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Applying integrated knowledge translation to address mental health among young immigrant and refugee… Hilario, Carla T. 2018

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APPLYING INTEGRATED KNOWLEDGE TRANSLATION TO ADDRESS  MENTAL HEALTH AMONG YOUNG IMMIGRANT AND REFUGEE MEN IN CANADA    by  Carla T. Hilario     B.S.N., The University of British Columbia, 2007  M.S.N., The University of British Columbia, 2012     A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF  THE REQUIREMENTS FOR THE DEGREE OF    DOCTOR OF PHILOSOPHY   in   The Faculty of Graduate and Postdoctoral Studies   (Nursing)    THE UNIVERSITY OF BRITISH COLUMBIA   (Vancouver)     June 2018   © Carla T. Hilario, 2018     ii  The following individuals certify that they have read, and recommend to the Faculty of Graduate and Postdoctoral Studies for acceptance, the dissertation entitled:  Applying integrated knowledge translation to address mental health among young immigrant and refugee men in Canada  submitted by Carla Hilario  in partial fulfillment of the requirements for the degree of Doctor of Philosophy in Nursing  Examining Committee: John Oliffe, Nursing  Co-supervisor Joy Johnson, Faculty of Health Sciences, Simon Fraser University Sciences, Simon Fraser University) Co-supervisor  Marla Buchanan, Counselling Psychology  University Examiner Paddy Rodney, Nursing University Examiner   Additional Supervisory Committee Members: Josephine Wong, Daphne Cockwell School of Nursing, Ryerson University Supervisory Committee Member Annette Browne, Nursing Supervisory Committee Member  iii  Abstract  Background: The mental health of young immigrant and refugee men has drawn much recent attention worldwide. Increased awareness regarding depression and suicide among men has intersected with pressing dialogues around how to best address the health needs of immigrant and refugee populations. Despite this attention, integrated knowledge translation (iKT) research in the field of mental health has yet to engage this group and virtually no studies have focused on their mental health experiences. The purpose of this research was to examine mental health and distress from the perspectives of immigrant and refugee young men living in Greater Vancouver, British Columbia, Canada.  Methods: An iKT approach was applied to integrate the perspectives of (1) research collaborators, who were six immigrant and refugee young men, and (2) an advisory group, comprised of service providers and program leaders into the study design and mobilization of the study findings. Narrative analysis methods, informed by the analytical lenses of social context and critical masculinities, were used to collect and examine the data from individual and group interviews with thirty-three immigrant and refugee young men (ages 15-22 years). Participatory video methods were used to facilitate the co-creation of a film with the collaborators based on qualitative data from the research interviews. A reflexive analysis was used to examine ethnographic field notes documenting the iKT design and the participatory video methods. Findings: The results reveal that (1) the participants’ distress-related experiences were shaped in part by masculine discourses; (2) experiences of second-class citizenship, in the context of their everyday life, influenced how young men perceived their mental health; and (3) iKT and participatory video methods can lead to new insights about power and representation.  iv  Conclusions: This dissertation contributes to the literature on immigrant and refugee youth mental health and young men’s experiences of distress. It provides insights to guide future iKT and participatory video research. The findings can inform equity-oriented practice, policy, and future research to support the mental health of immigrant and refugee young men in Canada.    v  Lay Summary Although the mental health of immigrant and refugee young men has drawn much recent attention worldwide, integrated knowledge translation (iKT) research has yet to focus on engaging this group about their mental health experiences. The purpose of this research was to examine mental health and distress from the perspectives of immigrant and refugee young men living in Greater Vancouver, British Columbia, Canada. The findings revealed that the participants’ distress-related experiences were shaped by masculine discourses and that experiences of second-class citizenship, in the context of their everyday life, influenced how they perceived their mental health. The results also suggested that iKT and participatory video methods can lead to new insights about power and representation. This dissertation contributes new knowledge about the experiences of immigrant and refugee young men in Canada to inform practice, policy and future research to address their mental health.       vi  Preface This study was undertaken under the direction and supervision of Dr. Joy Johnson, Dr. John Oliffe, Dr. Annette J. Browne, and Dr. Josephine Wong. Dr. Joy Johnson is a Professor in the Faculty of Health Science at Simon Fraser University (previously a Professor at the University of British Columbia). Dr. John Oliffe and Dr. Annette J. Browne are Professors in the School of Nursing at The University of British Columbia. Dr. Josephine Wong is an Associate Professor in the School of Nursing at Ryerson University.  I was responsible for the design and implementation of the research, including recruitment, data collection, and data analysis. I prepared initial and subsequent drafts of all chapters. My supervisory committee provided guidance on research question development, data collection and analysis plans, and writing. The University of British Columbia Behavioural Research Ethics Board approved the research undertaken for the completion of this dissertation (project title: “Influences of social context on mental health among immigrant young men: a collaborative integrated knowledge translation study”, approval certificate H14-01359). A scoping review was conducted as part of this dissertation. I was responsible for undertaking the review and wrote the first draft of the manuscript. A version of this work has been published:  Hilario, C., Oliffe, J., Wong, J., Browne, A., & Johnson, J. (2015). Migration and young people’s mental health in Canada: A scoping review. Journal of Mental Health, 24(6), 414-422.   vii  Chapters 4, 5 and 6 are based on manuscripts submitted for publication in peer-review journals. A version of chapter 4 has been accepted for publication in Health and is currently in press with the following authors: Carla T. Hilario, John Oliffe, Joy L. Johnson, Josephine Wong, and Annette J. Browne. A version of chapter 5 has been published: Hilario, C., Oliffe, J., Wong, J., Browne, A., & Johnson, J. (2018). “Just as Canadian as anyone else”: Experiences of second-class citizenship and the mental health of young immigrant and refugee men in Canada. American Journal of Men’s Health. Advanced online publication, doi: 1557988317743384. A version of chapter 6 has been submitted as a sole-author publication in a peer-review journal. It is currently under review.          viii  Table of Contents Abstract ................................................................................................................................... iii Lay Summary ............................................................................................................................ v Preface ...................................................................................................................................... vi Table of Contents .................................................................................................................. viii List of Tables ......................................................................................................................... xiii List of Figures ........................................................................................................................ xiv Acknowledgements ................................................................................................................. xv Dedication.............................................................................................................................. xvii Chapter 1: Introduction............................................................................................................ 