Examining the role of parental factors on depression amongUr

Examining the role of parental factors on depression among
Urban African American youth living in public housing
Anthony T. Estreet a,b, Dawn Thurmana, Sapphire Goodmana,b,
M. Taqi Tirmazia,b,
Takisha J. Cartera, and Von Nebbittc
aSchool of Social Work, Morgan State University, Baltimore,
Maryland, USA; bHealth & Addiction Research
Training Lab, Morgan State University, Baltimore, Maryland,
USA; cGeorge Warren Brown School of Social
Work, Washington University in St. Louis, St. Louis, Missouri,
USA
ABSTRACT
This study examined the potential risk and protective parental
factors
associated with depression among African American youth
living in
public housing. Utilizing a community-based participatory
research
approach, 239 African-American youth surveys were collected
during
2013–2014 in two urban public housing developments with low
socioeconomic profiles. Over half (52.3%) of the sample was in
high
school and female (58%). 65.3% reported living with their
mother
while 38% reported being employed. Bivariate analysis revealed
sig-
nificant correlations between depression and maternal substance
abuse, paternal monitoring, parent-child relationship, and
family

time. Results from the regression analyses indicated that higher
depression scores were significantly associated with youth who
reported poor parent-child relationships, low levels of paternal
super-
vision and high levels of maternal drug abuse. These findings
provide
support for claims about the importance of parent-child
relationship
and paternal monitoring as a protective factor for depressive
symp-
toms, particularly during adolescence. Moreover, findings
suggest
that interventions which are targeted towards urban African
American youth should address parental factors as a pathway to
decrease depression among this population.
KEYWORDS
Depression; risk factors;
protective factors; African
American; youth
Introduction
Depression among African Americans youth is a major public
health concern that has
been linked to substance use, heightened sex-risk and suicidal
behaviors (i.e., ideation and
attempts) (Breland-Noble, Burriss, & Poole, 2010; Okwumabua,
Okwumabua, & Wong,
2014). Although there has been a slight increase in focus on
depression among African
American youth over the last decade, this group remains
understudied in mental health
research (Matlin, Molock, & Tebes, 2011). Evidence suggests
that parents and family play
a critical role in the lives of their adolescent and emerging adult

children (Lindsey, Joe, &
Nebbitt, 2010). It is reasonable to postulate, therefore, that
parental factors are related to
the emotional well-being of urban African American youth.
Using a sample of 239 African
American youth living in urban public housing, this paper
contributes to the gap in
CONTACT Anthony T. Estreet [email protected] School of
Social Work, Morgan State University, 1700
East Cold Spring Lane, Baltimore, MD 21251, USA.
JOURNAL OF HUMAN BEHAVIOR IN THE SOCIAL
ENVIRONMENT
2018, VOL. 28, NO. 4, 494–508
https://doi.org/10.1080/10911359.2018.1430647
© 2018 Taylor & Francis
http://orcid.org/0000-0002-2413-6311
https://crossmark.crossref.org/dialog/?doi=10.1080/10911359.2
018.1430647&domain=pdf&date_stamp=2018-06-21
knowledge by assessing how, or whether, parental factors are
related to depressive
symptoms in this vulnerable population.
Epidemiology of depression
African American youth
According to the recent findings, approximately 2.5 million
U.S. youth ages 12–17 had a
major depressive episode (MDE) in the previous year. Of those
with MDE, approximately

nine percent represented African American youth who were
diagnosed during the same
period (SAMHSA, 2015). Additionally, an estimated 5.8 million
young adults (18–25)
were diagnosed with major depressive episodes during that same
period (SAMHSA, 2015).
According to the National survey for drug use and health, rates
of major depressive
episodes have significantly increased among youth since 2005
(SAMHSA, 2016).
Research has indicated that African American youth who reside
in high-risk environments
(increased levels of violence, substance abuse, and poverty)
such as public housing settings
have shown increased rates of depression (Nebbitt & Lombe,
2007; Nebbitt, Williams,
Lombe, McCoy, Stephens, 2014). Comparatively, past research
on African American youth
and depression has resulted in mixed findings. For example, a
recent study found lower
rates of depression among African American young people when
compared to their white
counterparts (Breland et al., 2014). Conversely, a few studies
have indicated that African
Americans experience depression at greater rates than other
ethnic groups (Lopez et al.,
2017; Yip, 2015). While others found no racial difference in
depression between African
American and White youth (Schraedly, Gotlib, & Hayward,
1999).
Research is inconclusive on age and gender differences among
youth with depression.
Previous research suggests that girls are twice as likely as boys
to develop depression and
symptoms of depression increase with age (Maughan,

Collishaw, & Stringaris, 2013).
Other studies found no associations between depression and age
(Bryant, 2008; Shaffer,
Forehand, Kotchick, 2002) or depression and gender among a
sample of urban African
American youth (Nebbitt & Lombe, 2007).
Youth in urban environments
Research has also identified a myriad of social determinants of
American youth (Respress, Morris, Gary, Lewin, & Francis,
2013). In addition to its impact on
education, self-esteem, and anxiety, depression has been linked
to substance use, sexually risky
and suicidal behaviors (i.e., ideation and attempts) (Busby,
Lambert, Ialongo, 2013; Jackson,
Seth, Diclemente, Lin, 2015; Ofonedu, Percy, Harris-Britt,
Belcher, 2012; Okwumabua,
Okwumabua, Wong, 2014). Despite an increase in attention to
American youth over the last decade, this group remains
underrepresented in mental health
research, which addresses depression and other mood disorders
(Breland-Noble, Al-Mateen,
Singh, 2016). Several researchers who have explored depressi on
among African American youth
sought to examine parental and familial risk and protective
factors (Agerup, Lydersen,
Wallander, & Sund, 2014; Boyd & Waanders, 2013; Campbell -
Grossman et al., 2016; Carter,
Dellucci, Turek, & Mir, 2015; Chen, 2013; Cooper, Brown,
Metzger, Clinton, & Guthrie, 2013;
Hurd, Stoddard, & Zimmerman, 2013). Additional studies have
found a decrease in depression

ENVIRONMENT 495
among African American youth who have an optimistic outlook
during stressful situations as
well as those who perceive to have a support system (Chen,
2013). Financial stressors were also
positively associated with depressive symptoms (Taylor,
Budescu, Gebre, & Hodzic, 2014).
African American youth are more likely to live in urban
communities marked by
residential segregation and concentrated poverty (U.S. Census
Bureau, 2010). The chal-
lenges of living in urban communities may be exacerbated for
young people living in and
around public housing (Nebbitt, 2015). Urban public housing
developments are often
epicenters of crime, violence, and alternative drug markets
(Nebbitt, 2015). Furthermore,
budget cuts and closure of key social services has led to a
weaker form of social safety net
and greater hardships among urban communities like public
housing. Despite living in
challenging environments and under foreboding circumstances,
many youth in these
communities can graduate high school, go to college and gain
employment, and become
healthy productive adults (Nebbitt, 2009). Indeed, it must be
extremely difficult to
navigate these harsh environments while simultaneously
managing challenges that come
with the developmental phase of adolescence.

Theorists (Nebbitt, Sanders-Phillips, & Rawlings, 2015) have
suggested that minority
families adapt to life in harsh environments by forming stronger
familial ties and networks
to protect children and youth. Parents and family may serve as
primary support systems in
harsh environments and especially during youth. The important
roles that parents play in
the lives of minority youth have been well documented. Parental
factors such as parent-
child relationship, parental encouragement, and parental
supervision have been found to
be protective factors against depressive symptoms (Henricson &
Roker, 2000; Lindsey, Joe,
& Nebbit, 2010; Nebbitt, Lombe, & Lindsey, 2007; Tandon &
Solomon, 2010).
Parental factors and depression
Several risk and protective factors have been identified in the
literature as follows: alcohol
use, cannabis use, dieting, coping strategies, other illicit drug
use, sleep, tobacco use and
weight (Cairns, Yap, Pilkington, & Jorm, 2014). Emerging
research on risk and protective
factors associated with depression include dating during
adolescence, media use, physical
activity, relationships with positive peers, self-disclosure to
parents and sports (Cairns
et al., 2014). Similarly, Lindsey and colleagues suggest that
parents and family play a
critical role in the lives of their youth and emerging adult
children (Lindsey et al., 2010). It
is reasonable to postulate, therefore, that parental factors are
related to the emotional well-
being of urban African American youth.

