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How to implement peer-based mental health services for foreign domestic workers in Singapore?

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Abstract and Figures

Foreign domestic workers (FDWs) in Singapore are at particular risk for developing mental health problems, whereby Filipino FDWs are deemed to be especially vulnerable towards developing them. Among the identified specific risk factors for developing mental health problems amongst FDWs are homesickness, a lack of social support, communication-related barriers and employer restrictions and abuse (HOME, 2015). Despite this vulnerability, FDWs face substantial barriers to seeking help when experiencing mental health problems. This is due to their marginalized status in Singapore, an inadequate legal protection with a resulting fear of deportation due to ill health (including mental illness) and the lack of available formal psychosocial support services for migrants (Huang & Yeoh, 2003; Ueno, 2009). In addressing FDWs’ susceptibility to mental health problems and the lack of respective support services for migrants in Singapore, the Humanitarian Organization for Migration Economics, a migrants’ rights non-governmental organization in Singapore, aims to develop tailored mental health services for FDWs. In doing so, FDWs’ desired methods of receiving help are taken into account - empirical evidence suggests that FDWs’ preference for seeking mental health support from informal sources (e.g. friends and family) rather than formal ones (e.g. a mental health professional) and receiving face-to-face mental health support from a trained fellow FDW (HOME, 2015). We present and discuss the results of a concurrent mixed-method evaluation of a pilot four-week peer-based mental health paraprofessional training program focused on Cognitive-Behavioural Therapy (CBT) for Filipina FDWs (Wong, 2016; Wong et al., 2017) that was delivered face-to-face in English. A self-report assessment measure was developed to evaluate participants’ perspectives of the training. Questions covered the participants’ assessment of the training program and preferred modes of the implementation of a permanent peer counseling service by HOME. Results from 37 participants of the training program indicated a high satisfaction with the program. Reported challenges included difficulties in understanding the training material and a perception of cognitive overload. Moreover, eight out of ten participants were willing to attend further training and more than seven out of ten agreed to be supervised by a qualified mental health professional. As to the mode of a future service, 73% of participants preferred providing peer counseling in a mixture of Tagalog and English. 75% favored delivering the service face-to-face as opposed to using ICT. The presented data overall suggests that there is strong interest in peer-based mental health support services by the target group and further corroborates the documented preference for trained peer support. Results further underline the feasibility of implementing this training program as part of a peer-based mental health service within a proposed broader stepped-care mental health service model for FDWs to be delivered by HOME in response to a service gap. We conclude that peer-based mental health programs may form a useful first-line mode of treatment and a means to improve accessibility to mental health care for FDWs. Peer-support approaches not only may provide an opportunity to mitigate mental health problems but also represent a means of empowerment for this marginalized group by giving them the capacity to access support within their community. Nonetheless, further challenges to capacity-building in service provision for FDWs exist - for instance, in relation to further streamlining the training curriculum to the target group’s needs and characteristics and manpower needs.
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Running head: PEER-BASED MENTAL HEALTH SERVICES
How to implement peer-based mental health services for foreign domestic workers in
Singapore?
Sudev Suthendran
Anja Wessels
Marian Wong Men Heng
Keng Shian-Ling
Author Note
Sudev Suthendran, Humanitarian Organization for Migration Economics, Singapore
Anja Wessels, Research Across Borders, Australia & Humanitarian Organization for
Migration Economics, Singapore
Marian Wong Men Heng, Department of Psychology, National University of
Singapore
Keng Shian-Ling, Department of Psychology, National University of Singapore
Correspondence regarding this article should be addressed to Sudev Suthendran.
Contact: sudev.suthendran@home.org.sg
Recommended citation:
Suthendran, S., Wessels, A., Wong, M. H. M., & Keng, S-L. (March 28, 2017). How
to implement peer-based mental health services for foreign domestic workers in
Singapore? Paper presented at the Migrating Out of Poverty: From Evidence to
Policy conference, London, UK.
PEER-BASED MENTAL HEALTH SERVICES
2
Abstract
Foreign domestic workers (FDWs) in Singapore are at particular risk for developing
mental health problems, whereby Filipino FDWs are deemed to be especially
vulnerable towards developing them. Among the identified specific risk factors for
developing mental health problems amongst FDWs are homesickness, a lack of social
support, communication-related barriers and employer restrictions and abuse (HOME,
2015). Despite this vulnerability, FDWs face substantial barriers to seeking help when
experiencing mental health problems. This is due to their marginalized status in
Singapore, an inadequate legal protection with a resulting fear of deportation due to ill
health (including mental illness) and the lack of available formal psychosocial support
services for migrants (Huang & Yeoh, 2003; Ueno, 2009). In addressing FDWs’
susceptibility to mental health problems and the lack of respective support services
for migrants in Singapore, the Humanitarian Organization for Migration Economics, a
migrants’ rights non-governmental organization in Singapore, aims to develop
tailored mental health services for FDWs. In doing so, FDWs’ desired methods of
receiving help are taken into account - empirical evidence suggests that FDWs’
preference for seeking mental health support from informal sources (e.g. friends and
family) rather than formal ones (e.g. a mental health professional) and receiving face-
to-face mental health support from a trained fellow FDW (HOME, 2015).
We present and discuss the results of a concurrent mixed-method evaluation of a pilot
four-week peer-based mental health paraprofessional training program focused on
Cognitive-Behavioural Therapy (CBT) for Filipina FDWs (Wong, 2016; Wong et al.,
2017) that was delivered face-to-face in English. A self-report assessment measure
was developed to evaluate participants’ perspectives of the training. Questions
covered the participants’ assessment of the training program and preferred modes of
the implementation of a permanent peer counseling service by HOME. Results from
37 participants of the training program indicated a high satisfaction with the program.
Reported challenges included difficulties in understanding the training material and a
perception of cognitive overload. Moreover, eight out of ten participants were willing
to attend further training and more than seven out of ten agreed to be supervised by a
qualified mental health professional. As to the mode of a future service, 73% of
participants preferred providing peer counseling in a mixture of Tagalog and English.
75% favored delivering the service face-to-face as opposed to using ICT.
The presented data overall suggests that there is strong interest in peer-based mental
health support services by the target group and further corroborates the documented
preference for trained peer support. Results further underline the feasibility of
implementing this training program as part of a peer-based mental health service
within a proposed broader stepped-care mental health service model for FDWs to be
delivered by HOME in response to a service gap. We conclude that peer-based mental
health programs may form a useful first-line mode of treatment and a means to
improve accessibility to mental health care for FDWs. Peer-support approaches not
only may provide an opportunity to mitigate mental health problems but also
represent a means of empowerment for this marginalized group by giving them the
capacity to access support within their community. Nonetheless, further challenges to
capacity-building in service provision for FDWs exist - for instance, in relation to
further streamlining the training curriculum to the target group’s needs and
characteristics and manpower needs.
PEER-BASED MENTAL HEALTH SERVICES
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1. Introduction
1.1 The Humanitarian Organization for Migration Economics (HOME)
The Humanitarian Organization for Migration Economics (HOME), founded in 2004,
is a non-governmental organization and registered charity with Institution of a Public
Character (IPC) status in Singapore. Dedicated to serving the needs and protecting the
rights of the almost one and a half million migrant workers in Singapore, the mission
objectives of HOME are to provide welfare services and education (empowerment)
for migrants in Singapore and to develop applied research on the socioeconomics of
migration in Singapore and the countries of origin to inform advocacy (see for more
details, HOME, 2017).
Each year, approximately 3,000 migrant workers receive assistance from HOME.
Approximately 60% of those assisted by HOME are FDWs. Through its day-to-day
interactions with the FDW community, HOME has clear insights into the challenges
faced by FDWs, as well as the support and services that they require.
1.2 Foreign domestic work in Singapore
Singapore has with about 36% of its population, one of the largest proportions of
foreign-born workers in the world (Rubdy & McKay, 2013). 17% of the total foreign
working manpower in Singapore comprises foreign domestic workers (FDWs) and
their numbers are projected to increase (Ministry of Manpower, 2016). The hiring of
live-in FDWs is deemed necessary for many households in order to manage domestic
demands (Wong, 1996) with about one in three households employing them in
Singapore (HOME, 2017). The documented 237,100 FDWs in Singapore are
predominantly female and primarily come from the neighbouring developing
countries of Philippines, Indonesia, Myanmar, India and Sri Lanka, with the majority
from the first two countries (HOME, 2015).
However, FDWs in Singapore face inadequate legal protection and unregulated labour
conditions (for a comprehensive review see HOME, 2015; 2017) compared to other
foreign workers and local employees. They are only allowed to work for a single
employer (to whom their work permit is tied to). Employers therefore have the
unilateral power to end an employment and to repatriate the FDW without reason or
to reject (or approve) a worker’s request to transfer employers. Employers are also at
liberty to determine the number of hours of rest, work hours a day and wages. Given
that most FDWs have come to Singapore to work for financial reasons (e.g. debts
back home), reporting legal violations to authorities is often not in the workers’
interests as they could lose their jobs. Overall, the above policies foster power
imbalance, and structural dependency on employers.