1 1.1 Introduction ................................................................................................................. 1 1.2 Research Purpose ........................................................................................................ 3 1.3 Research Questions ..................................................................................................... 3 1.4 Organization of the Dissertation .................................................................................. 4 1.5 Research Significance .................................................................................................. 5 Chapter 2: Literature Review................................................................................................... 6 2.1 Introduction ................................................................................................................. 6 2.2 Mental Health .............................................................................................................. 6 2.3 Young People’s Mental Health in the Context of Migration ......................................... 8 2.4 Masculinities and Men’s Mental Health ....................................................................... 9 2.5 Masculinities and Help-seeking for Depression.......................................................... 11 ix  2.6 Awareness and Stigma in Men’s Mental Health ......................................................... 13 2.7 Mental Health Promotion and Young Men’s Distress................................................. 14 2.8 Masculinities and Inequities in Men’s Health ............................................................. 14 2.9 Immigrant and Refugee Young Men’s Mental Health ................................................ 16 2.10 Integrated Knowledge Translation in Health Research with Young Men .................... 17 2.11 Arts-Based Methods in Men’s Health ........................................................................ 18 2.12 Summary of Review .................................................................................................. 20 Chapter 3: Methodology ......................................................................................................... 21 3.1 Introduction ............................................................................................................... 21 3.2 Study Design: Integrated Knowledge Translation ...................................................... 21 3.2.1 Initial Contact and Refining the Issue ................................................................. 23 3.2.2 Knowledge Refining .......................................................................................... 27 3.2.3 Knowledge Interpreting, Contextualizing and Adapting ..................................... 27 3.2.4 Implementation and Evaluation .......................................................................... 28 3.2.5 Embedding in Context ....................................................................................... 28 3.3 Study Site and Recruitment........................................................................................ 29 3.4 Data Collection .......................................................................................................... 30 3.4.1 Research Participants ................................................................................................ 31 3.5 Data Analysis ............................................................................................................ 32 3.5.1 Rigour and Validity ........................................................................................... 34 3.6 The New Frames Process ........................................................................................... 35 3.7 Theoretical Framing .................................................................................................. 39 3.7.1 Gender ............................................................................................................... 40 x  3.7.2 Critical Masculinities ......................................................................................... 40 3.7.3 Social Context ................................................................................................... 42 3.7.4 Summary of Theoretical Framing ....................................................................... 43 3.8 Ethical Considerations ............................................................................................... 43 3.9 Positioning Myself..................................................................................................... 45 3.10 Summary of Methodology ......................................................................................... 46 Chapter 4: “I Tend to Forget Bad Things”: Narratives of Distress among Immigrant and Refugee Young Men ................................................................................................................ 47 4.1 Background ............................................................................................................... 47 4.1.1 Mental health and masculinities ................................................................................. 48 4.1.2 Men’s distress in context .................................................................................... 49 4.1.3 Focusing on immigrant and refugee young men ................................................. 49 4.2 Methods .................................................................................................................... 50 4.2.1 Overview ........................................................................................................... 50 4.2.2 Setting and participants ...................................................................................... 51 4.2.3 Data collection ................................................................................................... 52 4.2.4 Data analysis ...................................................................................................... 53 4.3  Results ....................................................................................................................... 55 4.3.1 Norming Distress ............................................................................................... 55 4.3.2 Acknowledging Distress as Ongoing .................................................................. 58 4.3.3 Situating Distress ............................................................................................... 60 4.4 Discussion ................................................................................................................. 63 4.5 Implications for practice and future research .............................................................. 65 xi  Chapter 5: “Just as Canadian as Anyone Else”: Experiences of Second-Class Citizenship and the Mental Health of Immigrant and Refugee Young Men............................................ 67 5.1 Background ............................................................................................................... 67 5.1.1 Frameworks for Immigrant and Refugee Health ................................................. 68 5.1.2 Mental Health of Immigrant and Refugee Young Men ....................................... 69 5.2 Methods .................................................................................................................... 70 5.2.1 Recruitment ....................................................................................................... 71 5.2.2 Participants ........................................................................................................ 71 5.2.3 Data collection ................................................................................................... 72 5.2.4 Data analysis ...................................................................................................... 73 5.3 Findings .................................................................................................................... 74 5.3.1 A Better Life ...................................................................................................... 74 5.3.2 Living the (Immigrant) Dream ........................................................................... 77 5.3.3 Starting Again from Way Below ........................................................................ 