Sagrestano and colleagues (2003) explain that most studies
assessing depression among
African American youth tend to examine the association
between depression and exter-
nalizing problem behaviors. However, researchers have found a
positive relationship
between parental factors and depression. For example, several
studies have found an
inverse relationship between family cohesion and warmth and
depressive symptoms
(Bond, Toumbourou, Thomas, Catalano, & Patton, 2005;
Sagrestano et al., 2003). In
addition, researchers (Lindsey et al., 2010; Matlin, Molock, &
Tebes, 2011) have examined
the role of parental support and depression. For example,
Zimmerman and colleagues
(2000) found parental support serves as a protective factor on
depressive symptomology.
Similarly, Holt and Espelage (2005) reported that maternal
social support can moderate
the relationship between victimization and depressive symptoms
among African American
496 A. T. ESTREET ET AL.
males. Literature on the moderating effect of parental support
on gender is inconsistent.
Meadows (2007) and colleagues (Bean, Barber, & Crane 2006)
report a stronger associa-
tion between parental support and depression among girls rather
than boys. In other
studies, gender failed to moderate the effect of parental support
on depression (Chester,

Jones, Zalot, & Sterrett, 2007; Gutman & Eccles, 2007).
Tandon and Solomon (2009) found that living with an adult with
substance abuse
problems, greater exposure to violence, and delinquent peers
were related to higher
depressive symptoms among African American youth. However,
research on maternal
and paternal history of substance abuse, parent-child
relationships and depression is
limited. This study aims to examine the association between
parental factors and depres-
sion among a sample of African American living in and near the
public housing
development.
Purpose and hypothesis of present study
Given the current knowledge of risk and protective factors
associated with depressive
symptoms, this study examined paternal drug use, maternal drug
use, maternal encour-
agement, maternal supervision, paternal encouragement, and
paternal supervision as
potential parental factors associated with depressive symptoms
among African American
youth. Moreover, family time and parent-child relationship were
examined as family
factors. The aim of this study was to examine parent and family
risk and protective
variables for their potential association with youth depression.
The hypotheses for this
study were: (a) higher reporting of paternal and maternal drug
use will be related to higher
levels of depressive symptoms; (b) higher reporting of family
time, maternal supervision

and parent-child relationship will be related to lower levels of
depressive symptoms, and c)
higher reporting of maternal and paternal encouragement will be
related to lower levels of
depressive symptoms.
Methods
The current study is part of a larger cross-sectional study which
utilized a Community-
Based Participatory Research approach in examining the
sociocultural correlates of psy-
chological functioning and behavioral health of African
American youth living in public
housing and neighboring communities in North West Baltimore.
Community representa-
tives including parents and youth were primary participants
selecting variables under
investigation.
Participants
Participants were 239 youth selected from 2 urban public
housing developments and
neighboring catchment areas in Baltimore with approximately
70% of children living
below the poverty line (Baltimore Neighborhood Indicators
Alliance, 2014). They were
in high school (52.3%), graduated high school (29.3%), and
enrolled in college (14.3%).
The majority of participants were female (58%) with ages
ranging from 13 to 24. The
sample was drawn from predominantly African American
communities where 96.4% of
the students enrolled in public schools were African American
students and 89.5% of

ENVIRONMENT 497
people in the community were African-Americans (Baltimore
Neighborhood Indicators
Alliance, 2014). The median family income was $14,105 and
67.2% of families had an
annual income less than $25,000 (Baltimore Neighborhood
Indicators Alliance, 2014).
Instruments
Parent/child relationship was assessed using two subscales from
the National Youth Survey
(NYS), (Elliot, 1987). The first subscale is composed of 4-item
from the Quality of Parental
Relationship Scale. The 4-item subscale assesses a youth’s
perception of the quality of their
relationship with her parents. Participants were asked, for
example: “How satisfied are you
with your relationship with your parents?” Responses range
from “very dissatisfied = 1” to
“very satisfied = 5.” Another item asked, for example, “How
much warmth and affection
do you receive from your parents?” Responses range from “very
little = 1” to “a great deal
= 5.” The subscale demonstrated acceptable internal consistency
with the current sample
(α = .79). The second subscale included 4-items that assessed
the quality of time spent
with parents. Participants were asked, for example, “My parents
or the adult who has
taken care of me or takes care of me spends time just talking

with me.” Responses range
from “almost never = 1 to few times a day = 4”. The subscale
demonstrated acceptable
internal consistency with the current sample (α = .71). Each
subscale is summed so that
higher scores represent a higher quality parent-child
relationship.
Caregiver’s status was assessed using two items. The first item
states, In my household
the person I consider to be my MOTHER is: A biological
mother (e.g., your natural
mother who had you) = 1, my stepmother = 2, a relative (e.g.,
uncle, grandmother) = 4, an
adult who is not related to me (e.g., foster parent, or none of the
people I live with) = 4, I
live alone = 4. The second item states, In my household the
person I consider to be my
FATHER is: My biological father (e.g., your natural father) = 1,
my stepfather = 2, a
relative (e.g., uncle, grandfather) = 3, an adult who is not
related to me (e.g., foster parent)
= 4, I live alone = 5.
Parental Alcohol and Drug Use was assessed using four items.
The first two items ask,
“How often does your father use the drugs?” The second item
asked, “How often does
your mother use drugs?” Responses range from “none of the
time” to “once a month” to
“once a week” to “a few times a month” to “few times a week”
to “every day”. The choices
of drugs were marijuana, crack/cocaine, PCP, heroin,
prescription medication (i.e.
Oxycontin, Vicodin, Valium, Percocet). The next two items ask
“How often does your

father drink alcohol?” and “How often does your mother drink
alcohol?” Responses
ranged from “none of the time” to “once a month” to “once a
week” to “a few times a
month” to “few times a week” to “every day”.
Parental supervision and support
To assess parental supervision and support, youth completed the
Parental Attitude
Measure (PAM) (Lamborn, Mounts, Steinberg, & Dornbusch,
1991). PAM is a 12-item
scale that measures two latent constructs: parental supervision
(5-items) and parental
encouragement (7-items). In the current study, we modified the
12-item scale to assess
paternal supervision/encouragement and maternal
supervision/encouragement separately.
Following are examples of an item on the original parental
supervision subscale: “How
much does your parent or the adult who takes care of you really
know who your friends
are?” We modified this item to read: “How much does your
mother or the adult female
who takes care of you really know who your friends are?” and
“How much does your
father or the adult male who takes care of you really know who
your friends are?” Items
are scored on a four-point Likert scale ranging from “doesn’t
know = 1” to “know exactly
= 4.” The five-item subscales demonstrated acceptable paternal
and maternal reliability

with the current sample.
Parental encouragement
An example of an item on the original parental encouragement
subscale reads: “Does your
father/mother, stepfather/stepmother or the adult man/woman
who takes care of you push
you to do your best in whatever you do?” We modified this item
to read: “Does your mother,
stepmother or the adult woman who takes care of you push you
to do your best in whatever
you do?” and “Does your father, stepfather or the adult man
who takes care of you push you
to do your best in whatever you do?” Items are scored on a four -
point Likert scale ranging
from “never = 1” to “always = 4.” The 7-item subscales
demonstrated acceptable maternal
and paternal reliability, respectively, with the current sample.
PAM is scored by summing the
items with higher values indicating higher levels of supervision
and encouragement.
Depressive symptoms were assessed using the Center for
Epidemiologic Studies
Depression Scale (CES-D). CES-D has extensive use in
assessing depression and psychia-
tric epidemiology. The CES-D is a 20-item scale that assesses
mood, somatic complaints,
social interactions with others, and motor functioning.
Responses are rated on a 4-point
Likert scale ranging from “rarely or none of the time (less than
one day)” = 0 to “most or
all of the time (5–7 days)” = 3. The final score spans from 0 to
60, with a higher score
indicating greater impairment. Respondents with a score of 16
or higher are at greater risk