1.3 Vulnerability for ill mental health
The lack of sufficient laws and policies governing the living and work conditions of
FDWs leave them open to exploitative practices, and ultimately a “structurally hostile
work environment” (Ueno, 2009, p. 500). FDWs also face inadequate medical
PEER-BASED MENTAL HEALTH SERVICES
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insurance coverage especially for serious medical conditions that require major
medical procedures and extended hospital stays (HOME, 2017). Furthermore, the
domestic nature of FDWs’ jobs is often ambiguous as working hours are undefined
and household tasks can be varied and at the discretion of their employer. FDWs may
therefore have to take up a wide range of responsibilities from basic housekeeping to
caring for individuals with specific needs (e.g. children or the elderly). Furthermore,
the mandatory live-in nature of the job poses difficulties for FDWs to have sufficient
opportunities to socialize with others outside to develop a social support network.
These could leave FDWs open to being overworked, with inadequate rest and time to
develop social support systems or to engage in recreational pursuits. Taken together,
the combination of migration stress (due to financial and familial stress in their
countries of origin), and the structural constraints they face in the destination country
from the inadequate legal protection and possible less than ideal working and living
conditions can put FDWs in a stressful position.
Most FDWs further face other personal circumstances that leave them open to
experiencing psychological distress. Many FDWs are also mothers (54%; HOME,
2015) who have had to leave their families behind and who have taken on most of the
responsibility in financially providing for their families back in their countries of
origin. Hence the pressure of keeping their jobs as well as facing homesickness can
concomitantly increase FDWs’ experiencing isolation, stress and overall poor
psychological adjustment (Bagley, Madrid, & Bolitho, 1997; Nakonz & Shik, 2009).
Overall, socio-cultural-legal vulnerabilities (i.e. systemic conditions) evidently can
themselves predispose FDWs to experience psychological distress during their time in
Singapore. They can also contribute to perceived (and actual) high barriers for help
seeking and perpetuate a sense of helplessness when faced with mental distress.
1.4 Empirical evidence on mental health of FDWs in Singapore
HOME conducted the first large-scale mixed-method research (N = 670) on employed
FDWs’ mental health and related factors (HOME, 2015), using a self-administered
questionnaire. This study aimed to (a) assess working and living conditions of FDWs
in Singapore, (b) establish the prevalence of mental health problems among FDWs in
Singapore, and (c) identify relationships between mental well-being and employment
conditions of FDWs in Singapore. A detailed overview on the study’s methodology
and findings can be found at HOME (2015).
Overall, there was a high level of mental distress found in the FDW population in
Singapore, with more than one out of five participants (or 24%) classified as having
poor mental health (HOME, 2015). In comparison to worldwide and local statistics,
this number indicated that FDWs were more than twice at risk of developing mental
health problems. The most severe psychological symptoms highlighted were
“psychoticism”, followed by “depression”, and “interpersonal sensitivity”. The level
of mental distress related to “psychotic” symptoms suggests that professional
treatment is required. In summary, the protective and risk factors for all FDWs’
mental health (specific factors relevant sub-sample: i.e. Filipino, Indonesian, Burmese
can be accessed from HOME, 2015) is provided in Table 1.
PEER-BASED MENTAL HEALTH SERVICES
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Protective factors:
Risk factors:
FDWs’
individual
attributes and
behaviours
Perceived privacy in the
employer’s house
A perceived integration into
the employer’s family
A perceived treatment with
dignity by the employer or
employer’s family
Satisfaction with the employer
or employer’s family and with
working in Singapore
Debt
Physical health problems
Family concerns
Homesickness
Social
circumstances
Sufficient daily sleeping hours
An own room as sleeping
accommodation
Nutritional attention and
provision of sufficient daily
proper meals by the employer
Adequate medical and dental
attention by the employer
Frequent contact to
friends/family outside
Singapore or in home country
Language-related
communication barriers with
the employer or employer’s
family
Invasions of privacy by the
employer or employer’s family
Restrictions on communication
by the employer or employer’s
family
Verbal, physical, moral and
sexual abuse by the employer or
employer’s family
Note. Effect sizes: small, medium (based on bivariate correlation analysis)
Table 1: Protective and risk factors for all FDWs’ (regardless of nationality) mental
health (HOME, 2015)
Based on the HOME (2015) study, 43% of the surveyed FDWs highlighted that they
preferred to seek help from their peers rather than from professionals such as doctors
(1.6%) when facing emotional problems. An additional qualitative analysis of
participants’ coping mechanisms, captured via responses to the question of “What do
you think is the best way to help the emotional well-being of domestic workers in
Singapore?” revealed various internal and external factors (HOME, 2015). At the
internal level, they believed that open communication with their employers, having
strong social support and adapting to Singapore’s culture and knowing its laws were
helpful. At the external level (environment), participants highlighted that having
employers who trusted them, a government that played a larger role in regulating and
enforcing decent working and living conditions and the availability of civil society
organizations that provided formal support would be helpful for them (HOME, 2015).
Overall, the empirical evidence indicates that FDWs are particularly vulnerable as a
population to experience ill mental health and that migration stressors (e.g. leaving
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families back home, debt) and the conditions they find themselves working in (post-
migration) can precipitate and perpetuate poor psychological health.
1.5 Filling the mental health service gap for migrants in Singapore: The potential
of peer-based mental health services
Evidently, based on the data above, there are multiple levels of intervention and
support that can be provided to FDWs to support their well-being:
Figure 1: Multi-systems approach towards improving FDWs’ well-being (diagram
adapted from HOME, 2015)
Strategies on the environmental level often are at the country-level. They include the
cultural and social norms operating within Singapore, the existence of policies and
methods to reduce inequalities (including exploitative socio-economic practices), and
access to support systems such as healthcare. Changes at this level however, usually
take a considerable amount of time and coordinated efforts from multiple agencies.
The mental health needs of FDWs are potentially highly specific, owing to the unique
psychosocial circumstances they operate in, and are separable to a certain extent, from
the larger host population. A comprehensive understanding of specific community
mental health needs by healthcare professionals is therefore necessary to provide
context specific and culturally sensitive services to the FDWs community.
In the context of addressing the mental health needs of FDWs in Singapore, health
care professionals in Singapore would ideally have to be cognizant of these
circumstances and utilize culturally-relevant clinical strategies so as to provide the
most sensitive assessment and treatment to them. However, and critically, FDWs
themselves face huge barriers to seeking help owing to fear and anxiety over possible
deportation and/ or lack of knowledge on where or how to seek appropriate help for
their needs (HOME, 2015).
PEER-BASED MENTAL HEALTH SERVICES
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In addressing both the lack of mental health professionals who are able to provide
culturally sensitive interventions and the perceived barriers to seeking help, the use of
peer-based services may particularly be a useful mode of reaching out and
empowering the community.
1.5.1 Delivery of psychological therapies by paraprofessionals (peers)
In recent years, peer-based interventions have risen in popularity in a variety of
institutional and community contexts across the world, and have been used across
different age groups for a range of physical health outcomes (e.g. smoking cessation),
chronic disease management (e.g. Caroll, Lankin & Cooper, 2007), and mental illness
management (e.g. Fors & Jarvis, 1995; Lawn et al., 2007). Within this approach, non-
professionals can be briefly trained and supervised and to also collaborate with mental
health professionals to enhance preventive efforts and deliver treatment (Kakuma et
al., 2011).
Paraprofessionals are often peers belonging to the community of concern who, upon
receiving some basic level training from professionals, can provide interventions
(Miller, 1999). Within mental health, the term paraprofessional generally refers to
persons without formal training in the mental health care, non-experts or lay
psychotherapists (Montgomery, Kunik, Wilson, Stanley & Weiss, 2010). While the
delivery of psychological therapies has traditionally been through mental health
professionals (Moffic, Patterson, Laval & Adams, 1984), the use of paraprofessionals
has been relied on in the development of community-based interventions in places
(e.g. developing nations) where people have minimal access to professional care
(Boothby, 1994). They also often serve as links between professional agencies and the
community (Grant, Ernst, Phipps, Streissguth & Gendler, 1996). Other than making
the treatments of common psychological disorders (e.g. depressive and anxiety
disorders) more accessible to the community (den Boer, Wiersma, Russo & Bosch,
2005), they are cost efficient and empower the target group considerably (Bedell,
Cohen & Sullivan, 2000), and there has been some evidence that paraprofessionals
can achieve outcomes that are equal to or significantly better than those of
professionals (den Boer et al., 2005; Durlak, 1979; Hattie, Sharpley & Rogers, 1984).