80 5.4 Discussion ................................................................................................................. 87 5.5 Implications for Future Research ............................................................................... 90 Chapter 6: Representation and Power in Integrated Knowledge Translation and Participatory Video with Immigrant and Refugee Young Men ............................................ 92 6.1 Background ............................................................................................................... 92 6.1.1 The iKT Design and New Frames ...................................................................... 94 6.1.2 The Collaborators .............................................................................................. 95 6.1.3 The New Frames Process ................................................................................... 96 6.2 Methods .................................................................................................................... 97 xii  6.3 Findings .................................................................................................................... 97 6.3.1 Representation of the ‘Researched’ .................................................................... 98 6.3.2 Representation of the Research .......................................................................... 99 6.3.3 Representation of the Researcher ..................................................................... 101 6.3.4 Power: Performance and Agency ..................................................................... 102 6.4 Discussion ............................................................................................................... 105 Chapter 7: Conclusion .......................................................................................................... 108 7.1 Overview ................................................................................................................. 108 7.2 Summary of Findings .............................................................................................. 108 7.3 Key Contributions ................................................................................................... 110 7.4 Limitations .............................................................................................................. 112 7.5 Recommendations for Practice, Policy and Research ............................................... 113 7.5.1 Implications for Men’s Health and Research .................................................... 117 7.5.2 Implications for iKT Research and Practice ..................................................... 118 7.6 Conclusion .............................................................................................................. 118 References ............................................................................................................................. 119 Appendices ............................................................................................................................ 137 Appendix A: Participant Consent Forms.............................................................................. 137 Appendix B: Information Letter for Parent/Guardian ........................................................... 144 Appendix C: Interview Guide .............................................................................................. 147 Appendix D: Honorarium Form .......................................................................................... 150   xiii  List of Tables Table 1. Participant demographic data ……………………………………………………… 32    xiv  List of Figures Figure 1. Co-creating knowledge translation framework ……………………………………… 22 Figure 2. Research collaborators group guidelines …………………………………………...... 26 Figure 3. New Frames film set ………………………………………………………………....  38 Figure 4. iKT groups ……………………………………………………………….................... 95   xv  Acknowledgements I acknowledge that this research took place on the unceded land belonging to the xʷməθkʷəy’əm (Musqueam), Skwxwumesh (Squamish), Stó:lō, and səl’ilwətaɁɬ (Tsleil-Waututh) Nations. It is important for me to begin with this acknowledgment because the colonization and settlement of this part of the world by western Europeans was the starting point for the creation of the nation we now recognize as Canada. As an immigrant, I recognize that I am a racialized settler and an uninvited guest on these lands by way of the transnational migration of people following colonization and settlement.  This dissertation would not have been possible without the research collaborators (Garry, Marlio, Lukas, Sharif, Darrion, and Kyle – you were the best part of this project!) and the young men who stepped forward to share their stories. Thank you to the advisory group who provided guidance and insight grounded in their valuable work supporting diverse young people. I am grateful for the support of my supervisory committee, Dr. Joy Johnson, Dr. John Oliffe, Dr. Josephine Wong, and Dr. Annette Browne. Joy, you showed me how a leader can hold immense strength with deep compassion and a genuine commitment to build the next generation. Thank you for making me feel that I belonged. You are the best teacher I have ever had and I cannot thank you enough for guiding me through this journey. John, your time and efforts toward optimizing the dissertation is greatly appreciated as is your expertise in men’s health. Josephine, I am grateful for your unwavering support, enthusiasm, and generosity – you are a brilliant scholar and it is your kindness that distinguishes you. Annette, thank you for challenging my thinking and instilling in me a resolve to elevate the next generations.  xvi  I would like to acknowledge the funding provided to me by the University of British Columbia to support me during my studies. I was also fortunate to receive financial support and mentorship through the Knowledge Translation Canada CIHR Strategic Training Initiative in Health Research, which enhanced my research capacity and provided opportunities for me to build my network with colleagues from across Canada. Thank you to my family for your support and encouragement. Thank you to Papa and to my brothers, Nick and Norman, who sparked my interest in this work; to Mama and my sister Jan for showing me different ways of being strong. To fellow grad students and dear friends who shared this journey with me – Basia Pakula, Louai Rahal, Tara Raketti, Mona Gray, Sukhdeep Jassar, Lisa Wong, Jorge Salazar, Ajay Puri, Alysha McFadden, Wellam Yuko, Charlene Ronquillo, Holly McKenzie, Tracy Truant, Joseph Puyat, Melissa Moynihan, Maya Lefkowich, Christine Ou, Cara Ng, Robin Repta, Andres Barrero, Ilaria Capraro, Ignacio San Miguel, Giona Matasci, and many more souls –  thank you for the encouraging words, hugs, and beers when I most needed them. Will, thank you for believing in me, putting my goals first, and cheering me on every step of the way. Lola, thank you for loving me unconditionally.    xvii  Dedication This dissertation is dedicated to the memory of my loving grandfather, Avelino Sarmiento.       1  Chapter 1: Introduction 1.1 Introduction The mental health of young men is of growing importance on the public health agenda. In the past five years, there has been increasing awareness and research regarding men’s depression and suicide in Canada. This has furthered the work of intervening in the societal and institutional pressures on men ‘to remain silent’ about mental health and experiences of distress (Ridge, Emslie, & White, 2011). At the same time, recent media representations have portrayed young men in North America as struggling with difficult thoughts, emotions, and experiences, including loneliness, rejection, and social isolation, which may be exacerbated by ‘toxic’ forms of masculinity (Hamblin, 2016).  For young men from immigrant and refugee backgrounds, the context of mental health is uniquely shaped by their lived experiences of transnational migration and resettlement. As the Director-General of the World Health Organization (WHO) stated, “The world is experiencing the largest population displacements seen since the end of the Second World War” (2015). There are approximately 250 million international migrants worldwide (WHO, 2018), and about 60 million refugees displaced due to conflict in 2014, the highest number in recorded history (United Nations High Commissioner for Refugees, 2016). Human-induced environmental disasters, local and global conflicts, and increasingly inequitable distributions of wealth have shaped massive movements of people that require innovative solutions to fostering mental health in diverse societies.  