for clinical depression. Researchers have used various cut-off
scores ranging from 12 to 24
for youth (Stockings et al., 2015). Among community samples,
internal consistency
estimates range from .80 to .90 (Nebbitt & Lombe, 2007;
Stockings et al., 2015). The
CES-D demonstrated acceptable reliability with the current
youth sample (α = .82).
Procedure
Approval for this study was obtained from Morgan State
University Institutional Review
Board. Participants under 18 years of age were given an
informed consent form that
needed to be signed by parents as well as an assent form before
participating in the study.
Participants 18 years of age and older were allowed to sign the
consent form on the day of
the data collection.
The study utilized a self-administered survey technique both
individually and in small
groups of 5. The survey took between 30 – 45 minutes to
complete. Participants were
given a target gift card for participating in the study. Consent
forms and assent forms were
collected before data collection.
Youth were recruited in the public housing developments,
outside recreation centers
and social services agencies in the community. Recruitment
consisted of flyers and
announcements at local community centers. Members of the
research team, agency
liaisons, and community liaisons posted flyers in the housing

developments, in commu-
nity centers and in agencies around the housing developments.
In addition, recruitment
cards were distributed to youth living in the communities. The
flyers and recruitment
ENVIRONMENT 499
cards included a brief overview of the study, the date and
location for data collection, and
contact information for the PI and RA. In addition, respondent-
driven sampling techni-
que was utilized to recruit participants for the study.
Community engagement involved a consistent, malleable, and
sensitive plan. The
consistency of the plan involved a methodological process that
required community ties
and that reliably culminated with the successful collection of
data. The malleability of the
plan involved a willingness to make slight modifications to
accommodate the unique
characteristics of the public housing development and
catchment areas. The sensitivity of
the plan involved an awareness that public housing communities
are not monolithic; that
is, an understanding that each housing site is a unique context
in its own right; and within
each context, cultural norms may differ.
Using a Community Based Participatory Research (CBPR)
approach allowed a greater
buy-in from the community as members of the community took

part in all phases of the
study. Community engagement, honesty, and transparency are
salient to a successful com-
munity-based participatory research project. The researcher
fostered genuine rapport with
residents and asked for their involvement in all phases of the
research project. Residents are
considered primary stakeholders because their involvement is a
necessary and sufficient
condition to the success of CBPR within public housing
developments and neighboring
catchment areas. It is our position that without their support and
buy-in, research in public
housing and neighboring catchments areas would be extremely
challenging.
Analytic strategy
In preparation for regression analysis, several inferential
statistics were used to examine the
bivariate relationships between parent and family factors and
youth depression and to assess
gender and age differences. These analyses were conducted in
order to eliminate variables in
the regression analyses that did not have significant correlations
with youth depression.
Univariate statistics, Pearson’s correlations, independent t-tests,
and one-way ANOVAs
were conducted as part of our preliminary analysis. Our primary
analysis included an
ordinary least squared regression. Prior to conducting the
analysis, data were evaluated for
missing observations and normality. Missing cases and skewed
variables were within the
acceptable range. Descriptive statistics and graphs (e.g.,

measures of skewness and kurtosis,
histograms, Q-Q plots, and scatterplots) were also generated
and confirmed that regression
assumptions (normality, linearity, and homoscedasticity) were
met. In addition, variance
inflation factors (VIF) and tolerance values were also generated
and showed no multicolli-
nearity among the variables. Stepwise linear regression was the
primary analytic procedure.
Results
Sample characteristics
Participants in the study ranged in age from 13 to 24 years of
age with a mean age of 18.2
years. Females composed 58% sample. Over half (52.3%) of the
participants were in high
school, 29.3% had graduated high school and 14.3% were
enrolled in college. Almost
three-fourths (74.1%), of the sample lived with their parents,
21.3% living alone, and the
remaining 5% were living with relatives and/or friends. Sixty-
five percent of the sample
reported their mother lived in the household and 37.2% reported
their father lived in the
household. Lastly, 38.1% of the participants were employed at
the time of data collection.
Sample characteristics are presented in Table 1.
Pearson correlations were conducted to determine the

associations between parent/
family factors and depression. The results of the Pearson
correlation test are presented in
Table 2. The results show a statistically significant positive
correlation between depression
and maternal drug use (r = .16, p < .01). Additionally, there was
a statistically significant
negative correlation between family time (r = -.12, p < .01),
parent-child relationship (r =
-.27, p < .01), paternal supervision (r = -.16, p < .05) and youth
depression. Findings from
the t-test reveal no differences in regard to gender and ANOVA
revealed no difference in
depressive symptoms among early youth (13 – 15), middle
youth (16 – 19), and later
youth (20 – 24).
Parental factors
Participants reported an average of 15.11 (SD = 7.96) on
paternal encouragement and
average of 11.59 (SD = 5.25) paternal supervision. Participants
reported an average of
20.50 (SD = 8.89) on maternal encouragement and an average of
14.52 (SD = 6.05) on
maternal supervision. Lastly, 28.1% of the participant’s mothers
had problems with
Table 1. Sample characteristics.
Female (58%) Male (42%) Total
Variable n % n % N %
Early Adolescence 44 18.4 44 18.4 88 36.8
Middle Adolescence 45 18.8 37 15.5 82 34.3
Later Adolescence 49 20.5 20 8.4 69 28.9
In H.S. 77 32.2 48 20.1 125 52.3

Graduated H.S. 47 19.7 28 11.7 75 31.4
In-College 28 11.7 11 4.6 39 16.3
Living Situation
Living with parents 102 42.7 86 36.0 188 78.7
Living alone 36 15.1 15 6.3 51 21.3
Caregiver Status
Mother in-home 86 36.0 70 29.3 156 65.3
Father in-home 45 18.8 44 18.4 89 37.2
Employed 48 20.1 43 18.0 91 38.1
Table 2. Pearson correlations.
Pearson Correlations
1 2 3 4 5 6 7 8 9
1. Paternal Drugs —
2. Maternal Drugs .539** —
3. Family Time −.106 −.180** —
4. Parent-Child Relationship −.066 −.043 .503** —
5. Maternal Encouragement .056 −.036 .207** .252** —
6. Maternal Monitoring −.030 −.001 .253** .313** .370** —
7. Paternal Encouragement −.020 −.140* .191** .137* .261**
.354** —
8. Paternal Monitoring −.003 .050 .017 −.009 .072 .180**
.243** —
9. Depression (CESD) .071 .161** −.121* −.266** −.020 −.102
−.103 −.155** —
Means .66 .51 9.01 13.99 20.50 14.52 15.11 11.59 10.85
**. Correlation is significant at the 0.01 level (1-tailed).
*. Correlation is significant at the 0.05 level (1-tailed).
ENVIRONMENT 501

alcohol/drug use and 39.3% of the participant’s fathers had
problems with alcohol/
drug use.
Family factors
Participants reported an average of 13.99 (SD = 4.73) on family
child relationship and an
average of 9.01 (SD = 3.04) on family time.
Depressive symptoms
Participants reported an average depression score of 10.85 with
a standard deviation of
8.65. However, 28.9% of the participants had a score of < 16
and 17.6% had a score < 24.
Using the suggested cutoff score of 24 (Nebbitt & Lombe,
2007), a little over 17% of
participants reported minimal to mild symptoms. There were no
statistical differences in
regard to gender and age among the sample.
Predictors of depression
The results of the stepwise multiple regression analysis are
presented in Table 3. Of the 4
factors entered in the regression analysis, three emerged as
significant predictors of levels
of depression (F= 5.35, p< .005).
With a beta of -.266 (p< .01), parent-child relationship emerged
as the strongest
predictor of depression accounting for 7.1% of the variance in
depression. The second
strongest factor was paternal supervision (β= .152, p < .01)
accounting for an additional
2.3% of the variance in depression. The third strongest factor
was maternal drug use (β=

