qualitative research papers attached and for that paper, identify and comment on the theoretical perspective and key ethical issues apparent in the paper.

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Ethnicity & Health

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Heavy alcohol consumption among marginalised African refugee young people in Melbourne, Australia: motivations for drinking, experiences of alcohol-related problems and strategies for managing drinking

Danielle Horyniak, Peter Higgs, Shelley Cogger, Paul Dietze & Tapuwa Bofu

To cite this article: Danielle Horyniak, Peter Higgs, Shelley Cogger, Paul Dietze & Tapuwa Bofu (2016) Heavy alcohol consumption among marginalised African refugee young people in Melbourne, Australia: motivations for drinking, experiences of alcohol-related problems and strategies for managing drinking, Ethnicity & Health, 21:3, 284-299, DOI: 10.1080/13557858.2015.1061105

To link to this article: http://dx.doi.org/10.1080/13557858.2015.1061105

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Heavy alcohol consumption among marginalised African refugee young people in Melbourne, Australia: motivations for drinking, experiences of alcohol-related problems and strategies for managing drinking Danielle Horyniaka,b, Peter Higgsa,b,c, Shelley Coggera, Paul Dietzea,b and Tapuwa Bofud

aCentre for Population Health, Burnet Institute, 85 Commercial Rd, Melbourne, VIC 3004, Australia; bSchool of Public Health and Preventive Medicine, Monash University, 99 Commercial Rd, Melbourne, VIC 3004, Australia; cNational Drug Research Institute (Melbourne Office), Curtin University, Suite 6, 19–35 Gertrude Street, Fitzroy, VIC 3065, Australia; dCentre for Culture, Ethnicity and Health, 23 Lennox St, Richmond, VIC 3121, Australia

ABSTRACT Objective. Little is known about substance use among resettled refugee populations. This study aimed to describe motivations for drinking, experiences of alcohol-related problems and strategies for managing drinking among marginalised African refugee young people in Melbourne, Australia. Design. Face-to-face interviews were conducted with 16 self- identified African refugees recruited from street-based settings in 2012–2013. Interview transcripts were analysed inductively to identify key themes. Results. Participants gathered in public spaces to consume alcohol on a daily or near-daily basis. Three key motivations for heavy alcohol consumption were identified: drinking to cope with trauma, drinking to cope with boredom and frustration and drinking as a social experience. Participants reported experiencing a range of health and social consequences of their alcohol consumption, including breakdown of family relationships, homelessness, interpersonal violence, contact with the justice system and poor health. Strategies for managing drinking included attending counselling or residential detoxification programmes, self-imposed physical isolation and intentionally committing crime in order to be incarcerated. Conclusion. These findings highlight the urgent need for targeted harm reduction education for African young people who consume alcohol. Given the importance of social relationships within this community, use of peer-based strategies are likely to be particularly effective. Development and implementation of programmes that address the underlying health and psychosocial causes and consequences of heavy alcohol use are also needed.

ARTICLE HISTORY Received 3 February 2015 Accepted 11 May 2015

KEYWORDS Alcohol; culturally and linguistically diverse communities; refugee health; Africa; young people; qualitative research

© 2015 Taylor & Francis

CONTACT Danielle Horyniak [email protected]

ETHNICITY & HEALTH, 2016 VOL. 21, NO. 3, 284–299 http://dx.doi.org/10.1080/13557858.2015.1061105

1. Introduction

Forced migration is a growing issue in the twenty-first century. At the end of 2013, 51 million people worldwide had been forcibly displaced from their homes due to conflict or disaster (including 17 million refugees), with applications for asylum at their highest levels in two decades (United Nations High Commissioner for Refugees 2013, 2014). Each year, 60,000–70,000 refugees are resettled in Western countries, with Australia taking in roughly 14,000 refugees per annum, ranking among the top refugee-receiving countries worldwide (United Nations High Commissioner for Refugees 2012; Australian Government Department of Immigration and Border Protection 2014).

Forced migrants are vulnerable to health risks. In particular, pre-displacement traumatic experiences (including limited access to food, water and safe accommodation, loss or dis- ruption of livelihood, and exposure to violence), resettlement challenges (e.g. lack of social support, family separation, poverty and marginalisation), and acculturation chal- lenges associated with adapting to new physical and cultural environments have all been shown to negatively impact psychosocial health and well-being (Porter and Haslam 2005; Schweitzer et al. 2006; Steel et al. 2009; Kirmayer et al. 2011; Savic et al. 2013).