2  Canada is home to a significant immigrant and refugee population, particularly in its urban areas. Between July 2015 and July 2016 Canada welcomed approximately 320,000 people, in what was considered a record number for the country (CIC News, 2016); and people born outside of Canada represented over 20 percent of the country’s population, according to 2016 census data (Statistics Canada, 2018). In the Vancouver Coastal region of British Columbia, a province in western Canada, about one in three young people (ages 12 to 19) were born outside of the country (Smith et al., 2014).  Although the World Health Organization (2014a) has identified emotional distress and mental illness as the most significant health issue currently facing young people, research and policy development on mental health has only recently begun to attend to young people from immigrant and refugee backgrounds. In particular, there is a critical gap in health research that examines mental health and distress from the perspectives of young immigrant and refugee men. Research focused on their perspectives and experiences is needed to address the gaps in the literature on youth mental health, migration, and men’s health in order to inform effective initiatives aimed at supporting immigrant and refugee young men’s mental health. To enhance the relevance, effectiveness, and mobilization of health research into policy and practice, integrated knowledge translation (iKT) has emerged as a promising approach. Whereas end-of-project or ‘traditional’ knowledge translation approaches are based on the dissemination of research evidence after or near the completion of a project, iKT approaches encourage engagement throughout the research process and are informed by principles of participatory research (Bowen, 2015). The field of iKT remains nascent and its application requires investigation in community settings, particularly with immigrant and refugee young men. 3  1.2 Research Purpose To address existing gaps in the literature, the purpose of this research was to examine mental health and distress from the perspectives of immigrant and refugee young men through an integrated knowledge translation (iKT) design. The study was designed to optimize engagement between the researcher, the study population, that is, immigrant and refugee young men, and the people involved in delivering and organizing services, programs, and other initiatives to support mental health in the study population. Therefore, an iKT design was used to engage an advisory group, comprised of service providers and program leaders, and a team of immigrant and refugee young men in the role of research collaborators. Through this design, the study also examined power and representation in iKT and participatory video research methods with immigrant and refugee young men. 1.3 Research Questions The study was guided by the following research questions: 1. What are the linkages between masculine discourses and the narratives of immigrant and refugee young men about distress? 2. What are the connections between mental health and the migration and resettlement experiences of immigrant and refugee young men? 3. How are issues of representation and power experienced in integrated knowledge translation and participatory video with immigrant and refugee young men? 4  1.4 Organization of the Dissertation In Chapter 2, a review of relevant literature is provided to situate the purpose of this study and the research questions in relation to existing scholarship. In Chapter 3, an overview of the integrated knowledge translation study design is provided. The theoretical framing and methods for recruitment, data collection, and data analysis are also described.  In Chapters 4, 5, and 6, the empirical findings are presented. This dissertation follows a manuscript-based format. Each of the findings chapters addresses one of the research questions and is presented as a distinct manuscript, with a separate introduction and overview of relevant literature, methods, findings, discussion, and conclusion. To address the first and second research questions, I used a narrative analysis approach to interpret the qualitative interview data conducted between October 2014 and October 2015 with immigrant and refugee young men living in Greater Vancouver, British Columbia, Canada. To answer the third research question, I used a reflexive analysis of the iKT and participatory video processes undertaken to co-create an iKT initiative, New Frames, with a team of research collaborators who self-identified as immigrant and refugee young men. The manuscript-based format leads to slight overlap between the findings chapters with regards to the description of the study participants, methods, and the purpose of the overall research.  A concluding discussion is provided in Chapter 7. The overall findings, significance, and contributions of the research are discussed within existing literature. Future research opportunities and directions are also explored. 5  1.5 Research Significance Taken as a whole, this dissertation offers novel insights to address empirical gaps within the literature on men’s mental health and masculinities from the perspectives of young immigrant and refugee men in Canada. The study focused on the intersections of migration and masculinities at this particular time. In addition, the study provides methodological insights into the application of innovative participatory video approaches in integrated knowledge translation research. These insights contribute to efforts aimed at fostering young men’s mental health and building capacity, particularly among groups who are marginalized by the social, political and economic conditions within Canadian society. The research findings are relevant to the work of practitioners, policymakers, and academics. Findings from the study contribute nuanced knowledge about the ways in which social context shapes mental health experiences and how this can inform strategies that promote mental health, prevent mental illness, and facilitate early intervention. The empirical findings and methodological insights provide direction for future research and have implications for public health practice, education, policy related to supporting young men from immigrant and refugee backgrounds in Canada.     6  Chapter 2: Literature Review 2.1 Introduction This dissertation focused on the social context of mental health among immigrant and refugee young men in Canada using an integrated knowledge translation approach. To situate the research within the field, an overview of the literature on immigrant and refugee health, masculinities and men’s health, and young men’s mental health is provided. Findings from a scoping review on migration and young people’s mental health (Hilario, Oliffe, Wong, Browne, & Johnson, 2015), which was conducted as part of this dissertation, are also integrated. This chapter does not provide an exhaustive review; rather it focuses on critical gaps in the literature regarding the mental health experiences of immigrant and refugee young men, a group that is underrepresented in much of public health research. This chapter also provides a focused review of the literature on integrated knowledge translation, arts-based methodologies, and participatory video as it relates to mental health research with young immigrant and refugee men. 2.2 Mental Health This dissertation drew on the World Health Organization (WHO) definition of mental health as “a state of well-being in which every individual realises his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community” (2014b). Mental health is understood as more than the absence of mental illness; it is fundamental to individual and collective capacity for thought, emotion, and interaction. In this vein, mental health promotion is conceptualized as an approach that acknowledges determinants of mental health, comprises strategies across health and social 7  services to foster supportive environments, and involves populations in the context of everyday life (Joubert, Taylor, & Williams, 1996). Canada’s first national mental health strategy, Changing Directions, Changing