.142, p < .05) accounting for a modest 2.0% of the variance in
depression. These results
indicate that presence of depressive symptoms among African
American is a function of a
weak parent-child relationship, paternal supervision, and history
of maternal drug use.
Overall, this predicted regression model explains a modest
11.4% of the total variance in
levels depression. Therefore, a little over 88% of the variance is
unexplained.
Discussion
Understanding the relationship between depressive symptoms
and protective factors is
critical for advancing our knowledge of depression among
African American youth. The
current study sought to examine potential risk and protective
factors. Results from the
study suggest depressive symptoms among African American
youth are associated with
higher maternal drug use, family time, paternal supervision and
the parent-child
relationship.
We hypothesized that higher reporting of paternal and maternal
drug use will be
related to higher levels of depressive symptoms. This w as
partially supported. Higher
levels of maternal drug use were related to higher levels of
depressive symptoms. This
finding was consistent with a study that suggests examining the
relationship between
Table 3. Stepwise regression model: depression.
Model R R2 F p β t p

Parent-Child Relationship .266 .067 18.10 .000 −.266 4.900
.000
Paternal Monitoring .307 .094 6.05 .015 −.152 3.865 .000
Maternal Drug Use .338 .114 5.35 .022 .142 2.252 .000
parental alcohol and drug use and depressive symptoms (Tandon
& Solomon, 2010). Our
hypothesis regarding the relationship between paternal drug use
and depressive symptoms
was not supported. This could be explained by the fact that over
70% of African American
youth households within our study were single-parent homes in
which the mother was the
primary caregiver. The absence of a substance-abusing father in
the home may buffer the
impact of youth developing depression.
Parental factors need to be considered when exploring
depressive symptomology
among urban African American youth. As expected, key
parental factors (child-family
relationship, paternal supervision, and maternal drug abuse)
were associated with depres-
sion in our study. However, only partial hypothesis was found
to be true in the study, as
paternal and maternal encouragement, maternal supervision, and
paternal drug use did
not have statistically significant relationships. The findings of
this study affirm previous
studies with urban African American youth, which found an
association between parental

factors and depressive symptoms (Barton et al., 2015; Agerup et
al., 2014; Garthe, Sullivan,
& Kliewer, 2015).
Likewise, findings from this study were consistent with
previous literature, which found
a positive relationship between child family relationship and
depressive symptoms (Choe,
Stoddard, & Zimmerman, 2014; Hunt, Caldwell, & Assari, 2015;
Taylor, Budescu, &
Gebre, 2016). Findings also support previous research, which
suggests that lack of parental
supervision can lead to increased depressive symptomology
among African-American
youth (Hamza & Willoughby, 2011; Yap, Pilkington, Ryan, &
Jorm, 2014). Moreover, a
systemic review of the literature found a relationship between
maternal drug abuse and
depressive symptoms (Yap et al., 2014).
The results reported in this study offer a glimpse of the
relationship among parental
factors and depressive symptoms among urban African
American youth living in and
adjacent to public housing developments. Parent-child
relationships and parental super-
vision play a critical role in buffering the mental health risk of
African American youth in
urban communities. Findings from the study suggest that
interventions addressing depres-
sive symptoms among urban African American youth should be
targeted to address
parental factors that contribute to depression. In addition, future
research studying
depression among urban African Americans should include
comparative samples to

examine the difference regarding ethnicity. Given the
importance of parents in the lives
of children and youth, parental factors across ethnic
backgrounds should be explored.
Also, due to the complexities in the lives of urban African
American youth, longitudinal
studies should be conducted to explore the difference in
depressive symptoms across time.
Although measures to gauge youth depression have become
more established over time,
we need to utilize multiple measures and techniques to gauge
depressive symptoms
targeted to urban youth to ensure we are able to accurately
capture depressive sympto-
mology among this population. While the findings of this study
partially supported the
hypothesis between parental factors and depression, future
studies should aim to include
psychological functioning and behavioral health. The presence
of parental substance abuse
has been found to be correlated with sexual risk-taking
behavior, behavioral health, and
food insecurity (Lombe, Nebbitt, Chu, Saltzman, & Tirmazi,
2017; Nebbitt et al., 2015;
Lombe, Nebbitt, Sinha, & Reynolds, 2016).
ENVIRONMENT 503
Strengths and limitations
A strength of this study is its examination of key protective
factors related to parents. The study’s
approach to dichotomize parental factors into maternal

encouragement and monitoring and
paternal encouragement and monitoring is critical to examining
differences in maternal and
paternal factors regarding depressive symptoms among youth.
Although limited in its general-
izability, the information provided is useful for researchers ,
educators, and practitioners. Given
the relatively low to moderate level of depressive symptoms,
future research should aim to
further explore protective factors and strategies utilized by
urban African American youth in
combating stress. Due to the cultural nuances of urban
communities, multiple techniques and
measures to gauge depressive symptoms should be incorporated.
The cross-sectional design limits this study’s ability to establish
causal inferences. In
addition, the accuracy of the data collected is limited due to
response error as participants
recall and self-report their feelings, perceptions, and behaviors.
Also, numerous risk
factors such as discrimination, exposure to violence, delinquent
behaviors, and drug use
were not included in the analysis and may influence depressive
symptoms among the
sample. Furthermore, findings of this study are limited in its
generalizability as the data
were collected in and adjacent to housing developments in
North West Baltimore.
Generalizing to other urban communities and African American
youth should be done
with caution. Lastly, using a community based participatory
research approach blended
with a community action research approach may be critical in
developing trust, rapport,
and a collective research approach to address both community

and academic inquiry.
Conclusion
This study contributes to literature examining depressive
symptoms among a sample of
urban African American youth in and adjacent to public housing
developments (Breland-
Noble, Burriss & Poole, 2010; Lindsey et al., 2010; McMahon,
Coker, & Parnes, 2013;
Nebbitt et al., 2014; Tandon & Soloman, 2010). These findings
provide support for claims
about the importance of parent-child relationship and paternal
monitoring as a protective
factor for depressive symptoms, particularly during
adolescence. While maternal drug use
serves as a risk factor for depressive symptoms among this
population of urban youth,
paternal drug use does not. Our understanding of the samples
demographic could play a
tremendous role in the findings. Considering most of the study
participants (65.3%) reside
with their mother, it stands to reason their exposure to her
substance use would have a
greater impact as compared to paternal substance use. That is
not to say that the role of
the father is insignificant. Our research suggests that paternal
monitoring has a greater
effect on youth depressive symptoms than maternal monitoring.
Intervention efforts
aimed at parents of depressed youth may consider educating
fathers on the protective
role of their presence in their child’s life.
Acknowledgment

At the time of this publication, Dr. Anthony Estreet was a
Scholar with the HIV/AIDS, Substance
Abuse, and Trauma Training Program (HA-STTP), at the
University of California, Los Angeles;
supported through an award from the National Institute on Drug
Abuse (R25 DA035692).
Disclosure Statement
There is no financial interest held by any of the authors related
to this research or publication
Funding
U.S. Department of Health and Human Services, Health and
Resources Services Administration
Grant # G02HP27946
ORCID
Anthony T. Estreet http://orcid.org/0000-0002-2413-6311
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1Clini C, et al. BMJ Open 2019;9:e025465.
doi:10.1136/bmjopen-2018-025465
Open access
Assessing the impact of artistic and
cultural activities on the health and
well-being of forcibly displaced people
using participatory action research
Clelia Clini,1 Linda J M Thomson,2 Helen J Chatterjee2
To cite: Clini C, Thomson LJM,
Chatterjee HJ. Assessing the
impact of artistic and cultural
activities on the health and
well-being of forcibly displaced
people using participatory
action research. BMJ Open
2019;9:e025465. doi:10.1136/
bmjopen-2018-025465