Cognitive-Behavioural Therapy (CBT) is one of the most researched psychological
treatments (Butler, Chapman, Forman & Beck, 2006). The evidence-base for its
efficacy in treating a range of psychological disorders continues to increase, with its
use being extended to wider forms of disorders and problems (Beck, 1997; Dobson,
2009; Salkovskis, 1996). CBT is based on the premise that psychological distress is
due to negative cognitions, and the modification of unhelpful thinking styles (and
consequently behaviours) will alleviate symptoms. In particular, there is substantive
evidence for the efficacy of CBT for the treatment of depression (Parker, Roy &
Eyers, 2003; Tolin, 2010). Depression specifically is one of the more common mental
illnesses, and the leading cause for disability worldwide (World Health Organization,
2017). Particularly in the FDW community in Singapore, depressive symptoms are
the second most prevalent (HOME, 2015). In alleviating depressive and anxiety (both
often co-occur) symptoms, there is substantial evidence to show that CBT provided
by paraprofessionals is as effective as those delivered by professionals in reducing
those symptoms (e.g. Bright, Baker & Neimeyer, 1999; Kraus-Schuman et al., 2015;
Rahman, Malik, Sikander, Roberts & Creed, 2008).
PEER-BASED MENTAL HEALTH SERVICES
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Although no studies on the use of paraprofessionals in providing mental health
services for FDWs have been conducted, given the aforementioned structural and
socio-cultural barriers to mental health care for FDWs, and the literature on the use of
paraprofessionals (peers) in the delivery of therapy for depression, it would appear
feasible to consider the training of FDWs in delivering intervention to individuals in
need within the community.
3. Pilot study: mental health paraprofessional training for Filipino FDWs
A four-week peer-based mental health paraprofessional training program, focused on
the provision of CBT by Filipina FDWs was conducted. The results of a mixed-
method evaluation of this pilot training project were used to inform the future
implementation of a permanent peer counselling service by HOME.
The training exclusively involved female Filipino domestic workers due to their
particular vulnerability in developing depressive and anxiety symptoms (see Section
1.4). Sampling this particular population was also methodologically advantageous and
pragmatic as it achieved relative sampling homogeneity (as the FDW population in
Singapore speak a variety of native languages) and most Filipino FDWs were
sufficiently proficient in the English Language (Lim, 2010; McArthur, 2003).
3.1 Study objective and methodology
The overall aim of the study was to assess the effectiveness and acceptability of a
tailored CBT-based paraprofessional training program for a selected group of Filipino
FDWs (Wong, 2016; Wong et al., 2017).
The training content was adapted from a CBT paraprofessional training manual
originally developed for Burmese refugees in North Carolina, United States of
America (Buck, 2015). The adaptation involved (1) a replacement of refugee-specific
issues with ones that were more relevant to the FDW community in Singapore, (2)
community-relevant examples and homework exercises (Wong, 2016).
40 Filipino FDWs were recruited through social media and HOME. They
additionally had to meet the following criteria (a) able to travel physically to the
training site for four consecutive weeks, (c) literate in English, (d) have had at least
nine years of formal education (Wong, 2016). They were randomized into either the
intervention (or experimental) group (EG, n = 20) or a wait-list control group (WL, n
= 20).
The program was administered in a group format on HOME premises in four
weekly, three-hour sessions by two trainee clinical psychologists. The four sessions
covered the following topics: (1) introduction, depression and migration stress, (2)
depression and abuse, (3) depression and isolation, homesickness, loneliness, and (4)
depression and suicide, review (Wong, 2016). Each session consisted of didactic
teaching, discussions and role-plays to facilitate the learning of practical CBT
delivery skills. Session handouts and homework exercises were also provided to
consolidate topical knowledge and skills (Wong, 2016).
PEER-BASED MENTAL HEALTH SERVICES
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The following measures were completed by participants prior to the training
(baseline T1), one week after completing the training program (T2, post intervention)
and two months after the training (T3, follow-up) (see Figure 2 below and refer for
further details to Wong, 2016; Wong et al., 2017):
To capture the effectiveness of the program, the following outcome variables were
measured:
a. The Depression Literacy Questionnaire (Griffiths et al., 2004) assesses general
knowledge of depression on a 3-point scale (‘true’, ‘false’ or ‘i don't know’).
b. The Knowledge of Cognitive Behavioral Therapy Questionnaire (adapted from
Buck, 2015) assesses the level of knowledge of CBT by responding to nine
multiple-choice questions.
c. The General Self-Efficacy Scale (Schwarzer & Jerusalem, 1995) scale assesses a
general sense of perceived self-efficacy on a four-point Likert scale ranging from
1 (‘not at all true’) to 4 (‘exactly true’).
d. The Self-confidence in Supporting Individuals with Depression (adapted from
Wright & Jorm, 2009) assesses the level of confidence in supporting individuals
with depression on a scale from 0 (‘no confidence at all’) to 10 (‘very confident’).
e. The Attitudes Towards Seeking Professional Psychological Help-Short Form
(Fischer & Farina, 1995) measures attitudes towards seeking help for
psychological problems from professionals on a four4-point Likert scale ranging
from 0 (‘disagree’) to 3 (‘agree’).
f. The Depression Stigma Scale (Griffiths et al., 2006) assesses respondents’ own
attitudes towards depression on a five-point Likert scale, ranging from 0
(‘strongly disagree’) to 4 (‘strongly agree’).
g. The Depression, Anxiety and Stress scale- 21(Antony et al., 1998) is a short form
of Depression, Anxiety, and Stress Scale-42 (Lovibond & Lovibond, 1995) that
measures levels of depression, anxiety and stress on a four-point Likert scale from
0 (‘did not apply to me at all’) to 3 (‘applied to me very much, or most of the
time’).
To capture acceptability of the program (at T2), the following variables were
assessed:
a. Program attendance, that is, number of sessions participants attended, and
b. Dropout rate.
c. The Client Satisfaction Questionnaire–3 (Nguyen et al., 1983), is a three-item
survey that assesses participants’ level of satisfaction with the program.
d. The Participant evaluation of training (adapted from Buck, 2015) measured i)
reasons for participating in the program, ii) participants’ satisfaction of the
training, (iii) their level of understanding of signs and symptoms of depression,
(iv) the clarity of the skills taught by the trainers, and (v) the extent to which
participants found the training useful and valuable to community members. These
were assessed through open-ended and Likert scale questions.
e. HOME evaluation survey. HOME further designed a self-administered mixed-
method evaluation questionnaire to capture participants’ perspectives on the future
implementation of the training program (this measure is detailed in Section
2.4.3.1)
PEER-BASED MENTAL HEALTH SERVICES
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T1: Baseline
Intervention
T2: Post-intervention
(1 week after training)
T3: Follow-up (2
months after training)
Figure 2: Research steps and measurement times (adapted from Wong, 2016; p. 44)
Randomization to Intervention or
Wait-List (WL) group (n = 40)
Allocated to intervention
group (n = 20)
Allocated to WL group (n = 20)
Completed baseline
questionnaire (n = 19)
Dropped out (n = 1) (reason:
work schedule problem)
Completed baseline
questionnaire (n = 20)
Completed same set of
questionnaires before start of
training and after Intervention
Group completed training (n = 19)
Dropped out (n = 1) (reason: work
schedule problem)
Training:
- Attended all sessions (n = 13)
- Attended 3 sessions (n = 5)
- Attended 2 sessions (n = 1)
Training:
- Attended all sessions (n = 13)
- Attended 3 sessions (n = 6)
Completed post-intervention
questionnaires (n = 18)
Did not complete post-intervention
questionnaires (n = 1) (reason:
repatriated back to Philippines)
Completed post-intervention
questionnaires and HOME
Evaluation Survey (n = 19)
Completed 2-month follow-up
questionnaire (n = 17)
Did not complete 2-month follow-
up questionnaire (n = 2) (reason:
lost to follow-up x1; repatriated
back to Philippines x1)
Completed 2-month follow-up
questionnaire (n = 15)
Did not complete 2-month follow-
up questionnaire (n = 4) (reason:
lost to follow-up x1; repatriated
back to Philippines x1; not in
Singapore x2)
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It was hypothesized that participants who underwent the paraprofessional training
(EG) would report significantly
a) greater knowledge of depression,
b) greater knowledge of basic CBT skills,
c) lower stigma towards people with depression,
d) improved attitudes towards seeking professional psychological help,
e) greater self-confidence in supporting individuals with depression, and
f) greater self-efficacy
from (a) pre- (T1) to post-intervention (T2) and pre-intervention (T1) to two-month
follow-up (T3), and (b) compared to the wait-list group (CG) participants before
intervention.
Statistical analyses involved descriptive and inferential statistical procedures, such as
chi-square tests, independent and paired-sample t-tests, hierarchical linear multiple
regressions and Spearman’s rank-ordered correlations (on a 95% confidence level) to
test the hypotheses (for more details, refer to Wong, 2016). Effect-sizes (Cohen’s d)
were also reported to examine the clinical significance of observed changes over time
and (b) within groups (Cohen, 1988), for which values of .02, .05 and .08 represent
small, medium and large effects, respectively (Field, 2005).