Lives, provided a set of strategic directions for enhancing mental health and for building a system that will address the needs of all segments of the population (Mental Health Commission of Canada, 2012). The strategy highlighted the importance of attending to social determinants that shape access to mental health supports, and directions included mental health promotion among young people and reducing social inequities in access to mental services for “immigrants, refugees, members of ethno-cultural groups or who are likely to be racialized” (Mental Health Commission of Canada, p. 60). Among adult immigrants, those who have experienced discrimination and who are visible minorities are most likely to report declines in self-reported mental health compared to other recent immigrants (DeMaio & Kemp, 2010). The mental health of immigrant and refugee young people is shaped by experiences related to migration and to their social environments, including the accessibility and relevance of mental health services. Barriers to accessing services for newcomers include limited language proficiency, lack of cultural safety, difficulties navigating the system, fear of accessing services, and being seen as a burden on the system (Gagnon, 2002). In order to minimize barriers to accessing support, there is a need for services that are safe and responsive to the needs of immigrant and refugee groups in Canada. Ngo (2009) has argued that mental health services for immigrant youth in Canada have been sidelined, grounded in charity-based rather than rights-based frameworks. Given the significance of mental health among young people, there is a critical gap in empirical research that examines mental health and distress from the perspectives of immigrant and refugee young men.  8  2.3 Young People’s Mental Health in the Context of Migration In Canada, there is a growing body of scholarship on the migration and settlement experiences of young people. Immigration can be broadly defined as people’s movements to live in a country other than their place of birth. Immigrant youth have described the process of transnational migration as “moving out of a place you love for a reason” or being “forced to leave a country based on harsh circumstances and for religious and other reasons” (Salehi, 2010, p. 789).  Extant research with immigrant and refugee youth suggest that their mental health may be linked to immigration generation and length of residence. For example, first-generation immigrant youth in Canada, that is, those born outside of the country, have reported higher psychological distress compared to second or third-generation immigrant youth (Hamilton, Noh, & Adlaf, 2009). In British Columbia, population-based survey data suggest that Southeast Asian youth who have been in Canada for five years or less experience higher odds of extreme despair compared to their counterparts who have been in Canada for a longer period of time (Hilario, Vo, Johnson, & Saewyc, 2014).  As part of my doctoral work and the proposal for this dissertation, I led and published a scoping review of recent literature on migration and young people’s mental health in Canada (Hilario, Oliffe, Wong, Browne, & Johnson, 2015). The findings demonstrated that mental health among immigrant and refugee young people is shaped by factors at the individual, family, community and societal levels. In particular, the review suggests that the impact of harassment (Abada, Hou, & Ram, 2008), prejudice (Beiser et al., 2010), and racism (Rousseau, Hassan, Measham, & Lashley, 2008; Rousseau et al., 2009) on mental health warrant further examination.  9  The results of the scoping review also suggested that the majority of the research literature on migration and young people’s mental health employed quantitative methods that were designed to explore and test hypothesized correlates of mental health outcomes (Hilario et al., 2015). Many of the studies were based on data from population surveys conducted over 20 years ago and may not be as representative of more recent cohorts of immigrants. Although these studies have helped to identify factors associated with negative health outcomes, such approaches were limited in providing in-depth insights about experiences of mental health and the contexts of these experiences.  In general, the review demonstrated the paucity of research on gender and immigrant youth mental health (Hilario et al., 2015). Overall, the “complex, gendered dimensions of immigrant, migrant, and refugee health” (Spitzer, 2011, p. 4) have not been adequately examined. In most of the studies, gender was considered a ‘background’ variable that needed to be controlled for in statistical analysis. Significant gender-based differences in mental health outcomes were reported in several studies, and one study conducted separate analyses by gender (Khanlou, 2004). However, there was virtually no research focused on the experiences and perspectives of immigrant and refugee young men regarding their mental health. 2.4 Masculinities and Men’s Mental Health There is increasing understanding of the complex relationships between mental illness and gender. Statistics in Canada, for example, suggest high and rising rates of mental illness, substance use, and suicide among men (Pearson, Janz, & Ali, 2013). In 2012, approximately one in three young men (ages 15 to 24) reported having a mental illness in their lifetime; about one in five reported a mental illness in the last 12 months; and one in twenty experienced fair or poor 10  mental health (Statistics Canada, 2013). Beyond gender-related differences in rates and patterns of mental illness, some research in Canada also suggests that young men are significantly less likely than young women to use health services for mental health support (Szumilas, Kutcher, LeBlanc, & Langille, 2010).  Patterns of masculinity shape experiences of mental health and distress, through constructions that emphasize self-reliance, risk-taking, and dismissal of men’s health-related needs (Courtney, 2000). McQueen and Heywood (2002), for example, found that the cultural context for young men in the United Kingdom afforded few available concepts of masculinity for understanding their experiences, which shaped and constrained their narratives around distress in negative ways. The ‘silent suffering’ of men has also been explained with reference to gendered socialization, in which men learn to suppress emotions that may, in turn, contribute to mental health problems (Addis, 2008).  A meta-ethnography of studies on men’s perspectives on mental health found a link between compromised mental health and patterns of practice that are often associated with ‘traditional’ or ‘dominant’ forms of masculinity, including stoicism, emotional suppression, strength, and desire to control (Hoy, 2012). In the United States, conformity to ‘traditional’ or dominance-oriented masculine norms has been linked to greater depressive symptoms among adolescent boys transitioning to middle school (Rogers, DeLay, & Martin, 2017). These patterns shape men’s experiences of mental health and illness as well as their capacity to seek and receive support.  11  2.5 Masculinities and Help-seeking for Depression Reticence among most men to seek help for health-related concerns is well-documented. It has been described in terms of distancing themselves from emotional and physical needs that support their well-being (Courtenay, 2000). Some research also suggests a pattern of delayed help-seeking that has been linked to ‘traditional’ masculine behaviour (Galdas, Cheater, & Marshall, 2005). Studies suggest that many men are unwilling to disclose vulnerability or to seek help for mental illness (Riska, 2009), and can employ strategies to conceal their depression (Brownhill, Wilhelm, Barclay, & Schmied, 2005; Rochlen et al., 2010). In a systematic review of the literature on masculinity and men's help-seeking for depression, Seidler and colleagues (2016) found that conformity to traditional masculine norms such as stoicism may heighten self-stigma, reinforce maladaptive coping styles, and inhibit help-seeking. The study also found that men may struggle with recognizing signs and symptoms of depression.  