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org/ 10. 1136/ bmjopen- 2018-
025465).
Received 18 July 2018
Revised 14 December 2018
Accepted 17 December 2018
1Institute for Media and Creative
Industries, Loughborough
University London, London, UK
2Genetics, Evolution and
Environment, UCL Biosciences,
University College London,
London, UK
Correspondence to
Professor Helen J Chatterjee;
h. [email protected] ucl. ac. uk
Research
© Author(s) (or their
employer(s)) 2019. Re-use
permitted under CC BY.
Published by BMJ.
AbstrACt
Objective Drawing on a growing body of research
suggesting that taking part in artistic and cultural
activities benefits health and well-being, the objective
was to develop a participatory action research (PAR)
method for assessing the impact of arts interventions on

forcibly displaced people, and identify themes concerning
perceived benefits of such programmes.
Design A collaborative study following PAR principles of
observation, focus groups and in-depth semistructured
interviews.
setting London-based charity working with asylum
seekers and refugees.
Participants An opportunity sample (n=31; 6 males)
participated in focus groups comprising refugees/asylum
seekers (n=12; 2 males), volunteers (n=4; 1 males) and
charity staff (n=15; 3 males). A subset of these (n=17; 3
males) participated in interviews comprising refugees/
asylum seekers (n=7; 1 males), volunteers (n=7; 1 males)
and charity staff (n=3; 1 males).
results Focus group findings showed that participants
articulated the impact of creative activities around three
main themes: skills, social engagement and personal
emotions that were explored during in-depth interviews.
Thematic analysis of interviews was conducted in NVivo
11 and findings showed that artistic and cultural activities
impacted positively by helping participants find a voice,
create support networks and learn practical skills useful in
the labour market.
Conclusions The study expanded on arts and well-being
research by exploring effects of cultural and creative
activities on the psychosocial well-being of refugees and
asylum seekers. By focusing on the relationship between
arts, well-being and forced displacement, the study was
instrumental in actively trying to change the narrative
surrounding refugees and asylum seekers, often depicted
in negative terms in the public sphere.
IntrODuCtIOn
The recent All-Party Parliamentary Group on
Arts Health and Well-being Inquiry Report
shows a growing acknowledgement of the

impact of arts and creative practices, stating
‘arts engagement has a beneficial effect upon
health and wellbeing and therefore has a
vital part to play in the public health arena’
(APPGAHW, p11).1 Consensus among prac-
titioners defines well-being as ‘the dynamic
process that gives people a sense of how
their lives are going through the interac-
tion between their circumstances, activi-
ties and psychological resources or mental
capital’ (NEF, p3).2 Rather than depending
on a single factor, well-being is seen as
the result of interplay between different
elements, distinguishing personal well-being
(positive emotion, life satisfaction, vitality,
resilience and self-esteem) from social well-
being (supportive relationships, trust and
belonging).3 Other authors emphasise ‘resil-
ience and flourishing, rather than just surv
iving’ (Ander et al, p243),4 a crucial point
when investigating the situation of forc-
ibly displaced people who often survive in
extreme conditions and whose experience
is often discussed in terms of dehumanisa-
tion.5 6
Research conducted in the field of forced
displacement and mental health shows
that ‘asylum seekers and displaced people
report high rates of pre-migration trauma’
(Vaughan-Williams, p275),6 and typically
display significant levels of depression,
anxiety, posttraumatic stress disorder (PTSD)
and non-affective psychoses.7–11 Refugees and
asylum seekers often encounter postmigra-

tion living difficulties, such as socioeconomic
disadvantage, employment barriers, social
and emotional isolation, racism and hostility,
strengths and limitations of this study
► Focus on collaborative research.
► Different cultural and artistic activities studied.
► Researcher spent 5 months in research setting.
► Greater number of female than male participants.
► Focus groups attracted relatively low numbers of
refugees/asylum seekers.
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http://bmjopen.bmj.com/
http://dx.doi.org/10.1136/bmjopen-2018-025465
http://crossmark.crossref.org/dialog/?doi=10.1136/bmjopen-
2018-025465&domain=pdf&date_stamp=2019-04-04
2 Clini C, et al. BMJ Open 2019;9:e025465.
doi:10.1136/bmjopen-2018-025465
Open access
experience of detention and uncertainty related to the
asylum application process.7–9 12 If, as authors suggest,13–17
there is a strong link between mental health and socioeco-
nomic conditions in terms of employability, income and
housing, then the mental health of unemployed asylum
seekers living on low incomes in poor quality housing is
likely to be worse than that of the general population.
Arts-and-health practitioners believe that ‘aesthetics act
upon our senses to make us feel more, hear more and see
more than we otherwise might… feelings are intertwined
with mental, physical, spiritual and social health’ (Prior,
p4).18 Several studies explored the relationship between
arts, health and well-being and a growing body of evidence

suggests that cultural participation (including music, art
making, theatre, dance, museum and heritage activities)
enhances human health and well-being.1 19–27 Research
conducted in museums-and-health, for example, suggests
that ‘museum and art gallery encounters can help with
a range of health issues, enhance wellbeing, and build
social capital and resilience’ (Chatterjee and Noble,
p286).27 According to research conducted in Norway
with over 50 000 adults,28 participation in both receptive/
passive and creative/active cultural activities was signifi-
cantly associated with good health, life satisfaction, and
low anxiety and depression. Findings demonstrated how
manual creative practices such as knitting had a positive
impact on people suffering from depression and posttrau-
matic stress disorder because ‘the movements involved
in knitting are bilateral, rhythmic, repetitive, and auto-
matic’ (Cuypers et al, p40).28 The authors attributed the
positive mood of knitters to enhanced production of
serotonin resulting from repeated movements, and that
bilateral processes appeared to engage brain capacity
and facilitate a meditative-like state more readily than
unilateral ones. Although creative activities are seen to
provide major benefits for refugees and asylum seekers,
researchers have become ‘increasingly conscious of the
value of recording and analysing what has been happenin
g’ (Robjant et al, p1).8
The current study was conducted in the light of
mental health and arts-in-health/museums-in-health
evidence, and the large number of organisations that
engage migrants, refugees and asylum seekers in the
arts, with nearly 200 of these in the UK.29 The current
research was conducted at the Helen Bamber Founda-
tion (HBF), a charity offering support to refugees and
asylum seekers as victims of torture and human rights
violations. HBF adopts a holistic approach to support

its clients that includes cultural activities within a three-
phase model of integrated care comprising stabilisation
(medical and legal support), intervention (trauma-fo-
cussed therapy and general psychological care) and inte-
gration (attending the creative, computing and English
classes, and interacting with other clients). The model is
based on the needs of refugee/asylum seekers who often
require assistance on several fronts (eg, psychological
support might not be effective if a person does not have
a place to sleep or lives in a dangerous situation, though
giving people a place to sleep is not enough to overcome
trauma). Their creative arts programme (CAP) led by
volunteers includes art (painting and drawing), photog-
raphy, textiles (dressmaking and knitting) and singing,
and is attended by c.100 clients. The study took the view
that arts participation would enhance the sense of wel l-
being by allowing participants to form meaningful rela-
tionships based on trust and mutual support (improving
social well-being) and enhance self-esteem and self-confi-
dence (increasing personal well-being).
To provide voice and agency for participants, the study
used a collaborative approach to explore client experi -
ences of creative activities with HBF clients, staff and
volunteers acting as coresearchers. The research was
operationalised according to the principles of partic-
ipatory action research (PAR)30 31 as a ‘way of opening
up space for dialogue and conversation’ (Nicolaidis
and Raymaker, p28),32 aiming to ‘understand and also
improve a particular situation’ ,32 both pertinent aspects
when working with displaced people. The PAR approach
encourages an active contribution in the production of
knowledge within a collaborative framework, empha-
sising ‘equal partnerships’ (Daykin and Stickley, p167),33
and the ‘role of the participant in the design, implemen-

