahara countries may fare better than others in their intrusive experience and general health post migration. To date, only a handful of studies have been dedicated exclusively to Sub-Sahara Africa refugees living in developed nations and no studies used existing migration theory to explain differences in refugee migration outcomes post conflict. Most studies of post migration factors have concentrated on variance in the refugees' personal and social resources including fluency in the host nation's language, employment, and educational status; the availability and use of interpersonal, social, or community supports; difficulties in dealing with government bureaucracies; social isolation; separation from family; and discrimination. This research explores migration factors that push (unattractive attributes of origin country) or pull (attractive attributes of receiving country) Sub-Sahara Africa refugees to migrate and posits that this cluster of factors influences the intrusive experience and general health of refugees post conflict. Further, the rich and diverse geopolitical history of Sub-Sahara Africa and affiliations with and/or support from westernized nations may serve as protective or impeding factors to successful migration outcomes. As 43 million refugees attempt to navigate the host country's culture, successful post migration outcomes of refugee populations require increased knowledge and understanding of their needs by host countries such as the United States. However, before any of this can occur, empirical research that uses existing migration theory needs to accurately identify those factors that facilitate or impede immigrant populations post migration. This study seeks to fill this void. Key Words: Sub-Sahara Africa, migration, refugee, internal displacement, forced displacement, psychological functioning, social functioning, push factors, pull factors, colonization.