Alcohol is a cause of significant morbidity and mortality globally, accounting for roughly 5% of the total burden of disease (Begg et al. 2007; Rehm et al. 2009; Lim et al. 2012). In particular, alcohol is the leading cause of disease among adolescents and young adults, particularly those living in high-income settings (Gore et al. 2011). Alcohol use also contributes to a wide range of social, economic and legal harms at the individual, family and community levels (Laslett et al. 2011).

Ourunderstanding oftherelationship betweenforcedmigrationandalcoholuse remains limited. Although several studies have recorded lower rates of alcohol consumption and alcohol use disorders among some migrant and refugee groups compared with their host populations (Donath et al. 2011; Donato-Hunt, Munot, and Copeland 2012; Salas- Wright and Vaughn 2014), contrasting research has found higher rates of alcohol use and related harms among some ethnic and cultural minorities (Keyes, Liu, and Cerda 2012; Unger 2012). Migrant and refugee populations may be vulnerable to alcohol use for a number of reasons. First, traumatic or stressful pre- and post-migration experiences may lead to substance use as a coping or escape mechanism (Durrant and Thakker 2003). This is a particular concern among refugee populations, among whom high rates of mental disorders including depression and post-traumatic stress disorder have been documented (Fazel, Wheeler, and Danesh 2005; Steel et al. 2009). Second, migrant and refugee communities commonly experience unemployment and poverty and, as a result, may reside in disadvantaged areas where cheap alcohol is often readily available (Carter and Osborne 2009; Livingston 2012). Finally, acculturation to mainstream norms and a desire to gain acceptance in their new communities may play a role in increasing substance use (Reid et al. 2001; De La Rosa 2002; Durrant and Thakker 2003; Fosados et al. 2007). Importantly, the negative consequences of substance use may be exacerbated among migrant and refugee communities due to lack of knowledge about substance use and limited access to and uptake of health services (Neale et al. 2007; Morris et al. 2009; Browne and Renzaho 2010; Lee, Sulaiman-Hill, and Thompson 2013).

Despite the identified vulnerabilities among forced migrants, little research has examined alcohol use and related harms among permanently resettled refugee populations.

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A systematic review conducted in 2010 examining the influence of forced displacement on harmful alcohol use identified only 10 studies, 8 of which focused on refugees resettled in high- and middle-income countries (Weaver and Roberts 2010). Although these studies identified a number of risk factors for harmful alcohol use including male sex, younger age and experiences of trauma, these largely comprised quantitative studies, providing a rela- tively limited understanding of the ways in which these factors and other experiences associ- ated with forced migration may influence harmful alcohol use. There is a need for more in-depth, qualitative work examining harmful alcohol use among forced migrants, in order to improve the evidence base for informing public health interventions for these populations.

In Australia, communities from Sub-Saharan Africa have grown rapidly over the past two decades, with refugees from East Africa and North Africa (predominantly Sudan) comprising the majority of these communities (Hugo 2009). Studies involving African communities in Australia have documented experiences of unemployment, social disad- vantage, marginalisation and discrimination (Colic-Peisker and Tilbury 2007; Polonsky, Brijnath, and Renzaho 2011; Wille 2011). For African refugee young people, further chal- lenges have been documented in relation to language acquisition and difficulties adapting to the Australian education system and gaining meaningful employment (Brown, Miller, and Mitchell 2006; Poppitt and Frey 2007; Nunn et al. 2014). In addition, African young people, particularly those of Sudanese ethnicity, have been further marginalised by charac- terisation in public discourse as violent, criminal and a ‘problem group’ (Windle 2008; Australian Human Rights Commission 2010; Nunn 2010).

In recent years, high levels of alcohol consumption among disengaged and marginalised African refugee young people have been identified by community organisations as an emerging concern (Ahmed 2006; Ethnic Communities Council of Victoria 2007; Khawar and Rowe 2013). The issue has also received attention in the media (e.g. Oakes 2012; Petrie 2012). In the Western region of Melbourne, a major African community hub, studies of public drinking have identified African young people as a key group of concern, with researchers observing groups of young people gathering in public spaces (including spaces in which alcohol consumption is prohibited) and consuming large amounts of alcohol in a session (Dwyer et al. 2007; Papanastasiou, Higgs, and Dietze 2012; Manton, Pennay, and Savic 2014). Youth substance use support agencies operating in this region have also recorded an increase in numbers of clients from African back- grounds (Youth Support and Advocacy Service 2012). A brief snapshot of these clients found that they experience poor physical and mental health and high levels of disengage- ment from education and employment (Youth Support and Advocacy Service 2013). Beyond this, no research has examined alcohol use among African refugee young people in Australia in detail. Our study aims to address gaps in knowledge about patterns of alcohol consumption, motivations for drinking, and consequences of drinking among this group, and provide evidence to inform the development of interventions to reduce alcohol use and related problems among resettled refugee youth more broadly.