tation, and dissemination of the research’ (Vaughn and
Jacquez, p78).34 The collaborative character of PAR is
grounded in efforts to ‘democratise the research process’
(Blumenthal, p3),35 so ‘equal weight and consideration
is given to the contributions of both the community and
academic partners’ (Braun and Clarke, p170)36 again
valuable for everyone involved but specifically refugees/
asylum seekers. One of the pillars of PAR, especially when
community-based is ownership.37
By offering equal weight to client contributions
focusing on the relationship between forced displace-
ment and arts participation, the study aimed to empower
participants by developing their sense of ownership in
the project. Through collaborative working between the
charity, displaced people and academics, the purpose
of the research was to codevelop a methodological
approach to address the needs of refugees/asylum
seekers and to coproduce interview questions that could
be applied in the UK and international settings. The
objectives were to expand on arts-in-health and collab-
orative research approaches by exploring the benefits
of engagement in cultural and creative activities on
the health and well-being of forcibly displaced people
and contribute to the current debate on migration and
public health.
MethOD
Design
Qualitative research conducted comprised observation,
focus groups and one-to-one semistructured interviews
with clients, volunteers and staff as coresearchers within a
collaborative PAR approach.38
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Participants
The study recruited an opportunity sample of volunteer
participants through information leaflets and contact
details in reception. Clients were approached by the
researcher using two recruitment criteria: (i) clients had
received therapy for at least 2 years prior to the research
and had entered the integration stage of the model of
integrated care; this meant that though still vulnerable,
clients had established a therapeutic relationship of trust
enabling them to form safe relationships in the wider
community and move forward with their lives; and (ii)
they had attended at least one of four CAP groups (art,
photography, singing and textiles) for around 2 years.
All participants spoke English sufficiently well to partic-
ipate having attended English classes for about 2 years
as part of integrated care. In total, 31 (6 males) partic-
ipants volunteered for the study and attended focus
group comprising 12 (2 males) refugees/asylum seekers,
4 (1 males) volunteers and 15 (3 males) charity staff. Of
these, 17 (3 males) participated in interviews comprising
7 (1 males) refugees/asylum seekers, 7 (1 males) volun-
teers and 3 (1 males) staff.
Patient and public involvement
HBF staff were instrumental in the application for research
funding and collaborated with the researcher to deter-
mine the study’s objectives. HBF clients were involved
in the recruitment process by recommending that other
clients join them in the research, though the researcher
ensured that they matched recruitment criteria (above).
In keeping with PAR, research questions and outcome
measures concerning the effects of cultural and creative
activities on the psychosocial well-being of refugees/
asylum seekers were determined by coresearchers (HFB
clients, volunteers and staff) with differing involvement

depending on their role at the charity. Focus groups and
interviews gave voice to clients’ priorities and preferences
but, due to their vulnerability, no personal information
was requested as the process of remembering could have
been difficult.7 10 Although some participants mentioned
personal issues and experiences, they were not encouraged
to do so. Data generated by coresearcher involvement in
the research collaboration informed focus groups, in turn
focus group outcomes led to the development of ques-
tions for the in-depth interviews to follow. In addition to
participation in focus groups and interviews, a core group
of seven coresearchers (three clients, two volunteers, two
staff, with one male per category) were involved in design
of the interview guides, discussion of emerging themes
and dissemination of the research findings to other partic-
ipants for verification and comments, in accordance with
PAR principles.33 The results of the research were fed back
to everyone involved with HBF through ongoing commu-
nication with the researcher, an internal report lodged at
the charity, and an end-of-project event.
Data collection
Data collection carried out by the location-based
researcher consisted of three stages: stage 1 (months
1–2) participant observation; stage 2 (months 3–4) focus
groups and stage 3 (month 5) semistructured interviews.
In stage 1, participant observation was used as a starting
point ‘for studying how organisations work, the roles
played by different staff and the interaction between staff
and clients’ (Pope et al, p32).38 The researcher attended
creative classes for clients and spent a day a week working
from HBF (12–15 hours per week) to determine the
nature of focus groups. In stage 2, four focus groups
were held, first and final with clients (n=8, n=4, respec-
tively), second with volunteers (n=4), and third with staff

(n=15). In the focus groups, participants were asked to
discuss research questions (box 1) involving ways of gath-
ering information on the impact of creative activities, and
reasons for attending groups (or in the case of volunteers
and staff, reasons for involvement). All focus groups were
organised informally to facilitate development of discus-
sion among participants and allow an exchange of experi -
ences and ideas. Ideas that emerged during focus groups
laid the basis for first drafts of interview questions, tailored
to clients, volunteers or staff (box 2). In line with the
collaborative ethos, drafts were circulated to receive feed-
back from coresearchers prior to the interview stage, and
volunteers and staff were consulted and asked to provide
comments and suggestions for interview questions. For
stage 3, clients (n=7), volunteers (n=7) and staff (n=3)
participated in interviews with the researcher using a
semistructured format to allow free expression within the
research constraints and limit potential research bias.30 39
Data analysis
A first informal thematic analysis was conducted by
the researcher while writing field notes consisting of a
chronicle of descriptive rather than analytic events both
observed and provided by coresearchers as the ‘raw mate-
rial of the research’ (Kemmis et al, p38).30 The process
box 1 Focus group questions
Clients
1. Why do you like the Helen Bamber Foundation (HBF)
creative arts
programme?
2. How would you gather information or evidence about the
benefits

of artistic activities?
3. Which creative arts classes have a positive impact on the
lives of
refugees?
Circle the option(s) that you think work best or add another one.
Arts and Crafts Drawing Films Knitting Photography Singing
Textiles.
Volunteers
1. Why do you volunteer at the HBF?
2. How do you think your group benefits clients?
3. How would you collect evidence on the effects of
participating in
artistic activities?
staff
1. Why do you recommend clients to attend creative arts
groups?
2. What do you think are the benefits of attending arts groups?
3. How would you collect evidence on the effects of
participating in
artistic activities?
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of transcribing notes was used to identify key points
connected to the research question. This preliminary
analysis informed focus group topics where points were
discussed more in detail. After the first round of focus
groups, all notes were compiled into a word document
and repeatedly read by the researcher and coresearchers
to search for recurring topics and themes. Thematic
analysis of focus group outcomes were explored in detail

during interviews. All interviews were recorded and
transcribed to become familiar with the data and begin
the coding process.37 All details in the transcripts were
recorded verbatim (eg, sighs, laughter, silences and tears)
as their exclusion could have changed the meaning
expressed.30 Transcriptions were uploaded into NVivo11
box 2 Interview questions
Clients
1. How long have you been attending the creative arts
programme
(CAP) classes for?
2. Which groups do you attend?
3. Why did you choose this/these groups(s)?
4. What do you like the most about these groups?
5. Is there anything about the groups that you find difficult?
6. Anything you would like to change?
7. Is there a group you prefer? Which one? Why?
8. How do you feel when you attend this group?
9. Do you think there are benefits of attending these groups? If
so
what are they?
10. During our previous meeting, it emerged that participants
feel that
groups allow them to learn new or improve already acquired
skills.
Do you agree? Have you learnt any new skill? And what do you
think about the possibility of learning new skills? (How does
that
impact your life?)
11. Another element which emerged during our meeting is that

people
enjoy the social aspect of these groups: meeting people and
finding
new friends. What do you think about this? [supporting
questions:
do you like being around other people? Why? What happens
when
you attend a session? Have you made new friends? How do you
feel about that?]
12. Among all of the reasons why you enjoy attending the
creative arts
group, which one is the one that you feel strongest about?
13. Why do you keep attending?
14. If you could compare the way you were feeling before
joining any
of these activities and the way you feel now, would you say you
feel
any different? Explain.
15. Creative activities of course are part of the support that
Helen
Bamber Foundation (HBF) offers to its clients. Do you think
that you
would feel the same about yourself today even without
attending
these creative activities groups? Why?
16. Do you think that taking part in these creative activities has
had
any influence on the way you see yourself? And the way you see
yourself in London?
17. If you were to recommend someone to join a group, what