There have been various approaches to research on men’s help seeking: comparisons of service use by sex, investigations of gender role socialization and men’s behaviors, and frameworks in which health behaviors are viewed as gender performances (Addis & Mahalik, 2003). The third approach has gained traction in recent years as the literature has turned to nuanced analysis of the context of men’s mental health experiences. For example, findings from a study with men living in the United Kingdom suggest that many men with depression draw on values associated with hegemonic masculinity, which may contribute to suicide (Emslie, Ridge, Ziebland, & Hunt, 2006). At the same time, Emslie and colleagues found that it was also important for men to reconstruct a valued sense of self, and that some men are redefining masculinity outside of hegemonic discourses – emphasizing sensitivity, intelligence, and creativity over hegemonic masculine narratives such as control.  12  While studies on help-seeking based on masculine norms and behaviors have offered insights into men’s service engagement patterns, some researchers have noted the limitations of research focused on the prediction of help-seeking (Wenger, 2011). For Wenger, help-seeking is a learned practice and is interactive, that is, grounded in a process of engaging with others. Help-seeking can take multiple forms, for example, direct and indirect approaches to asking for support, and may not always lead to the resolution of a health problem. Therefore, conceptualizations of help-seeking need to take into consideration the ways in which men perceive and respond to illness, their experiences of accessing supports, and the contexts of those experiences, including sociocultural norms, particularly regarding gender and masculinity. The relationship between help-seeking for depression and discourses linked to masculinities has been explored in some qualitative research among men with depression in Canada (Johnson et al., 2012). Johnson and colleagues found that the majority of participants reproduced the discourses that contribute to men’s reticence to access professional care. However, some men described help-seeking through discursive frames that challenged hegemonic masculinity and binary representations of masculine ideals that discouraged men’s use of mental health services. Help-seeking for depression among college men has also been linked to three recurring themes in the literature: denying weakness, limiting self-disclosure and mustering autonomy; and redefining strength (Tang, Oliffe, Galdas, Phinney, & Han, 2014). Masculine identities among college men with diagnosed or self-identified depression have been characterized as the ‘angry man’, who uses anger to release pain and distress; the ‘solitary man’, who isolates himself due to fear of judgment; and the ‘risk-reliant man’, who uses strategies viewed as ‘risk’ behaviors including drug overuse (Oliffe, Galdas, Han, & Kelly, 2013). Oliffe and colleagues have described these categories as ‘faux masculinities’ that emerge in response to depression.  13  A review of qualitative research on men's views regarding depression found two main themes in the literature: men perceiving depression as ‘weakness’ and norms regarding masculine ideals (Krumm, Checchia, Koesters, Kilian, & Becker, 2017). For McQueen and Henwood (2002), paying close attention to language and cultural discourses, particularly tropes linked to traditional masculine ideals, and using these to open spaces provides “a starting point for contesting fixed contradictory meanings that lock young men into frameworks entailing psychological distress” (p. 1507). Exploring ‘alternative’ masculinities - beyond dominant representations of stoic, independent, and invulnerable masculinity within Western culture (Krumm et al.) - may also offer young men new frameworks for understanding their experiences. 2.6 Awareness and Stigma in Men’s Mental Health Research also suggests that men’s reticence to seek help may be associated with levels of awareness and stigma around mental illness. In the case of depression, for example, findings from a survey study with men across Canada showed that nearly two in five men did not feel well-informed about depression, including its symptoms and approaches to treatment, although most men (nearly four out of five) were aware of depression as a significant health issue (Ogrodniczuk, Oliffe, & Black, 2017). Furthermore, stigmatizing views about men’s depression have been found to be higher among male survey participants compared to their female counterparts (Oliffe et al., 2016). Existing research suggests the value of interventions and strategies that increase men’s knowledge about mental health while helping to address the stigma around mental illness among men. 14  2.7 Mental Health Promotion and Young Men’s Distress Mental health promotion strategies aimed at preventing mental illness, such as depression and suicide, can also be strengthened by focusing on men’s experiences of mental health beyond illness. The relationship between societal and institutional pressures on men ‘to remain silent’ about their distress, for example, and their capacity to find the words to acknowledge their experiences has warranted further study (Ridge, Emslie, & White, 2011). Most of what is known about men’s distress is derived from studies with men living with a diagnosis of mental illness such as depression or with men living with a chronic illness. The majority of the literature on men’s mental health has focused on depression and on help-seeking from professionals (McKenzie, Jenkin, & Collings, 2016).  As Hoy (2012) has noted, there is a need for new analytical entry points into men’s mental health research that extend beyond the prevailing biomedical disease models. Some research, for example, has explored men’s use of meditation to cope with significant distress (Lomas, Cartwright, Edginton, & Ridge, 2013). In general, however, there has been little research from the perspectives of men without diagnosed or self-reported depression, particularly among young men. This dissertation addresses this gap by focusing on the perspectives of young men from immigrant and refugee backgrounds regarding their experiences of distress and mental health. 2.8 Masculinities and Inequities in Men’s Health Within the field of men’s health, there has been growing recognition of marked inequities among men. In the United States, racial and ethnic minority men, particularly African Americans, experience higher rates of morbidity and mortality compared to white men (Williams, 2003). For Williams, these patterns are shaped by gendered responses to stress and access to health services, 15  as well as economic marginalization, working conditions, and cumulative adversity over the life course, which disproportionately affect the health of racial and ethnic minority men, particularly those with low socioeconomic status.  Masculinity is constructed and accomplished in relation to specific contexts. Evans and colleagues (2005) have suggested, for example, that Black men in North America experience greater stigma around prostate cancer screening than white men because of less access to masculine capital in the context of marginalization and racism. A study with South Asian men in the United Kingdom revealed variations in understandings of masculinity; these men emphasized the importance of wisdom and caring for their health and their families over discourses that viewed disclosure as being ‘unmanly’ (Galdas, Cheater, Marshall, 2007). Similarly, research with South Asian men in Canada regarding physical activity has indicated masculine ideals that did not necessarily rely upon Western notions of masculinity (Oliffe et al., 2009). In addition to the role of culture in shaping masculine ideals, critical theories of masculinities have drawn attention to how class and racialization shape the types of masculinities that men are able to embody (Pease, 2009). With increasing transnational migration and diasporic communities, there has been emerging interest on masculinities among immigrant and refugee men, including “the social and cultural meanings associated with what it means to be a man in a context in which immigrant men are marginalised by class, race and ethnicity in the dominant culture” (Hibbins & Pease, 2009, p. 7). Experiences of migration and marginalization due to ethnicity or race, for example, may intersect with the construction of masculinities among immigrant and refugee men.  As Hibbins and Pease have argued, “white hegemonic masculinity has dominated the discourse about what it means to be a man” (p. 12). 