2. Methods

2.1. Study design and participant recruitment

In 2012–2013, we conducted a qualitative study examining alcohol and illicit drug use among marginalised African migrants and refugees from Melbourne’s western suburbs

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(Horyniak et al. 2014). Eligibility criteria for inclusion in the study were: being born in any part of East Africa or Sudan; aged 16 years or older; living, working or studying in the City of Maribyrnong or City of Brimbank (two local government areas in Melbourne’s inner west, population ∼275,000); and having ever used any illicit drugs.

Recruitment largely involved field-based opportunistic sampling in Footscray, the major transport and business hub for the region, and advertisement through local health and welfare service providers with young African clientele. Authors DH, PH and SC (the primary research team for the study) spent several months in the field, conversing and enga- ging with young people of interest in the spaces which they frequented. Key young people with whom we developed strong relationships acted as ‘brokers,’ introducing us to other members of their social group. Young people who expressed an interest in the study and were available to complete the study interview on the day or who were willing to schedule an interview were invited to participate. The aim was to recruit a diverse sample in relation to country of birth, age, migration experiences and experiences of substance use, rather than a representative sample. Further information regarding participant engagement and recruitment methods has been previously published (Horyniak et al. 2014).

2.2. Data collection

Data were collected through face-to-face interviews (conducted by DH), which were facili- tated by a semi-structured interview guide developed in consultation with community welfare workers of African background. Key areas of discussion included migration to Australia, social integration in Australia, patterns, contexts of and motivations for alcohol consumption, and health and social consequences of alcohol consumption. Ques- tions such as ‘Can you tell me a bit about when, where and why you drink alcohol?’ encouraged participants to describe personal experiences of alcohol use, and it is from these narratives that ‘motivations’ for alcohol consumption are drawn. Interviews took place in a mobile study van or office space located adjacent to the field site, and lasted between 15 and 80 minutes. All participants provided written informed consent. Partici- pants were reimbursed AUD$30 at the completion of the interview. Ethical approval for the study was obtained from the Monash University Human Research Ethics Committee.

2.3. Data analysis

All interviews were audio-recorded and transcribed verbatim. Pseudonyms were assigned to all participants, and any potentially identifying information divulged during interviews was deleted from the transcripts. Interview transcripts and field notes were managed using Nvivo Version 10 (QSR International, Doncaster, Australia).

Interviews with 16 participants, aged below 30 years who self-identified as refugees when describing their migration experiences, were analysed. Analysis employed a thematic approach using inductive coding, with the aim of understanding emic interpretations of individual participant’s experiences. All coding was conducted by DH. DH, PH and SC communicated frequently during the participant engagement, data collection and data analysis processes, reflecting on the content of participant interviews and the coding of key themes. This process allowed for discussion of different interpretations of the data from diverse perspectives (one younger female epidemiologist who has travelled

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extensively in Africa, one male qualitative researcher with a background in social work and harm reduction with Vietnamese communities, and one female social scientist with exten- sive experience in conducting field-based research with people who use illicit drugs), limit- ing the potential impacts of assumptions and prejudices that any individual researcher may have had during any phase of the study. A return visit to the field site was also con- ducted in September 2013, during which preliminary findings were discussed with a small number of participants to ensure that our interpretations accurately reflected participants’ understandings of their own behaviour.

3. Results

3.1. Participants

The participants were 16 men aged 18–30 years (median: 24 years). Twelve participants were born in Sudan (including nine from areas which are now part of the Republic of South Sudan), two in Eritrea, and one each in Kenya and Somalia. Most participants had spent significant amounts of time in refugee camp settings in Africa or in neighbour- ing countries such as Egypt prior to migration to Australia. Participants had resided in Australia for between 6 and 14 years at the time of the interview (median: 10.5 years). Post-migration experiences commonly included family separation (many had arrived in Australia with a member of their extended family while immediate family remained in Africa) and disengagement from education and employment.