would
you say?
Volunteers
1. What do you teach?
2. How long have you been volunteering for?
3. Why did you decide to volunteer?
4. How did you learn about the HBF?
5. What do you think your group offers clients?
6. What are the main challenges you face/have faced as a
volunteer?
7. Do you find it difficult to engage clients in the activity you
coordi-
nate? What do you think clients like about the way you (and
your
colleagues) handle the sessions? Is there anything that clients
do not like?
8. How would you describe a typical session?
9. What do you think people like the most about your group?
10. Do you ever discuss emotions with clients? Or their
personal
situation?
11. Look at the notion of well-being defined by NEF (New
Economics
Foundation):
Well-being as ‘the dynamic process that gives people a sense of
how
their lives are going through the interaction between their
circumstanc-
es, activities and psychological resources or mental capital.’
(NEF 2008,

p3)
Continued
box 2 Continued
According to the NEF, there are different components to well -
being,
such as:
‘Personal wellbeing (emotional wellbeing, satisfying life,
vitality, resil-
ience, self-esteem and positive functioning) and social
wellbeing, in-
cluding supporting relationships and trust and belonging.’ (NEF
2009)
12. Do you think that the activity you lead has any impact on
the
well-being of clients? Elaborate.
13. If you were asked to recruit people for your group, what
would you
say to convince them to join?
14. Would you use different words to promote your group with
men
and women? Why?
15. Do you think that your group makes a difference in the lives
of
clients? How? Why?
16. And what about your own life? What is the impact of your
volunteer
activity on your own life?
staff

1. How long have you been working at HBF for?
2. Why did you decide to work here?
3. What is your role?
4. As part of your work, do you have any direct contact with
clients?
5. Could you say a few words on your relationship with clients?
6. How would you describe your own experience at HBF so far?
7. What are the main challenges that you face/have faced in
your
position?
8. Do you think that your own gender influences the ways in
which
clients relate to you?
9. In your position, do you discuss clients’ personal situations
and
feelings?
10. If so, do you think that the cultural background of clients
affects
the way in which you discuss emotions? If it does, how and
why?
11. What are the main challenges of discussing emotions with
clients?
12. Could you say a few words on the Model of Integrated
Care? Do you
think it works? And if so, why?
13. Do you recommend clients to attend any of the CAP groups?
What
do you say in this case?
14. What role do you think cultural and creative activities play
in the

recovery of clients?
15. Are there any particular activities that, in your opinion, are
more
popular with clients?
16. Would you say that the programme makes a difference in the
lives
of clients? If yes, please elaborate.
17. Have you witnessed clients benefiting from their own
participation
in the creative arts programmes? If yes, in what ways? o
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to produce nodes from coding-relevant concepts. NVivo’s
word frequency query facilitated the search for keywords
(including stem words and synonyms) grouped under the
same theme. The text search query provided a compre-
hensive analysis of data. After coding of data into initial
themes,37 a review of themes followed to refine the
analysis.
results
Focus groups
Focus group data were analysed using thematic analysis
(NVivo11). Findings showed consistenc y in the way all
HBF participants (clients, volunteers and staff) articulated
their reflections on the impact of creative activities. The
benefits of creative activities were highlighted in clusters
emerging from around three main overarching themes:
‘skills’, ‘social aspects/friendships’ and ‘mood-personal
sphere’; the latter subdivided into ‘brain’ (creative
thought processes), ‘routine’, self-expression’ and ‘confi-
dence’. During focus groups, coresearchers were asked

to write answers to the questions posed, and a collective
discussion followed. Clients responded consistently about
benefits of the creative programmes. One client listed
‘Activities help my brain think about other stuff and keep
me busy and relaxed. You can’t think about bad things. To
learn more skills. I can use skills to help others’.
Learning new or improving existing skills was a key
theme emerging out of focus groups, as skill development
appeared to change clients’ perceptions of their status; as
a female volunteer at HBF for 2 years suggested ‘partici-
pants do not feel assessed as clients, they are just learners
or artists. These groups paved the way for identifications
different from being a victim, a refugee or an asylum
seeker’. Clients also mentioned how acquiring new skills
was an important factor in improving self-esteem; one
client wrote about attending CAP ‘Give me confidence.
Make me feel good and useful. Change my mood. Learn
new things and meet people. Improve my skills. Give me
hope to lead a better life’.
Learning new skills was a benefit connected to the
second theme that emerged during focus groups, the
social aspect. It allowed people to meet others in similar
situations and create friendships and/or a support
network; as a client wrote ‘Allows me to feel included.
Safe environment. Improves my mood. Learn new skills.
Gets me out of the house. Meet new people’. Staff too
recognised the social aspect of activities as a major benefit,
with one suggesting ‘in these groups, clients learn to have
balanced, reciprocal relationships, which they have not
experienced before or for a long time given their expe-
rience of violence (trafficking). They provide clients
with an alternative identity, that is, they are not simply
victims here, they are learners, artists, dressmakers, etc.’
Similar themes emerged in the volunteer focus group

during which a relatively new male volunteer involved of
4 months was impressed by the solidarity between clients,
emphasising the benefits of the ‘feeling of belonging to
a group’ and ‘strong support that people receive from
other members’.
The third and final theme that emerged when discussing
the benefits of CAP the mood-personal sphere. Staff
commented on the mood enhancing benefits of CAP for
people with PTSD; one staff member observed ‘creative
activities allow clients to momentarily leave out their
problems or memories, by focusing on a particular activity
they cannot think about anything else’. The focus group
with staff emphasised that being busy in the company
of others allowed clients to feel safe and not to dwell on
their own situation. In concentrating on learning new
skills, clients blocked out (although for short periods)
memories of the past. Importantly, responses illustrated
that focus group participants perceived their involvement
as beneficial at multiple and overlapping levels. Enhance-
ment of mood appeared to derive from not only meeting
new people, forging meaningful relationships and feeling
part of a group but also connected to a growing self-con-
fidence and self-esteem experienced as clients acquired
new skills.
Interviews
During interviews, clients elaborated on practical and
social skills, and commented on the positive effect of
attendance on their mood and emotion:
Practical skills: learning new practical skills or improving
those previously learnt emerged strongly among asylum
seekers without the right to work. As a client pointed out:

I have learned a lot of skills: I’ve learned sewing, now
I’m learning art, I can do better, before I didn’t know
how to draw a person, to mix colours, you know such
things… so you keep on learning, slowly by slowly,
then in the end you find yourself, you’re a profes-
sional, so that is very great… to me… I like to come,
always and attend, and listen to what they tell me, and
I do it.
Or, as another client explained:
I’ve learned new skills […] and you can never waste
your time learning new skills. New skills always help
you in your life, always. So, everything I’ve learned
will help me. You think like ‘film club, learning how
to edit, etc.’. People pay people on YouTube to edit
their films, and I’m, like, I could just do my own, if I
wanted to have a YouTube channel, I can do my own.
Skill improvement provided a sense of achievement
and improved self-confidence, talking about learning
new skills, one client observed:
When you are in this situation it feels like life has, in
a way, stopped. And you can’t do anything to change
it. But by doing all this activity you feel, or I felt … it
was like, you know, that I was learning something in
my life, rather than just waiting.[…] For instance, if I
go for a job somewhere, where you have to write what
skills you have, so I could include all of this. I mean I
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don’t have a certificate or, like, proper qualifications,
but I’ve all those skills, so I feel like, it is, in a way,

impressive? Because you feel like, you know, rather
than just waiting and not doing anything, you have
been learning.
The sense of self-improvement associated with learning
skills was linked to the perception that by learning, clients
were preparing themselves for a new life when they would
be allowed to live and work in the UK, countering the
perception that life for them had stopped and giving
them something to look forward to. The process of skills
learning was not simply a vertical one; peer learning was
equally important, stressing the importance of social
aspects.
Social skills: the opportunity to overcome social isola-
tion and create a social network emerged as one of the
benefits of creative engagement. As one client indicated:
The groups changed me because you know when I
come, I feel lonely and doesn’t have anybody. I was
lonely I don’t even know whether there will be a home
from morning to live in. But when I started coming
these groups, I told you I feel active, I feel coming to
see people, that I speak to. I don’t even know how to
communicate with people before. I told you because
of my coming here I now feel to communicate to peo-
ple. Before I never communicate to people, I don’t
know how to do it. And I don’t know how to play with
people. But these groups make me now taught me:
play with people, to meet me.
The client expressed the difficulties of establishing new
relationships and the feeling that the group was a place
in which they could regain this ability to connect with
other people. The social aspect was an important point
reiterated in all interviews; fellow clients were described