16  In the Canadian context, immigration, class, and visible minority status1 are closely intertwined. Evidence shows that immigrant and visible minority groups in Canada are increasingly living in poverty (Shields et al., 2011), and economic exclusion has been linked to discrimination, which impacts the health of immigrant men (Edge & Newbold, 2013). Among immigrant youth, previous research suggests an association between discrimination and symptoms of depression (Tummala-Narra & Claudius, 2013). There is increasing recognition that the experiences of men are not amenable to broad generalizations of men as a single category, particularly in the context of diverse societies. However, there is a critical gap in mental health research from the perspectives of racially diverse or visible minority young men. 2.9 Immigrant and Refugee Young Men’s Mental Health Within the literature on the mental health of immigrant and refugee populations, there has been some investigation of gender in relation to the incidence of mental illness and patterns in the use of health services. In Australia, research suggests higher odds of depression among immigrant men from non-English speaking backgrounds compared to their Australian-born counterparts (Straiton, Grant, Winefield, & Taylor, 2014). In Canada, one study suggests that the rates of use of health services for psychological distress are significantly lower among immigrant men compared to their non-immigrant counterparts (Kirmayer et al., 2007). Previous research with international university students suggests that distinct cultural constructs, such as family-based shame, were linked to masculine ideals in the context of depression (Oliffe, Robertson, Kelly, Roy, & Ogrodniczuk, 2010).                                                1 The term visible minority refers to "persons who are non-Caucasian in race or non-white in colour and who do not report being Aboriginal”, as defined by Canada’s Employment Equity Act of 1986 (Government of Canada, 1995). 17  In Canada, little is known about the experiences and perspectives of diverse immigrant and refugee young men regarding their mental health (Edge & Newbold, 2013). As mental health initiatives are designed and implemented, research is needed to inform interventions that are responsive to the experiences of all groups in Canada. As Hoy (2012) suggests, the field of men’s health research requires nuanced contextual analysis of social determinants and conditions that give rise to mental health vulnerabilities among and between groups of men. Exploring the perspectives of young men who do not describe their experiences in terms of mental illness also has the potential to garner new insights to inform mental health promotion efforts.  This dissertation addresses several gaps in the literature by focusing on the perspectives and experiences of immigrant and refugee young men regarding distress and mental health. To my knowledge, this is the first empirical study focusing on mental health in this group in the Canadian context. Findings from the research can inform services, programming, and policy that address the relationships between mental health and the range of intersecting social relations that shape the everyday experiences of immigrant and refugee young men living in Canada. 2.10 Integrated Knowledge Translation in Health Research with Young Men Knowledge translation can be broadly defined as efforts to mobilize knowledge into action and to make research more relevant to practice and policy. Integrated knowledge translation (iKT) is a particular approach that engages knowledge users throughout the study and develops knowledge exchange strategies during the research process (Kothari & Wathen, 2013). Informed by principles of collaborative inquiry (Kothari & Armstrong, 2011) and community-based participatory research (Wallerstein & Duran, 2010), iKT has emerged as a promising approach for optimizing engagement with groups traditionally excluded from research processes and who 18  are likely most affected by the issue under investigation. While there has been some research on knowledge translation and the development of online men’s health resources (Lohan, Aventin, Oliffe, Han, & Bottorff, 2015), little has been written about the application of iKT in mental health promotion with immigrant and refugee young men using participatory arts-based methods. 2.11 Arts-Based Methods in Men’s Health Within the field of knowledge translation in health research, the use of arts-based methods has attracted significant attention in recent years (Fraser & al Sayah, 2011). It has been argued that the arts nurture empathy and are useful for knowledge production and translation (Kontos & Poland, 2009). Arts-based methods in qualitative health research are viewed as strategies for increasing knowledge exchange through greater engagement of participants and making the research more accessible while also providing techniques for generating data that provide participants with different modes of expression (Boydell, Gladstone, Volpe, Allemang, & Stasiulis, 2012; Carter & Ford, 2013). Innovative arts-based KT strategies are considered an opportunity to “put the art back into healthcare in a robust, scientific way” (Parsons & Boydell, 2012, p. 3). Reviews of knowledge translation in child and youth mental health have sought to evaluate approaches such as workshops, education materials, and communities of practice (Barwick et al., 2012). However, there is little research on the potential contributions of arts-based methods in iKT mental health promotion research with young men.  Beyond the field of knowledge translation, visual methodologies such as photovoice have been used to provide contextual insights through participants’ photographs and narratives. Photovoice, for example, was developed as a participatory health promotion strategy (Wang, Yi, Tao, & 19  Carovano, 1998); it was viewed as an action research method for enhancing women’s health by supporting people to record community challenges and strengths, promoting critical dialogue around the photographs, and facilitating the presentation of findings to policymakers (Wang, 1999). Photovoice has been used to engage young people in health promotion (Strack, Magill, & McDonagh, 2004) and community change initiatives (Wang, 2006).  While photovoice involves the use of participant-driven or participant-produced photographs, photo-elicitation refers to the process of using photography to guide discussions during interviews. Drawing on their research with men who had survived prostate cancer, Oliffe and Bottorff (2007) found that photovoice and photo elicitation methods were effective at encouraging men to talk more openly about their illness experiences, challenging assumptions of men as stoic and unwilling to self-disclose. Oliffe and Bottorff have asserted that photovoice may be particularly amenable to research with marginalized groups of men. Innovative participatory visual methods are increasingly being developed to enhance engagement with community groups (Gubrium, Harper, & Otañez, 2015). Beyond photography, participatory approaches using film and video are emergent methodologies in health research aimed at foregrounding the perspectives of marginalized groups and building community capacity. For Mitchell and colleagues (2012), “the use of video as a participatory visual methodology builds on a set of practices and relationships that are used to identify and address community needs or social problems” (p. 1). Video has been used in research with people living with severe mental illness (Parr, 2007), in health promotion with migrant and ethnic minority communities (Chiu, 2009), and as a pedagogical tool for young people to share their lived experiences in relation to educational, economic, and social vulnerabilities (Schensul & Dalglish, 2015).  20  Although forms of participatory video have been used in community development work for several decades, the practices undergirding the methodology are understudied (Mitchell, Milne, & de Lange, 2012). Further critical engagement is warranted with regards to its use in health research and common assumptions underlying its approach. The relevance and application of participatory video to mental health research with young men has not been explored. Therefore, this dissertation addresses a gap in the literature by examining issues of power and representation in the use of participatory video with young immigrant and refugee young men within an integrated knowledge translation project. 