3.2 Results
Statistical analyses revealed that there were no significant differences between the
groups on any of the demographic variables or outcome measures (i.e. depression
literacy, knowledge of CBT, general self-efficacy, self-confidence in supporting
individuals with depression, attitudes towards seeking professional psychological
help, levels of depression, stress and anxiety) at baseline (Wong, 2016). The
demographic variables also did not predict changes on any of the outcome measures,
suggesting there is no potential for co-variation. This therefore allowed for the
combination of both the intervention and wait-list groups (i.e. combined sample) for
the pre-post-follow-up analysis of the outcome variables (Wong, 2016).
The table below provides an overview of the sample characteristics based on
demographic variables of the study participants:
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Table 2: Sample description (adapted from Wong, 2016, p. 42)
Variable
Value
Intervention
Group (n =
19)
WL Group
(n = 19)
Age
Mean (range)
37.6 (27-50)
39.6 (32-53)
Marital status
Single, never married (%)
Married (%)
Separated, divorced, widowed (%)
36.8
31.6
31.6
60
20
20
Education
Completed High School
(Secondary) 4 years
Completed University
78.9
!
21.1
65
!
35
Religion
Roman Catholic
Christian
73.7!
26.3
70
30
Time working
in Singapore
Mean years (range)
9.3 (3-24)
9.6 (1-24)
Number of rest
days in current
job
1/ week and public holidays (%)
1/ week (%)
2/ month (%)
3/ month (%)
57.9
36.8
0
5.3
60
30
5
5
3.2.1 Effectiveness of training program
Following training, both groups (i.e. IG and WL group) showed significantly greater
depression literacy, CBT knowledge, improved attitudes towards seeking professional
psychological help, and lower stigma towards depression (see Wong, 2016 for
detailed descriptions of statistical procedures, results and discussion).
Depression literacy and CBT knowledge: From baseline (T1) to post-intervention
(T2), both groups demonstrated significant increases in depression literacy (t(36) =
3.00, p <. 001, d = .09) and CBT knowledge (t(36) = 2.63, p < .05, d = .04).
A significant increase in depression literacy pre to post training (t(29) = 5.80, p < .001,
d = .09) and CBT knowledge (t(31) = 2.34, p < .05, d = .04) was also measured long-
term at two-month follow-up (T3).
Attitudes towards seeking professional help for psychological problems and
depression stigma: Both groups further showed significantly improved attitudes
towards seeking professional help for psychological problems (t(36) = 2.53, p < .05, d
= .04).
At two-month follow-up (T3), the significant improvement of attitudes towards
seeking professional health for psychological problems (t(31) = 2.83, p < .01, d = .05)
compared to the baseline was sustained.
Depression stigma: Both groups showed significantly lower stigma towards
depression (t(36) = 3.00, p < .01, d = .05) from pre-to post-intervention.
Levels of stigma towards depression remained stable from baseline to follow-up, i.e.
PEER-BASED MENTAL HEALTH SERVICES
13
there were no significant changes.
General self-efficacy and self-confidence in supporting individuals with depression:
The combined sample indicated – contrary to the hypotheses – a significantly lower
general self-efficacy (t(34) = 3.51, p = .001, d =.06) from pre-to post-intervention.
However, at two-month follow-up (T3), there were no significant changes in general
self-efficacy compared to the baseline measurement. Additionally, a negative
correlation between the number of sessions attended and and change in self-
confidence (r = -.412, p<0.5) was identified, indicating that attending more sessions
was associated with reduced self-confidence.
In summary, all participants (i.e. not in comparison between the intervention group
and wait-list group), demonstrated greater knowledge of depression and basic CBT
skills as well as improved attitudes towards seeking professional psychological help
and lower stigma towards people with depression (trend observed). However, there
was a short-term (T2) decrease in participants’ general self-efficacy, which later
stabilized (T3).
3.2.2 Acceptability of training program
Program attendance: 92% of those allocated to the program completed at least 3 out
of four sessions. No significant differences were found between the number of
sessions attended and changes in assessed variables (for the program’s effectiveness)
from pre to post-training (Wong, 2016). There was a negative correlation between
number of sessions attended, level of depression stigma (r = .338, p = .058); and
stress levels as reflected on DASS (r = .340, p = .057) from pre-training to two-
month follow-up.
Dropout rate: Overall, 97% of participants attended 75% of the training (i.e. 3 out of
4 sessions), indicating a degree of feasibility. Three participants did not complete the
intervention - one did not achieve the minimum 75% attendance stipulation, one had
dropped out citing work schedule issues, and the other was repatriated to the
Philippines (refer to Figure 2). Of the remaining 37 participants who completed the
intervention, 26 attended all four sessions (70%), while 11 attended three sessions
(30%). Therefore based on the original participant number of 40, the attrition rate is
7.5%.
Participant satisfaction: On the satisfaction with the program, 48.7% were very
satisfied with it, while 51.4% were mostly satisfied. No one was unsatisfied. All
participants also reported a perceived increase in knowledge and skills to be more
valuable and helpful to the community (75.7% strongly agreed and 24.3% agreed).
This could be indicative of a sense of enhanced empowerment amongst the
participants.
Additionally, participants’ reasons for participating in the training program (through
an open-ended question on the participant evaluation questionnaire) were
descriptively captured and subsequently categorised (Wong, 2016). The main reasons
participants highlighted were:
PEER-BASED MENTAL HEALTH SERVICES
14
Table 3: Participant reasons for participation
Reason
n
To help others including family and friends who need help
28
To gain more knowledge about mental health, depression, CBT and
coping skills
25
To help oneself
25
3.2.3 HOME’s evaluation
Participants were also invited to complete an additional post-training assessment. This
assessment measure was developed by HOME to further elicit participants’ views on
implementing the paraprofessional training program as part of HOME’s welfare
services. This measure was administered alongside the other measures described
above to both groups one week after the training ended (T2). Both open-ended and
multiple-choice questions were used and covered three areas: (a) assessment of CBT
training, (b) satisfaction with CBT training, and (c) Implementation of peer
counseling service as part of HOME’s mental health program. Descriptive statistics
are presented below (n = 37).
Assessment of CBT training: The majority of participants (59.5%) indicated that the
aspect they liked the most were the CBT-specific techniques (e.g. thought record) as
well as counseling micro skills (e.g. reflective listening). On the aspects that they
liked the least, 43% indicated that there was nothing they did not like and they
enjoyed all aspects of the program, 40.5% highlighted specific CBT skills (e.g.
thought monitoring, goal setting) and session topics (e.g. abuse and suicide), and the
rest did not favour doing homework exercises between sessions.
Satisfaction with CBT training (i.e. the trainers and training satisfaction): On trainer
satisfaction: 86.5% were ‘very satisfied’, and the remaining 13.5% were ‘satisfied’.
Qualitative data revealed that majority of the participants found the trainers to be
“understanding”, “clear”, “informative” and “helpful”. On satisfaction with the
training overall: 75.7% were ‘very satisfied’, 21.6% were ‘satisfied’ and 2.7%
indicated ‘neutral’. The primary reason for their satisfaction was the perceived
enhancement of their knowledge and skill set. Furthermore, although many had
expressed gratitude at having the training opportunity, some challenges were reported.
These largely related to difficulties understanding the training material and the
perception that the four-week training bloc was too rushed.
Implementation of peer counseling service: Participants’ views on service delivery
matters (e.g. language, communication platform) as well training and development
issues (e.g. willingness to be supervised, further training sessions) were also sought:
PEER-BASED MENTAL HEALTH SERVICES
15
Table 4: Preferences on service delivery and training/ development issues
Question
Response (multiple choice)
*participants could select
more than one option
% (n =
37)!
Communication preference
(best way to help a FDW in distress)?
In person
Telephone
Email/ text message
Social media (e.g. Facebook)
75.7
16.2
10.8
21.6!
Language preference?
English
Tagalog
Mixture of English &
Tagalog
21.6
5.4
73
Availability to be a peer counsellor for
HOME?
Yes
Maybe/ Not sure
No
70.3
29.7!
0
Willingness to attend more training
sessions?
Yes
Maybe/ Not sure
No
81.1
18.9
0
Willingness to be supervised by a mental
health professional regularly?
Yes
Maybe/ Not sure
No
73
21.6
5.4
Communication preference: Consistent with research on migrants’ culturally-
informed perceptions of help-seeking and previous empirical evidence (HOME, 2015;
Selkirk, Quayle & Rothwell, 2014), majority of the sample preferred providing
assistance to their fellow FDWs through face-to-face contact. A follow-up qualitative
analysis revealed that the majority felt that physical presence would enable better
understanding of one’s difficulties and to express concern – i.e. a perceived greater
relational intimacy with the support seeker.
Language preference: Similarly, the majority preferred providing the service in a
mixture of Tagalog (the Philippines’ national language) and English. Apart from
participants’ personal comfort levels with language choice, linguistic (and cultural)
similarity with the service consumer (peer) is advantageous given that it facilitates
communication of culturally bound mental health beliefs and symptom expression.
This can further elicit the perception of being understood. Research has indicated that
ineffective intercultural communication (e.g. being misunderstood by a health
professional of host country due to accent issues or language proficiency) is a barrier
to seeking healthcare services amongst migrants (Gluszek & Dovidio, 2010; Maneze,
DiGiacomo, Salamonson, Descallar & Davidson, 2015). The participants’ choice of
both English and Tagalog also indicates their recognition of flexibility and fitting with
the service consumer’s language preference.