as ‘friends’ but also as ‘brothers and sisters’. Arts activities
allowed clients to create a community characterised by
solidarity, as one client explained:
If you’re in a situation where you’ve been completely
isolated from people for a while and you just don’t
know who to trust, or to be around people, it’s one
of those spaces where you can get to meet people,
socialise, and actually make friends.[…] And these
friendships do last. A life-time, because you under-
stand what the person has gone through, you don’t
have to explain a lot, you know, they just know that
you’ve been through something terrible.[…] So, it’s
easier when you have people here who just under-
stand what you’ve possibly been through.
This remark connects with the observation that ‘engage-
ment in participative creative arts activities in communi -
ties can help to build social capital, address loneliness
and social isolation, and build personal confidence and a
sense of empowerment’ (Staricoff, p32).25 The awareness
of experiencing similar situations makes clients feel free
to share their own experiences with one another but also
not to, if they did not feel like opening up:
There is a sense of community: you know you go
there, you know there are people like you in the same
situation you’re not going to be judged, so it’s that
sense of community: we know what’s going on, we
don’t have to talk about it.[…] It’s a distraction from
immigration and we know we are all going through
it, but we don’t have to talk about it. There are other
things going on in life, and we talked about, for ex-
ample in the art group, the works we produced and
what we could do, what we could achieve and get in-

spired by each other’s work.
Again, this remark introduced the third broad theme
which emerged out of the interview analysis, which was the
impact of creative arts on personal mood and emotion.
Mood and emotion: learning or improving skills
while forging long-lasting relationships in a context of
deep social isolation (outside of HBF), inevitably had a
substantial impact on mood and emotion. In discussing
this aspect of creative arts, interviewees focused particu-
larly on how groups allowed them to have a routine, a
‘luxury’ one client said ‘when you can’t do nothing but
waiting for the government to decide on your right to stay
in the country’. Routine combined with skills learning/
improving was thought to have a positive impact on
clients’ mental health; ‘having something to do’ and
‘something to look forward to’ were recurrent expres-
sions during interviews. As one client noted:
I used to come here every day of my life: Monday,
Tuesday, Wednesday… because I don’t have anywhere
to go, so I just come here, and I attached myself to
the groups, we met, we talk, we… then I’ve gone to
knit, I’ve gone to do computer, reading, many things
I learnt here, so I just like it.
Another client elaborated further:
It’s something that I look forward to. One thing you
have to bear in mind is that I am not working, and I
am not studying, you know, so it was the only thing
that I would look forward to because it was something
to do, otherwise I would just be at home, doing noth-
ing, you know, feeling very sorry for myself, getting
upset all the time. I mean I still feel that way but at

least there’s something to look forward to, when you
don’t have hope or something to look forward to, it
increases your depression levels, so for me it’s helped
me greatly.
This statement describes the social and emotional
isolation as part of postmigration living difficulties. The
routine of classes, together with an awareness that others
in similar situations would attend, provided comfort to
clients, countering feelings of isolation:
There is nothing else for you and it’s also a way of,
like, using your time wisely, ‘cause at the end of the
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day most of the time you’re just sitting down doing
nothing, and doing nothing slowly begins to affect
your mind, your brain, you know you become lazy, you
know you literally are just in a four-squared room[…]
The benefits of a routine were increased by inclusion of
creative activities that according to clients and volunteers,
had a positive impact on mood because they exercised
the brain and allowed clients to find a new language to
express themselves. As a client stated:
[Attending creative groups] gives you a lot of confi-
dence, you know. And it allows your brain to think
outside of the box because I think we are just in that
box and… but when you attend these classes, your
mind, you know, opened and you learn new things
and you want to then learn other things as well.
This comment highlights an important link between

arts and feelings; as another stated:
It is more of expressing, more of letting go, it’s like
getting a spirit out of you, and you don’t have nec-
essarily have to tell someone ‘I’ve done this because
of that and that, and this’, you know. Because some-
times you just don’t find the voice to talk about it and,
I, as a person am really shy and, you know, I feel easily
embarrassed, you know.[…] So… that’s why I’m into
arts, yes I’m doing arts really.
Clients agreed that the possibility of self-expressing
without having to articulate their feelings, helped them
grow emotionally and gain confidence. It was not only
clients who benefited from CAP; findings also pointed to
the positive impact on volunteers, a point stressed by all
volunteers when discussing personal experiences.
DIsCussIOn
Creative and cultural activities were observed over a
sustained period of 5 months. Clients participating in the
activities had reached the integration stage of the model
of integrated care consequently had been taking part in
CAP activities for 2 plus years prior to the research. Activ-
ities provided refugees and asylum seekers with new skills,
including practical and technical skills, and social and
life skills involving language acquisition obtained partly
through informal peer learning and mutual support.
Learning new skills contributed to the sense of well-being
and empowerment experienced by HBF clients. The time
spent by the researcher at the HBF was vital for familiari -
sation with the context, getting to know people involved
in the organisation and explaining the research to recruit
participants from among clients, volunteers and staff.
The fact that several clients attended more than one
group per week (2–4) made it possible to forge trusting

relationships and recruit coresearchers, allowing them to
feel comfortable in speaking their mind. A possible issue
here was that the number of groups attended by clients
was not accounted for, so it was not evident as to whether
increased participation furthered benefits at a higher/
faster level. Once recruited, participants remained with
the study in their coresearcher roles and continued to
attend activities on a weekly basis for the 5 months (except
for rare absences due to illness).
Activities appeared to positively enhance mood and
emotion both for clients and volunteers facilitating
CAP groups. Although passive participation was not
compared,28 active and creative participation in the
groups specifically benefited the clients. A key reason
was that asylum seeker status in the UK would not have
permitted alternative occupation or employment, so
clients might not have otherwise left their homes or
met people on a regular basis. In keeping with previous
research, participants reported that participation in
cultural and social activities contributed to their social
health,18 and aligned with a growing body of evidence1
to suggest that creative activities enhanced mental well -
being,19–27 helping clients to develop self-confidence
and resilience.21 Client preferences for activities indi -
cated that singing was their favourite group, followed
by photography, art and textiles. Singing was regarded
as beneficial because it allowed people to meet socially
and work collaboratively, aspects considered important
in countering loneliness. Findings aligned with a recent
qualitative study indicating that choral singing promoted
improvements in social, emotional, physical and cogni-
tive functioning and that benefits were experienced simi -
larly irrespective of age, gender and nationality.40 In the
current study, photography, art and textiles were praised

by clients for the skills taught and although social aspects
were relevant, skills that allowed participants to continue
activities at home (eg, sewing and drawing) were highly
valued. Interviewed staff were asked to comment on the
popularity of activities, and although the order was the
same as that of clients, they were not asked their opinion
on which were most beneficial.
The current study bridged the gap between two research
disciplines: arts-in-health and forced displacement and
mental health. It contributed to existing literature by
demonstrating beneficial effects of creative activities on
the well-being of refugees/asylum seekers and showed
that PAR was an appropriate and ‘democratic’ means
of collaboration between displaced communities and
academics (Bradbury, p3).39 In contrast with traditional
research where ‘academics benefit from the research, but
often the people involved hear very little if anything from
the researcher again’ (Daykin and Stickley, p78),33 a core
element of PAR is that research should be meaningful
and have tangible outcomes for coresearchers as they
work together to bring about significant change within
their community or society at large. In the current study,
client involvement in the research and their decision to
organise a public exhibition to showcase their artwork
was a means for them to interact with wider society and
actively rewrite the narrative around asylum seekers and
refugees, often depicted in negative terms in the public
sphere.41
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Adopting a PAR approach is important when working
with immigrant communities as it ensures that the research
question is of ‘genuine importance’ (Vaughn and Jacquez,

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