3.2. Patterns of alcohol use

Young people visited Footscray on most days so that they could meet and socialise with friends from different areas of Melbourne. Almost all participants reported consuming alcohol on a daily or near-daily basis. They routinely arrived in Footscray between early and mid-morning, and remained until early evening, consuming alcohol (most commonly cheap cask wine, spirits and high alcohol content pre-mixed drinks) throughout the day. Multiple purchases of alcohol were made on any given day, with participants often pooling money with others to do so.

Participants spoke of the importance of ‘controlling’ their drinking, rather than being controlled by drinking, or ‘letting alcohol drink them’ as it was described. This was initially enacted through self-imposed rules, such as drinking only on weekends or when they did not have to work or attend appointments the following day, drinking only until a pre- specified time, and drinking only with friends who were known and trusted. Despite this, as the excerpt below demonstrates, although many participants began this way, such control could be difficult to maintain, for many, evolving into daily use:

Girma: ‘I started drinking honestly at home … I didn’t, like, drink every day, cos I was still going to high school and all that stuff, and whenever I did drink it’d be like weekends, Satur- day, Friday night, cos you go to the city, to a nightclub … We got used to that, like every weekend, then somehow it goes to weekdays, it’s like … ’

Interviewer: ‘Yep. You don’t even realise that you’re … ’

Girma: ‘You’re gone far … ’

(Girma, age 26, Eritrean)

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Participants linked this notion of control with alcohol dependence or ‘addiction.’ For example, despite reporting often drinking 10–20 cans of pre-mixed spirit drinks in a day (1.4 standard drinks each), Jok stated that he could ‘control alcohol’ and ‘quit any time I want,’ and that he was ‘not like other people who get addicted to alcohol.’ Similarly, Joseph reported that he did not consider himself an addict because even though mentally he felt dependent on alcohol, physically, his body could ‘handle it.’ The term ‘addiction,’ and its implication of loss of control and association with the use (and in particular injec- tion) of illicit drugs, was stigmatised; despite being one of few participants who referred to himself as an ‘addict,’ James reported having become violent towards other people who referred to him in this way.

Despite the discourse emphasising control, it was common for participants to report drinking with the intention of becoming extremely intoxicated. Commonly referred to as drinking ‘to the limit,’ these occasions involved drinking until losing consciousness or until other adverse consequences, such as being arrested, were experienced. Not being allowed to drink ‘over the limit’ was identified as one reason for drinking in public spaces, rather than in licensed venues.

3.3. Motivations for alcohol use

Three unique but interconnected themes emerged when participants spoke about their motivations for engaging in these heavy patterns of alcohol consumption and intoxication: drinking to cope with trauma, drinking to cope with boredom and frustration, and drink- ing as a social experience.

3.3.1. Drinking to cope with trauma Study participants commonly described traumatic and stressful experiences in their birth countries such as witnessing the deaths of family members, experiencing violence, and navigating the myriad challenges of growing up in refugee camps. Many participants reported ongoing challenges since arriving in Australia, particularly in relation to a lack of family support and, in some cases, estrangement from family. For example, John arrived in Australia at age 11 with his brother and sister-in-law. He soon began to believe that he was the cause of arguments between the couple and eventually chose to move out of their home, living in youth accommodation and experiencing periods of homelessness. Abuk was in a similar situation, forced to leave his aunt’s home not long after arriving in Australia because he refused to leave school to get a job to help support the family.

As a result of these traumatic and stressful experiences, participants reported ongoing feelings of hopelessness and anger, loss of motivation and difficulty sleeping. For many, alcohol was used as a means of escaping from these ‘problems in my head,’ as it helped to ‘forget’ and ‘let everything pass.’ As Gabriel explained, ‘You’re full of information, you don’t know how to get rid of it, and you just want to feel stress free. So you drink.’

3.3.2. Drinking to cope with boredom, frustration and marginalisation As mentioned earlier, participants were generally disengaged from both education and employment. With little disposable income, participants had few affordable activities in

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which to engage, and for many, drinking served as a ‘distraction’ and a way of ‘killing time.’

Beyond simply drinking to combat boredom, however, participants also spoke of drink- ing to cope with the frustrations of their everyday lives, particularly continued experiences of marginalisation, discrimination and rejection:

Being white – everything is easy … . It’s just our colour – people judge us with that too much, you know? And it pisses us off, mate. You know, some people even give up … If someone trying [sic] to get a job, trying to get a job, and they keep refusing you, and they look inside himself, ‘I’m fucking black man, no one will accept me.’ Where is he gonna go? He’s gonna come, sit down and drink. ‘Cause fuck man, I tried. No one can see I tried, but I know myself I tried. (Gabriel, age 19, South Sudanese)

In this sense, drinking reflected a sense of resignation; as James reflected: ‘Life on the street – that’s the life I choose for me. I’ve been doing this for a long time and that’s what I’m good at … We’ve never had a good life before, never ever.’