Availability to be peer counsellors: Although the majority indicated that they were
available to be peer counsellors for HOME and preferred face-to-face service
PEER-BASED MENTAL HEALTH SERVICES
16
provision, the frequency for in-person availability was expectedly limited. Most were
only available on Sundays (i.e. the usual rest day for domestic workers in Singapore),
with a minority available on weekday evenings. The greatest availability was found to
be via social media or text messaging. This suggests that flexibility in service
provision will be necessary, with due consideration given to setting and time in order
to accommodate the realities of the working lifestyle of most FDWs in Singapore.
Willingness for further training and supervision: Research has indicated the
importance of continued education and skill development of paraprofessionals
(Durlak, 1979). This is especially important as despite the empirical evidence
supporting the value of paraprofessionals, there have been reports of inadequate
training and supervision, unethical behaviour and professionals’ misgivings of
paraprofessionals’ clinical performance (Durlak, 1979). Continuing education and
training and clinical supervision are considered to be the primary methods of
improving paraprofessionals’ service delivery (Sotelo, 2015). These are expected to
assist paraprofessionals in developing technical knowledge and skills as well as to
consequently increase their perceived efficacy in service delivery (Durlak, 1973;
Sotelo, 2015).
The majority of the participants indicated a willingness to attend further training and
to be supervised by a mental health professional. This finding is especially vital in
further highlighting the acceptability of the peer/ paraprofessional approach amongst
the participants. Despite, short-term lowered self-efficacy of the participants, it is
encouraging that the participants recognised that they needed more support and were
open to investing their time and efforts in additional training and supervision.
3.3 Significance of results
As to the substantive or clinical significance of the results, the short and long-term
increase (T2 and T3) in depression literacy is of a large magnitude with a confidence
level of over 99.99%. This outcome strongly underlines the learning impact of the
training, especially given the small sample size. Additionally, enhanced literacy is
hypothesised to facilitate one’s own help-seeking behaviour and for identifying and
assisting others in need (Rickwood & Braithwaite, 1994). Although there was a
significant increase in CBT knowledge, the post-training effect was of a small effect
size. This suggests that there is a need to address any pedagogical issues in content
delivery so as to maximise participants’ learning of CBT’s principles and methods. It
is likely that the program was too intensive (i.e. too much information and too little
time). Participants’ comprehension levels could also be affected by language issues or
preferences (this will be discussed in section 2.5.3.1 when considering overall training
evaluation data). The increase in attitude towards seeking professional help (with a
medium effect size at T3) suggests a benefit of in this population as to the known
hesitation to seek help when facing mental health problems (e.g. the fear of
deportation if having health issues, as mentioned in the introduction). Equally, the
short term decrease in stigma levels towards people with depression (which remained
stable over time) suggests that the training is helpful in confronting mental health
related stigma. This is especially a crucial finding as stigma itself discourages mental
health service utilisation. Filipinos in particular have been found to be generally
reluctant in seeking professional help for psychological problems (Hechanova, Tuliao,
PEER-BASED MENTAL HEALTH SERVICES
17
Teh, Alianan, & Acosta, 2013), with Filipino migrant workers facing added barriers
such as fears of deportation and cultural mistrust (David, 2010). Research has also
documented that this hesitance could be due to Filipino cultural norms such as
internalised shame (‘e.g. hiya’) or culturally bound lay conceptualisations of mental
illness that is incompatible with the medical model (Abdullah & Brown, 2011; Lauber
& Rössler, 2007; Tuliao, 2014). Indeed it has been found that such lay mental health
beliefs in the Philippines exist. These create the impression that mental health
professionals are not helpful or that mental illnesses are due to supernatural causes or
due to an individual’s weakness in his or her willpower or character fraility which
altogether emphasise personal blame and responsibility (Santa Rita, 1993; Thompson,
Manderson, Woelz-Stirling, Cahill & Kelaher, 2002; Tuliao, 2014).
With regards to medium effect size of the decrease in participants’ general self-
efficacy following training, it is likely that participants could have been overwhelmed
by the new knowledge and skills they had learnt within a short period of time. It is
likely that ‘unlearning’ or assimilating a new way of handling emotional difficulties is
a substantial endeavour and could have left participants feeling inadequate in applying
the new information and skills learnt (as opposed to mere receipt of new knowledge –
e.g. symptoms of depression). This is plausible given the aforementioned culturally
bound norms of handling psychological difficulties in Filipina society (e.g. Tuliao,
2014). Additionally, observations by the facilitators of the program (the first and third
authors of this paper), indicated that majority of participants had particular difficulties
during the role-play component of the program, which required participants to
demonstrate skills. Participant’s struggles included using counseling microkills (e.g.
reflective listening) and applying the CBT ‘hot-cross bun model’- both of which are
necessary for the effective delivery of CBT. Participants had difficulties utilising a
collaborative approach and were observed to be relying on directive, advice-giving
methods as one would so with a friend. This also appears to be consistent with
literature – for instance, within the Filipino community, the etiology of depression is
seen as relationship-related and resolvable through talking with friends, family or
community members (Hechanova, Tuliao & Ang, 2011; Tuliao, 2014), and as such,
within cultural norms, seen as the ‘best’ way to handle such emotional distress. While
this does signify that peer-support is beneficial and favourable generally, cultural
considerations will have to be accounted for in the context of efficaciously delivering
specific psychological therapies as peer paraprofessionals (or professionals; Hwang,
Myers, Abe-Kim & Ting, 2008; Yamada & Brekke, 2008). Yet another explanation
could have been that participants, while filling out the general self-efficacy scale –
which is a global measure of personal agency in dealing with a range of demanding or
novel situations and that which is influence by one’s mastery (Bandura, 1994;
Schwarzer, 1994) – could have rated their competence in handling challenging
situations based on their perceived (lack of) ability in mastering the necessary skills in
supporting individuals with depression following the training, thereby affecting self-
efficacy ratings.
PEER-BASED MENTAL HEALTH SERVICES
18
4. Implementing peer-based mental health services for FDWs in Singapore
4.1 Implications of the pilot study results for the implementation of
paraprofessional training
As to the recruitment of peer counsellors, the transient nature of FDWs poses a
structural service dilemma for HOME. This is because FDWs in Singapore enter
Singapore generally on (renewable) 2-year work permits. This together with the fact
that they can be repatriated at any time without reason, brings the sustainability of a
relatively stable group of paraprofessionals (or peer support providers in general) into
question. Pilot results further indicate the need for modifications to future
paraprofessional training programs. As to the training period, given the intensity of
the four weekly 3-hour training sessions, and the steep learning curve of the
participants, the most evident modification recommended is to increase the training
period with shorter sessions so as to maximize learning and the acquiring of skills
through more opportunities for practice. The program would also likely benefit from
further cultural adaptations that involve not only FDW specific issues (that has been
done in the current program) but also adaptations that are unique to the Filipino
community (and the other nationalities in the future – e.g. Burmese, Indonesian).
Hence the consideration of the ‘multiple cultures’ (Rathod & Kingdon, 2009) that
migrant workers live in is vital. This would ultimately produce more culturally
sensitive paraprofessional training and care. This is also consistent with the general
call to the mental health profession to incorporate cultural adaptations into their
delivery of empirically founded psychological therapies (such as CBT) to minority
clients (such as migrants; Bernal, Jimenez-Chafey & Rodriguez, 2009). There is
recognition that without sensitivity to cultural norms, there would be a barrier during
the cognitive and behaviour change process, which affects a treatment’s efficacy
(Rathod & Kingdon, 2009). A useful conceptual framework for incorporating cultural
adaptations into mental health services is provided by Healey and colleagues (2017).
In general the adaptations can occur across three levels – (a) community outreach and
involvement (e.g. involving FDWs in the adaptation process), (b) changes in structure
and process of service delivery (e.g. matching language and/ or nationality of FDW
with that of trainer’s; translation of material to native language as a supplement), and
(c) adaptation of content (e.g. cultural allusions, references to values, culturally
appropriate examples). Finally,!it will be necessary to develop a base of mental health
professionals willing to provide continual training and supervision to these
paraprofessionals. However, a key challenge of this would be to have professionals
who are familiar with the FDW community and the key issues they face, as well as to
provide their expertise as supervisor on a voluntary basis. Apart from issues of
manpower, a system of assessing paraprofessional training outcomes (e.g. assessment
and evaluation measures) will need to be developed.
4.2 Envisioning community-level care with a stepped-care approach
The paraprofessional training described above has focused on the delivery of CBT to
alleviate depressive and anxiety symptoms. However, the scope of peer-based mental
health services can be expanded to include preventive services. With the recognition
that there is “no health without mental health” (Prince et al., 2007, p. 859) and the
importance of mental health for living a socio-economically productive life,
PEER-BASED MENTAL HEALTH SERVICES
19
preventive programs would be particularly useful for the FDW community to enhance
the community’s mental health literacy and to also subsequently facilitate help-
seeking behaviour without a fear of repercussions.
