S2045796021000068jra 1..12

Aims. Refugees and asylum-seekers are typically exposed to multiple potentially traumatic events (PTEs) in the context of war, persecution and displacement, which confer elevated risk for psychopathology. There are significant limitations, however, in extant approaches to measuring these experiences in refugees. The current study aimed to identify profiles of PTE exposure, and the associations between these profiles and key demographics, contextual factors (including ongoing stressors, method of travel to Australia and separation from family), mental health and social outcomes, in a large sample of refugees resettled in Australia. Methods. Participants were 1085 from Arabic, Farsi, Tamil and English-speaking refugee backgrounds who completed an online or pen-and-paper survey in their own language. Constructs measured included PTE exposure, demographics, pre-displacement factors, ongoing stressors, post-traumatic stress disorder symptoms, depression symptoms, anger reactions, plans of suicide and social engagement. Results. Latent class analysis identified four profiles of PTE exposure, including the torture and pervasive trauma class, the violence exposure class, the deprivation exposure class and the low exposure class. Compared to the low exposure class, participants in the traumaexposed classes were more likely to be male, highly educated, from Farsi and Tamil-speaking backgrounds, have travelled to Australia by boat, experience more ongoing stressors and report both greater psychological symptoms and social engagement. Conclusions. This study found evidence for four distinct profiles of PTE exposure in a large sample of resettled refugees, and that these were associated with different demographic, psychological and social characteristics. These findings suggest that person-centred approaches represent an important potential avenue for investigation of PTE exposure in refugees, particularly with respect to identifying subgroups of refugees who may benefit from different types or levels of intervention according to their pre-migration PTE experiences. Rates of psychological disorders amongst forcibly displaced persons are high compared to host countries’ populations (Blackmore et al., 2020). Refugees are often exposed to one or more potentially traumatic events (PTEs) in the context of war, persecution or displacement (Johnson and Thompson, 2008; Steel et al., 2009), with research highlighting the negative impact of exposure to PTEs on the mental health of refugees and asylum-seekers (Porter and Haslam, 2005; Steel et al., 2009). To date, two approaches have generally been employed to measure PTE exposure in refugees. The first involves the use of trauma event checklists, where participants indicate whether they have been exposed to a variety of specific types of trauma events, yielding a count of trauma exposure. Checklist-based methodologies have uncovered a robust relationship between PTE exposure and poor mental health in refugees (Mollica et al., 1998; Haldane and Nickerson, 2016; Hecker et al., 2018; LeMaster et al., 2018). These approaches, however, have critical limitations (Netland, 2001), as they (1) assign equal weighting to each specific type of PTE in the overall trauma exposure score (Houston et al., 2011; O’Donnell et al., 2017; Rasmussen et al., 2018), and (2) measure whether an individual has been exposed to a particular type of trauma, without measuring the frequency of exposure (Rasmussen et al., 2018), making them better equipped to investigate the mental health impact of the variety of trauma exposure rather than the dosage of trauma exposure (Rasmussen et al., 2018). An alternative approach has focused on investigating the association between types of PTEs and psychological disorders in refugees. Here, researchers have implemented variable-centred data reduction methods (such as factor analysis or principal component analysis) to trauma checklists’ data, identifying groups of PTEs with shared variance, to investigate the association between exposure within these ‘trauma categories’ and mental health. These methods are problematic, however, for several reasons. First, they assume that the population of interest is homogenous in terms of how PTE types influence one another. For example, these approaches would assume that the relationship between PTEs such as torture and exposure to combat is consistent across individuals, whereas these relationships are likely to differ markedly in reality, with some torture survivors having been exposed to combat, while others have not. Furthermore, these approaches assume consistency across a sample in terms of how different types of PTEs impact mental health outcomes (Laursen and Hoff, 2006; O’Donnell et al., 2017). Furthermore, the binary (yes/no) nature of checklist data in these studies is incompatible with statistical approaches such as factor analysis and principal component analysis, which, at least in their default modes, assume that data are continuous or ordinal in nature (Rasmussen et al., 2018). This may result in inappropriate statistical analyses being applied to the data. Finally, these approaches assume that a hypothesised latent construct is indicated by the variables that are specified to load on this construct. Latent constructs refer to theoretical or unobserved phenomena that cannot be measured directly. Psychological constructs have generally been conceptualised as being latent, whereas objective experiences such as PTEs are by definition not latent (Rasmussen et al., 2018). A useful approach to investigating the co-occurrence of trauma events in refugees, and how profiles of exposure relate to mental health outcomes, is latent class analysis (LCA). LCA is a personcentred statistical approach that, in this context, would allow for the identification of sub-groups of refugees according to their profiles of exposure to PTEs (Collins and Lanza, 2010). LCA has increasingly been seen as the approach of choice in examining the association between trauma and mental health in groups who have been exposed to multiple traumatic events (O’Donnell et al., 2017). This approach uses multiple statistical fit indices to determine the optimal number of classes in a particular sample, and facilitates the investigation of predictors and correlates of class membership on a variety of variables of interest (e.g. mental health outcomes). LCA overcomes a number of the limitations in research to date, such that it allows for (1) investigation of the co-occurrence of PTE types without the assumption that there is a latent underlying variable ‘causing’ trauma exposure, (2) determination of the probability of experiencing each PTE type in specific subgroups of refugee participants, instead of yielding a count variable that assumes traumatic events have equal weight in influencing outcomes and (3) facilitating the comparison of models across refugee samples, allowing us to determine whether there are prototypical profiles of PTE exposure that are consistent across groups and contexts. Although LCA has been used numerous times with other trauma-exposed groups (O’Donnell et al., 2017), to date only one study has employed LCA with a refugee sample. Sengoelge and colleagues (2019) identified three classes of PTE exposure in 1215 Syrian refugees resettled in Sweden, namely a ‘multiple violent and non-violent trauma’ class (39.3%), a ‘witnessing violence and multiple non-violent trauma’ class (40.8%) and a ‘low multiple trauma’ class (20.1%), with those in the ‘multiple violent and nonviolent trauma’ class showed greatest severity of psychological symptoms. This study was limited, however, by restricted investigation of trauma types, limited consideration of correlates of class membership and a focus on a single refugee group which limits generalisability to other forcibly displaced populations. Accordingly, an important outstanding question is the extent to which profiles of PTE exposure emerge in a diverse sample of refugees, and how these profiles are related to psychological outcomes. Furthermore, understanding how exposure to particular groups of PTEs impacts social functioning is an important line of enquiry. For example, it has been hypothesised that exposure to interpersonal PTEs, often encountered by refugees (e.g. trauma and sexual assault) leads to greater disruption in ongoing social functioning (Nickerson et al., 2014). To date, however, there has been limited evidence to interrogate this hypothesis. Empirical evidence regarding how trauma events co-occur and contribute to both psychological and social outcomes would be important in advancing understanding of the psychosocial impact of the refugee experience, and informing tailored public health programming and interventions for refugees according to their profiles of PTE exposure. This study proposed to examine profiles of PTE exposure in a large sample of refugees from diverse backgrounds residing in Australia, and investigate the association between these profiles and key demographic characteristics, ongoing stressors, psychological and social functioning.