3.3.3. Drinking as a social experience Alcohol was also seen as a part of social interaction and friendship. Many participants had known each other prior to arrival in Australia, and commonly referred to each other as ‘my people’ or ‘my brothers.’ Sharing alcohol was not only a way to ‘have fun’ and ‘kick back’ together, but also helped to create a relaxed environment, in which participants could reminisce about Africa, and find support in their shared experiences.

Direct peer pressure was rarely identified as a driver of alcohol consumption; rather, pressure to participate in drinking was more commonly internally driven and related to social expectations. For example, Girma reported that he often drank because he felt uncomfortable watching others drinking and having fun and not participating. On the day he was interviewed, Jok reported that it was the first time he had drunk alcohol in Footscray. He had only arrived in Melbourne recently and had come into Footscray with one other person he knew, and joined in with the larger group’s drinking as a way to help build new friendships. Cultural norms and expectations also played a role in this, with some participants reporting that declining to share alcohol if it was offered to you was considered disrespectful.

As described in more detail in the following section, although alcohol functioned as a social lubricant, both re-enforcing existing bonds between young people, and helping to build new friendships, alcohol also played a role in causing problems between friends.

3.4. Experiences of alcohol-related problems

When asked about the ways in which alcohol had affected their lives, participants ident- ified a range of health and social consequences of their alcohol use. Physical health con- sequences included dehydration, lack of appetite, poor nutrition and general malaise. Several participants reported that they had previously been active in soccer and basketball teams, but no longer had the motivation or fitness to play sports. Reports of episodes of losing consciousness were common, and as mentioned earlier, were associated with drink- ing ‘to the limit.’ On several occasions, our research team phoned emergency services to attend to participants who displayed signs of acute intoxication. During the time our team

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conducted the fieldwork for this study, two deaths in which alcohol was a contributing cause occurred among young African people who frequented the study site.

Injuries sustained under the influence of alcohol were a common occurrence, and resulted from falls, car accidents, and incidents of violence. Some participants reported that incidents of violence occurred more commonly within the group, rather than with outsiders, and were generally a result of a minor disagreement which escalated as a result of the effects of alcohol:

You know like when you’re drunk, you’re talking about something that happened last week, or last year or something … they misunderstand each other coz they’re blabbing, they’re not really saying the words right out. And then one of the other guys, he takes it wrong, coz he’s drunk too and he’s not listening properly. It starts with things happening like that and then it just goes off. And once it goes off, the other guy jumps in for the other guy, the other guy jumps in for the other guy, and it gets carried away. (Girma, age 26, Eritrean)

Others, however, reported that random, unprovoked, incidents of violence also occurred while under the influence of alcohol. For example, Daniel reported that heavy drinking could make young people easily provoked:

If you’re over the level you’d be fighting for sure. But not one of your friends … I mean, if you go in a train, someone just, I don’t know, say something wrong to you, you might just straight away hit them.

Participants were sensitive about the ways in which African young people were rep- resented in the media, feeling that they were unfairly singled out and that alcohol- related violence was no greater an issue among Africans than other groups of young people.

Participants also identified a number of social consequences of alcohol consumption. The primary concern for most participants was the impact their drinking had on their interpersonal relationships. Gabriel reported that his girlfriend often threatened to leave him because of his continued drinking; he recalled one incident where he chose to pour out a full bottle of whisky to prove to her that he valued his relationship with her more than alcohol. James reported that his four-year-old daughter was currently in her grand- mother’s custody, and although he was scheduled to visit her once a week, he often did not attend because he had been drinking. In turn, this caused him to drink more, to cope with his sadness and frustration at being denied access to his daughter.

Drinking was a major source of inter-generational conflict. Participants reported that alcohol use was highly stigmatised in African communities and that their consumption of alcohol contributed to their marginalisation. Reflecting the collectivist nature of African cultures, young people who consume alcohol risk becoming ostracised not only from their family, but also from the broader community:

They see you start drinking – your own mum can kick you out! … Our community, they’re not good. They’ll go and talk to the parents and say ‘Look at your kid!’ [They’re doing it] to protect themselves, to make their name good. (Abuk, age 24, South Sudanese)

If they see you drinking – no one says to you ‘hello’. (Hassan, age 29, Somali)

Drinking also had a significant …