Given the vast heterogeneity of peer-based mental health interventions in the
literature (Brown et al., 2007; Simoni, Franks, Lehavot & Yard, 2011), appropriate
frameworks would also guide HOME’s program development.
Figure 3 below presents Brown and colleagues’ (2007) framework for identifying the
scope of peer-based interventions in mental health. It was developed to support
current and forthcoming peer-support initiatives (Brown et al., 2007).
Figure 3: A framework for positioning peer-based approaches in mental health
promotion (Brown et al., 2007)
The framework above highlights a range of possible peer-based approaches that
mental health service delivery can take. In the case of the paraprofessional initiative,
it would likely best fit within “formal support” group of interventions. There are other
possible areas of preventive intervention that can occur to further empower FDWs in
Singapore. In particular, mental health professionals could be involved in developing
and conducting thematic mental health literacy workshops that serve to enhance
knowledge and to impart skills and/ or healthy coping methods (much like a ‘self-
help’ book). Members of the FDW community could also then be involved in
translating the material or to also collaboratively conduct the workshops to the
community (i.e. culturally sensitive psychoeducation). Given the strong social
networks within the FDW community in Singapore, such knowledge may also be
informally passed down (i.e. a ‘trickle down’ effect) to members of the community.
Similarly, information technology methods can also be capitalized on to deliver
content knowledge, given that the use of social media amongst FDWs in Singapore is
rife (HOME unpublished research). It is envisaged that such efforts in spreading
mental health awareness can somewhat attenuate the stigma of mental health issues
(that is prevalent amongst many Asian cultures; Ng, 1997) within the FDW
community through enhanced knowledge and to consequently facilitate greater help-
seeking behaviour.
PEER-BASED MENTAL HEALTH SERVICES
20
It is recognised that while peer-based services may be empowering for the migrant
community, such services alone may not be sufficient to provide comprehensive
mental health care to the FDW community. It is therefore necessary that some thought
be given to incorporating the formal health care system into providing services for the
community (i.e. a community-level care model). In particular, peer-based programs
would be well positioned to fit at the lowest level within a stepped-care (SC)
approach to mental health service delivery for the community. The SC approach is
used as means of improving the public’s access to psychological therapies (Richards
et al., 2012). Under this approach, the majority of individuals are first provided with
the least intense, least expensive and least restrictive (i.e. the most effective yet least
resource intensive) intervention in the first instance (level 1). Individuals who do not
respond well to this first level of treatment will be then “stepped up” (to level 2) to
more intense interventions. At this level, treatment is provided by professionals in an
outpatient setting and for presenting concerns that are more severe. At level 3
(highest), treatment would be provided in an in-patient setting.
The stepped-care approach also recognizes that a partnership between the professional
community and the FDW community is vital for providing mental health
interventions that will best resonate with the FDW community’s needs and interests.
At the most basic level, peer-based approaches would facilitate within the FDW
community (1) knowledge and (2) access to a safe social space to address any mental
health concerns. Given that HOME is highly familiar to the FDW community, and has
played a significant role in advocating for them in Singapore, it is arguably best
positioned to build the peer-based service and to facilitate the building of professional
networks higher up the rungs of the stepped-care model. Mental health professionals
who eventually form a part of this network of mental health care providers would also
ideally be culturally sensitive to the needs and difficulties of the FDW community.
4. Conclusion
The FDW community in Singapore is generally susceptible to developing mental
health difficulties. Having left their families behind, they often come to work in
Singapore with a perceived loss of social support and increased stress and anxiety
from dealing with acculturation issues, and possible distressing work and living
conditions. However, the community is in general reluctant to seek professional help
for psychological difficulties. This can be due to a persistent anxiety and fear of
possible repatriation if found ill, or specific cultural barriers. Given the importance of
mental health for living a meaningful and productive life, it is crucial that the mental
health needs of FDWs be addressed on multi-systemic levels.
Overall, given that the paraprofessional training study is the first of its kind to be
conducted with the FDW community, its results are promising. The paraprofessional
program was well-received by the participants, as evidenced by both the low drop out
rates, willingness (motivation) to engage in further training and supervision as well as
their interest in becoming a peer counsellor for HOME. Notwithstanding these
encouraging signs, there are further considerations to be accounted for if this
paraprofessional training program and a subsequent peer counseling service is to be
developed and sustained in the long-run by HOME.
PEER-BASED MENTAL HEALTH SERVICES
21
The peer-based approaches discussed in this paper could potentially help and
empower the community to address their own psychological needs in a culturally
congruent manner, alongside the current socio-legal constraints FDWs face. While
peer-based mental health services may be feasible in forming a preventive and first-
line approach towards managing psychological distress, it is equally necessary that
affordable, accessible and sensitive systems of formal mental healthcare be developed
to serve the FDW population in Singapore.
HOME’s lead on this role is also a small step towards advocating for FDWs’ rights to
access mental health care, through not only empowering FDWs but also through
forging collaborative partnerships with mental health agencies and professionals who
are keen to know more and to develop contextually appropriate mental health
interventions for the community. It is hoped that these partnerships will eventually
form a stable referral system through which FDWs can access affordable, yet
culturally sensitive mental health care.
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PEER-BASED MENTAL HEALTH SERVICES
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... Two of the 12 included articles had a quantitative study design [44,45], four had a qualitative study design [46][47][48][49], and five had a mixed-methods study design [24,[50][51][52][53]. One article was a news report [54]. ...
... One article was a news report [54]. Four of the articles were conducted in Hong Kong SAR, China [45,[48][49][50]; three in Singapore [51,53,54]; two in Macao SAR, China [44,47]; another three from each of the three countries, including South Korea [52], Philippines [24], and Canada [46]. The number of participants of the included articles varied significantly from 5 [52] to 2017 [50], and the mean or median age ranged from 35.1 [24] to 42.9 years [47]. ...
... Another type of peer support was para-professional trained peer support, which trained MDWs as peer supporters with some professional helping or counselling skills to provide peer support for other MDWs with supervision and support from healthcare professionals, such as psychologists [51,53,54]. Wong and colleagues [51,53,54] developed a mental health para-professional training program for Filipino MDWs in Singapore. ...
Article
Full-text available
The effectiveness of peer support in improving mental health and well-being has been well documented for vulnerable populations. However, how peer support is delivered to migrant domestic workers (MDWs) to support their mental health is still unknown. This scoping review aimed to synthesize evidence on existing peer support services for improving mental health among MDWs. We systematically searched eight electronic databases, as well as grey literature. Two reviewers independently performed title/abstract and full-text screening, and data extraction. Twelve articles were finally included. Two types of peer support were identified from the included studies, i.e., mutual aid and para-professional trained peer support. MDWs mainly seek support from peers through mutual aid for emotional comfort. The study's findings suggest that the para-professional peer support training program was highly feasible and culturally appropriate for MDWs. However, several barriers were identified to affect the successful implementation of peer support, such as concerns about emotion contagion among peers, worries about disclosure of personal information, and lack of support from health professionals. Culture-specific peer support programs should be developed in the future to overcome these barriers to promote more effective mental health practices.
... Poor communication could jeopardize the FDWs' interpersonal relationships with their colleagues, care recipients and their family members. Language-related communication barriers with the care recipient or care recipient's family can be described as risk factors for FDW's mental health [36,37]. Our thematic analysis revealed that employers, supervisors, and colleagues all contribute to the FDW's mental health status, whether it be positive or negative. ...
Article
Full-text available
Taiwan is expected to reach super-aged status by 2026, leading to an increased demand for elderly caregiving services. Low local unemployment and a dwindling working-age population mean the island’s care system relies heavily on female foreign domestic workers (FDWs) from Southeast Asian neighbors such as Vietnam to satisfy labor shortages. Although suggested by anecdotal evidence, limited research has been conducted on the link between the shortfall in FDW qualifications, training, preparedness, and expertise and their employment stressors. Therefore, this study aims to assist FDWs by evaluating their stressors and helping them better understand health care delivery by (1) administering the Modified Caregiver Strain Index (MCSI) revised 2003 questionnaire, (2) performing semi-structured in-depth one-on-one interviews, (3) classifying interview results according to thematic analysis, and (4) using these themes to devise and deliver a 12-week multilingual health education teach-back program. Our results indicate that Vietnamese FDWs face specific challenges, including language barriers, homesickness, intensive physical and psychological work demands, stress adaptation, and occupational exposures. Despite yielding no significant improvements in caregiving strain, our intervention, conducted at the height of the COVID-19 pandemic, pinpoints and classifies areas of grave concern and proposes recommendations that can assist long-term care (LTC) stakeholders in understanding and overcoming their respective challenges, thereby improving the quality of elderly care.
Technical Report
Singapore is one of the largest destination countries for foreign domestic workers (FDWs) in Southeast Asia. Yet, evidence suggests that FDWs in Singapore are vulnerable to labour exploitation due to a lack of adequate work regulations and legal protection, and the systemic nature of their employment conditions. The aim of this research was to (a) identify the extent and practices of labour exploitation and associated risk factors among employed FDWs in Singapore, based on (inter)national standards of labour rights, as well as to (b) gain an exploratory understanding of the underlying psychological, socio-economic and legal mechanisms of labour exploitation in Singapore. The research adopted a mixed-method approach and involved overall 799 FDWs and 80 FDW employers. Empirical evidence was collected in three stages. Qualitative data were captured from FDW focus groups (N = 13) during the design phase to inform research criteria for the main data collection. The main data collection included the collection of quantitative and qualitative data via semi-structured interviews with 735 employed Filipino and Indonesian FDWs in Tagalog and Bahasa Indonesia respectively (stratified convenience sample). A follow-up discussion with FDW employers (N = 80) and FDWs (N = 51) sought their views and opinions on possible solutions to mitigate labour exploitation in Singapore. As to the prevalence of labour exploitation, in total only one-third (33%) of the 735 surveyed FDWs were employed in work conditions in which there was no reported exploitation or coercion by their employers, as defined by the International Labour Organization (ILO). The majority of workers (60%) were identified as exploited, of which 23% were identified as victims of forced labour, a form of labour exploitation with both exploitative and coercive elements. 10% of surveyed FDWs were identified as being trafficked (through deception and/or coercion) into their current exploitative employment, whereby the majority of these workers were trafficked into forced labour conditions. Based on a total number of 243,000 documented FDWs in Singapore, it is estimated that more than 145,000 FDWs in Singapore might be affected by exploitative employment conditions, of which over 55,000 workers are likely to be victims of forced labour. Furthermore, over 24,000 FDWs in Singapore could have been trafficked into exploitative foreign domestic work in Singapore. Overall identified risk factors for FDW exploitation are coercive employer behaviour and the worker incurring expenses for necessities, which are likely to compensate for employer neglect. FDWs in forced labour, i.e. when coercive employer behaviour is used to extract exploitative labour, are especially more likely to incur expenses for necessities and to use their personal finances to pay for meals and other essentials that should be provided by their employer as mandated by Singapore law. Further, FDWs who are victims of forced labour are more likely to have a short current employment duration (of six or fewer months), experience language barriers when communicating with their employer, and be of Filipino nationality. During recruitment, FDWs who were deceived about employment conditions and experienced coercion during their recruitment are more likely to be trafficked into exploitative work in Singapore, mainly in the form of forced labour. Regarding involved parties, multiple economic dependencies exist (apart from the FDW’s financial dependents in her country of origin) between the FDW and her employer, the recruiter in the FDW’s home country and her employment agency in Singapore, as well as between the FDW employer and the Singapore government. These dependencies are based on different debt bondages that lead to various salary deductions for the FDW and costs for the employer and leave the worker seriously economically disadvantaged with an average salary even below the average in her home country. We conclude that labour exploitation in Singapore is, in fact, systemically enabled bonded labour. Focusing on the mitigation of FDW labour exploitation in Singapore, most surveyed FDW employers (67%) reacted positively towards having the option of live-out accommodations for FDWs, which could decrease excessive working volume (93% of FDWs in the sample were affected) and isolation (66% affected) experienced by FDWs in Singapore. As to the abolishment of the security bond that all employers must pay to the Singapore government, most employers recognized structural dependencies between the bond and a perceived responsibility for their employee beyond work, and, in concordance with FDWs discussion participants, desired a change in the existing legal system. This study serves as the first large-scale research to identify the prevalence and manifestations of labour exploitation among FDWs in Singapore and provides statistically conclusive relationships between labour exploitation on the one side and coercive employer behaviour, abuse of the FDW’s vulnerability in Singapore, and deceptive and coercive recruitment. We further captured FDW experiences and assessment of labour exploitation as well as the acceptance of FDW employers, as key stakeholders, as to possibilities to mitigate labour exploitation through selected amendments in the Singapore FDW employment conditions. FDWs continue to play an important role in Singaporean households, and many of these workers have become a part of their employer’s family. FDWs are integral not just to the Singaporean society, but also to its economy. The appreciation of their contribution should be reflected in Singapore’s laws and regulations, and in the way FDWs are treated and cared for. As such, this research provides empirical evidence to allow for informed decision making to foster implementation and enforcement of fair, decent and dignified foreign domestic work in Singapore.
Technical Report
Full-text available
Singapore is one of the largest destination countries for foreign domestic workers (FDWs) in Southeast Asia. Yet, evidence suggests that FDWs in Singapore are vulnerable to labour exploitation due to a lack of adequate work regulations and legal protection, and the systemic nature of their employment conditions. The aim of this research was to (a) identify the extent and practices of labour exploitation and associated risk factors among employed FDWs in Singapore, based on (inter)national standards of labour rights, as well as to (b) gain an exploratory understanding of the underlying psychological, socio-economic and legal mechanisms of labour exploitation in Singapore. The research adopted a mixed-method approach and involved overall 799 FDWs and 80 FDW employers. Empirical evidence was collected in three stages. Qualitative data were captured from FDW focus groups (N = 13) during the design phase to inform research criteria for the main data collection. The main data collection included the collection of quantitative and qualitative data via semi-structured interviews with 735 employed Filipino and Indonesian FDWs in Tagalog and Bahasa Indonesia respectively (stratified convenience sample). A follow-up discussion with FDW employers (N = 80) and FDWs (N = 51) sought their views and opinions on possible solutions to mitigate labour exploitation in Singapore. As to the prevalence of labour exploitation, in total only one-third (33%) of the 735 surveyed FDWs were employed in work conditions in which there was no reported exploitation or coercion by their employers, as defined by the International Labour Organization (ILO). The majority of workers (60%) were identified as exploited, of which 23% were identified as victims of forced labour, a form of labour exploitation with both exploitative and coercive elements. 10% of surveyed FDWs were identified as being trafficked (through deception and/or coercion) into their current exploitative employment, whereby the majority of these workers were trafficked into forced labour conditions. Based on a total number of 243,000 documented FDWs in Singapore, it is estimated that more than 145,000 FDWs in Singapore might be affected by exploitative employment conditions, of which over 55,000 workers are likely to be victims of forced labour. Furthermore, over 24,000 FDWs in Singapore could have been trafficked into exploitative foreign domestic work in Singapore. Overall identified risk factors for FDW exploitation are coercive employer behaviour and the worker incurring expenses for necessities, which are likely to compensate for employer neglect. FDWs in forced labour, i.e. when coercive employer behaviour is used to extract exploitative labour, are especially more likely to incur expenses for necessities and to use their personal finances to pay for meals and other essentials that should be provided by their employer as mandated by Singapore law. Further, FDWs who are victims of forced labour are more likely to have a short current employment duration (of six or fewer months), experience language barriers when communicating with their employer, and be of Filipino nationality. During recruitment, FDWs who were deceived about employment conditions and experienced coercion during their recruitment are more likely to be trafficked into exploitative work in Singapore, mainly in the form of forced labour. Regarding involved parties, multiple economic dependencies exist (apart from the FDW’s financial dependents in her country of origin) between the FDW and her employer, the recruiter in the FDW’s home country and her employment agency in Singapore, as well as between the FDW employer and the Singapore government. These dependencies are based on different debt bondages that lead to various salary deductions for the FDW and costs for the employer and leave the worker seriously economically disadvantaged with an average salary even below the average in her home country. We conclude that labour exploitation in Singapore is, in fact, systemically enabled bonded labour. Focusing on the mitigation of FDW labour exploitation in Singapore, most surveyed FDW employers (67%) reacted positively towards having the option of live-out accommodations for FDWs, which could decrease excessive working volume (93% of FDWs in the sample were affected) and isolation (66% affected) experienced by FDWs in Singapore. As to the abolishment of the security bond that all employers must pay to the Singapore government, most employers recognized structural dependencies between the bond and a perceived responsibility for their employee beyond work, and, in concordance with FDWs discussion participants, desired a change in the existing legal system. This study serves as the first large-scale research to identify the prevalence and manifestations of labour exploitation among FDWs in Singapore and provides statistically conclusive relationships between labour exploitation on the one side and coercive employer behaviour, abuse of the FDW’s vulnerability in Singapore, and deceptive and coercive recruitment. We further captured FDW experiences and assessment of labour exploitation as well as the acceptance of FDW employers, as key stakeholders, as to possibilities to mitigate labour exploitation through selected amendments in the Singapore FDW employment conditions. FDWs continue to play an important role in Singaporean households, and many of these workers have become a part of their employer’s family. FDWs are integral not just to the Singaporean society, but also to its economy. The appreciation of their contribution should be reflected in Singapore’s laws and regulations, and in the way FDWs are treated and cared for. As such, this research provides empirical evidence to allow for informed decision making to foster implementation and enforcement of fair, decent and dignified foreign domestic work in Singapore.
Article
Full-text available
Background: Membership in diverse racial, ethnic, and cultural groups is often associated with inequitable health and mental health outcomes for diverse populations. Yet, little is known about how cultural adaptations of standard services affect health and mental health outcomes for service recipients. This systematic review identified extant themes in the research regarding cultural adaptations across a broad range of health and mental health services and synthesized the most rigorous experimental research available to isolate and evaluate potential efficacy gains of cultural adaptations to service delivery. Methods: MEDLINE, PsycINFO, CINAHL, EMBASE, and grey literature sources were searched for English-language studies published between January 1955 and January 2015. Cultural adaptations to any aspect of a service delivery were considered. Outcomes of interest included changes in service provider behavior or changes in the behavioral, medical, or self-reported experience of recipients. Results: Thirty-one studies met the inclusion criteria. The most frequently tested adaptation occurred in preventive services and consisted of modifying the content of materials or services delivered. None of the included studies focused on making changes in the provider's behavior. Many different populations were studied but most research was concerned with the experiences and outcomes of African Americans. Seventeen of the 31 retained studies observed at least one significant effect in favor of a culturally adapted service. However there were also findings that favored the control group or showed no difference. Researchers did not find consistent evidence supporting implementation of any specific type of adaptation nor increased efficacy with any particular cultural group. Conclusions: Conceptual frameworks to classify cultural adaptations and their resultant health/mental health outcomes were developed and applied in a variety of ways. This review synthesizes the most rigorous research in the field and identifies implications for policy, practice, and research, including individualization, cost considerations, and patient or client satisfaction, among others.
Article
Full-text available
This article examines the legal framework regulating unskilled and low-skilled migrant workers in Singapore. It argues that the current legal framework discriminates against these migrant workers and conceptualizes them as undesirable for inclusion in the wider society. This, it is contended, is premised on the assumption that migrant workers could be sequestered from the local population to some extent. This article provides some challenges to this assumption, highlighting instead some of the broader social and political consequences of this exclusionary legal framework. Consequently, it is argued that a more inclusive and integrationist approach is needed, and some positive developments are highlighted.
Article
Full-text available
Understanding factors that influence health-seeking behaviour of migrants is necessary to intervene for behaviour change. This paper explores Filipino migrants’ perceptions of facilitators and barriers to maintaining health in Australia. Open-ended survey item responses reflecting factors that assisted and hindered health following migration to Australia were inductively analysed. Three hundred and thirty-seven of the 552 survey respondents (61%) provided open-ended responses. Responses were grouped into two major categories: individual factors, including personal resources and cultural influences, and environmental factors encompassing both the physical conditions in the host country and health service access. Awareness of practices that enhance health was a major personal facilitator of health-seeking behaviour; however, competing priorities of daily living were perceived as barriers. Cultural beliefs and practices influenced health-seeking behaviour. Despite high self-rated English language skills in this population, new migrants and the elderly cited communication difficulties as barriers to accessing health services. Insight into facilitators and barriers to health-seeking behaviour in this less researched migrant population revealed tools for enhancing engagement in health promotion programs addressing healthy lifestyle.
Article
Full-text available
The Institute of Medicine advocates the examination of innovative models of care to expand mental health services available for older adults. This article describes training and supervision procedures in a recent clinical trial of cognitive behavioral therapy (CBT) for older adults with generalized anxiety disorder (GAD) delivered by bachelor-level lay providers (BLPs) and to Ph.D.-level expert providers (PLPs). Supervision and training differences, ratings by treatment integrity raters (TIRs), treatment characteristics, and patient perceptions between BLPs and PLPs are examined. The training and supervision procedures for BLPs led to comparable integrity ratings, patient perceptions, and treatment characteristics compared with PLPs. These results support this training protocol as a model for future implementation and effectiveness trials of CBT for late-life GAD, with treatment delivered by lay providers supervised by a licensed provider in other practice settings.
Poster
Introduction Approximately one in every five Singaporean households employs Foreign Domestic Workers (FDWs) (Humanitarian Organization for Migration Economics [Home], 2015). Mental health problems, especially depression, are prevalent among FDWs in Singapore (HOME, 2015). Yet, there is a lack of empirically-supported interventions to address their mental health needs. Objective To train FDWs as mental health paraprofessionals with selected CBT skills for depression, which may enable them to provide basic assistance to their fellow domestic workers with depressive symptoms. Aims To present and assess the effectiveness and acceptability of a 4 weekly 3-hour group CBT-based paraprofessional training program for FDWs. Methods Participants were randomized into either an intervention or a wait-list control group. Participants in the wait-list group received the training after the intervention group completed the training. Both groups completed questionnaires assessing attitudes towards seeking psychological help; stigma towards people with depression; self-confidence in delivering CBT; general self-efficacy; knowledge of depression and CBT before, immediately after, and two months following the training. Results Thirty-eight out of 40 participants completed the program. Both groups did not differ on changes in any of the outcome variables. However, within-group analyses showed improved attitudes towards seeking professional health for mental health issues; greater depression literacy; and CBT knowledge following the training. These changes were sustained at 2-month follow-up. All participants indicated high level of satisfaction with the program. Conclusions These preliminary results highlight the potential effectiveness and feasibility of implementing the training as a stepped-care mental health service to address the high rate of depression among the FDW community.
Article
It has long been recognized that the history and fortunes of Singapore have been closely intertwined with migrants and migration (e.g., Yeoh 2007). In this chapter, I suggest that the fortunes of the various languages in the ecology of Singapore - their various rises and falls - can also be seen to be not only intertwined with migrants and migration but also very much affected by politicians and policies. Rather than simply consider these as distinct factors in the scenario, however, I represent them as components of an integrated ecological model for understanding the dynamics of the evolution of English in Singapore.2 Such an approach in linguistic study - widely associated with work by Mufwene (e.g., 2001, 2008) - uses ecology for language as a metaphor from biology and population genetics. Ecology encompasses both internal and external aspects (or intra- and extralinguistic features): this includes not only internal factors, such as the typology of languages in the feature pool, from which an emerging linguistic variety draws its features through a process of competition and selection, and the frequency of particular linguistic features; it also includes external factors, such as power relations between speakers of the languages, relative prestige of languages, and so on, all of which contribute to the relative dominance of a language. The significance of ecology in the investigation of linguistic features of Singapore English (SE) has been demonstrated in previous work, addressing discourse particles (Lim 2007a, 2007b, 2009a) and the presence of tone (Lim 2008b, 2009b, forthcoming), focusing in particular on internal factors of the ecology, namely the typological dominance of Sinitic varieties in the feature pool - Cantonese, in particular, where particles are concerned, for their richness in number, tone and meaning. This present chapter focuses primarily on the external factors in the ecology of Singapore, examining in some detail what I identify as the two major forces that play a role in raising the dominance of certain languages over others. The first force, as identified at the outset of this chapter, comprises the changing trends in immigration patterns which are an important factor in Singapore's dynamic ecology, and which are particularly significant in the early British colonial period, in more recent decades, and in these current and future years. The other significant force involves the implementation of various - again, swiftly changing - language policies which impact on the importance that the different languages have at different periods of time. To some extent then, this approach can be seen to be echoing what is expressed in Bloom (1986: 359), where 'up to the early part of [the twentieth] century, the linguistic situation of Singapore, in particular the division between English speakers and non-English speakers, was determined largely by settlement patterns and colonial policy, or the lack thereof'. However, this chapter aims to go further than this, and not just in terms of the time line. The first half of the chapter will provide an analytical account of Singapore's immigration patterns and policy implementation from the (pre-)colonial era to the present day (for the period up until the 1980s, see also Bloom 1986 for a more comprehensive and critical survey than what is possible here). What is important to bear in mind what these patterns and policies translate to in ecological terms. By this I mean how we can understand the policy decisions and immigration patterns in terms of how they lead to different communities and/or their languages becoming more or less dominant in the ecology during a particular period - either because certain languages have been given institutional support or are seen as having certain capital (after Bourdieu 1984), or because the communities that speak the language are more dominant because of their greater numbers or economic strength or prestige. The identification of dominance contributes, in turn, to explaining the dynamics of language evolution: the more dominant a community or language in the external ecology, the greater the likelihood that features of that language are dominant in the competition process and are selected from the feature pool into the emergent linguistic variety.3 Further, patterns of both immigration and policy change over time, and indeed do so relatively swiftly and distinctively in Singapore's case. This chapter shows how, by proposing a periodization for Singapore's ecology using these two factors, we can recognize several distinct eras, each with relatively stable characteristics. Based on this, we can then identify which languages are dominant in the ecology in the different eras. Finally, in the second, shorter part of this chapter, these eras of immigration and policies are related to the linguistic ages first outlined in Lim (2007a), and suggestions are made for the influence on SE that the dominant languages have had in each age.4 Recognizing that migration and policies have been crucial factors in Singapore's history and development is, of course, not novel; what this chapter does is to show how such factors can be viewed in an integrative model of ecology, as well as provide an illustration of the value of an ecological approach in an analysis of the structure and evolution of a linguistic variety. © 2010 by Hong Kong University Press, HKU. All rights reserved.
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