2.12 Summary of Review  This brief overview of relevant literature situates this dissertation within existing scholarship on migration, masculinities, and young men’s mental health. This chapter provides justification for the design and conduct of the research. I have noted the gaps in the literature on immigrant and refugee young men, and have also provided an overview of iKT, arts-based approaches, and participatory video research. In the following chapter I describe how I am situated in relation to the research, the theoretical framing of the dissertation, and the methodology and methods employed in the study.   21  Chapter 3: Methodology 3.1 Introduction In this chapter, the overarching approach to the research conducted for this dissertation is described. I explain the integrated knowledge translation design and describe the roles of the advisory group and the research collaborators. I describe the approach to recruitment, data collection, data management, and data analysis, and provide rationale for using narrative analysis and ethnographic methods. I also describe the use of participatory video methodology in the creation of New Frames.  Last, I locate the study in relation to key theoretical orientations that shape my work. Given the manuscript-based style of this dissertation, a more detailed discussion of the methodologies that informed each analysis is presented in Chapters 4, 5, and 6. 3.2 Study Design: Integrated Knowledge Translation This study was designed based on an integrated knowledge translation approach. Integrated knowledge translation (iKT) is an approach that engages knowledge users throughout the study and develops knowledge exchange strategies during the research process (Kothari & Wathen, 2013). Integrated knowledge translation can facilitate stakeholder engagement in knowledge exchange and the development of research questions and processes of inquiry in order to optimize the relevance, impact, and uptake of research. Frameworks have been developed to effectively integrate KT into population health research (Kitson et al., 2013) through iterative research processes in which knowledge production and implementation are integrated (Powell et al., 2013). For example, the co-creating KT (co-KT) framework offers a systematic guide for conducting integrated KT (see Figure 1 below). 22   Figure 1. Co-creating knowledge translation framework (Powell et al., 2013, p. 4) I adapted the co-KT framework, developed by Powell and colleagues (2013), to enhance engagement with the study context and to develop ‘context specific data’ through distinct yet iterative phases: 1) initial contact and refining the issue; 2) knowledge refining and testing; 3) knowledge interpreting, contextualizing and adapting; 4) implementation and evaluation; and 5) embedding in context, translating to other contexts. This provided an organizing framework for the processes undertaken in this study, including the participatory video initiative completed as a mid-project iKT strategy. In the following sections I detail how these processes unfolded over the course of the study. 23  3.2.1 Initial Contact and Refining the Issue  Drawing on the framework proposed by Powell and colleagues (2013), I initiated the project by engaging with the study context, the first and most important step in the framework. Initial contact involved conversations with inter-sectoral networks of stakeholders, defined in the co-KT framework as knowledge users, health and service providers and representative groups, who were involved in delivering and designing youth mental health supports, particularly with immigrant and refugee communities. These discussions took place up until the research proposal was finalized. The goal of this step was to listen and to learn from people ‘on the ground’. The consultations with service providers and program leaders in the study context helped to clarify the research gap to be addressed. I shared the research proposal and asked for feedback from the service providers, organizations and stakeholders, some of whom would later be part of the advisory group.  New relationships were established and existing ones were strengthened through a common vision of respecting diverse knowledge and advocating for health equity and social justice (Kothari & Armstrong, 2011). I met with leaders who were actively engaged in creating social change around youth mental health (Canadian Mental Health Association, Kelty Mental Health), immigrant and refugee youth integration in the education systems (Vancouver School Board Engaged Immigrant Youth program), civic engagement (Fresh Voices-Vancouver Foundation), and supports for newcomers to Canada (Immigrant Services Society of British Columbia). The advisory group included five knowledge users from these organizations.    24  The Advisory Group The advisory group supported the project by informing the research questions, facilitating the recruitment of research collaborators and study participants, and providing guidance around data collection and analysis. During the study, three structured meetings with the advisory group were held in addition to numerous unstructured consultations. The advisory group assisted in the recruitment of the research collaborators and the study participants through word-of-mouth and by circulating information within their networks, such as through emails and blog posts about the study (for example, http://keltymentalhealth.ca/blog/2014/09/ubc-research-study-mental-health-male-immigrant-youth). In addition, I was invited to join a community-based roundtable, the Collaborative Opportunities for Resources (CORe) network, which was established by one of the advisory group members at the time I was developing the proposal for my dissertation. Housed at the Canadian Mental Health Association Vancouver-Burnaby branch, the network included representatives from various organizations that supported young people’s mental health, including the local school board, health authorities, youth centres and community centres. The Collaborators In addition to engaging an advisory group as part of the iKT design, it was important for me to work closely with the population of focus. With this goal in mind, six young men who self-identified as immigrants and refugees were recruited as research collaborators. The team of collaborators was convened at the outset, so that they were engaged in informing the research questions; refining the study design and data collection methods; facilitating the interpretation of data; and designing the iKT initiatives. The collaborators self-identified as immigrant and refugee young men from China, Philippines, Mexico, Colombia, and Afghanistan. They were 25  between the ages of 15 and 20 at the beginning of the study. Having a diagnosis of mental illness was not a requirement to participate nor was expertise in filmmaking or videography. As with other types of groups the team underwent a dynamic process of developing rapport and trust, building consensus, and establishing norms. In the first three meetings, the collaborators were tasked with identifying individual and group goals. I asked the collaborators to write down three or four goals they hoped to achieve through the project. Goals ranged from gaining work experience, expanding networks, and learning about the research process, to helping others (“like a big brother”), learning about mental health, and creating awareness about the needs of immigrant youth. Apart from contributing to the project, the group also aimed to make meaningful connections and to learn from each other: “to know more about young guys and about ourselves too”, “to create something we can share back to the community”, and “become a reason why each of us would want to become better people”.   A set of community guidelines was developed based on the team’s goals, vision and values (Figure 2 on the following page). One of the collaborators suggested and led this process, writing down suggestions from the team on a large flipchart paper and markers. After the meeting, I circulated a typed copy of the guidelines and posted the original in the meeting room as a reminder for the group. The group worked from these guidelines to move forward while maintaining an open, iterative plan for action.     26  New Frames Community Guidelines 1. Disagreements that happen during the meeting should not affect our relationships/friendships outside of the meeting 2. Confidentiality – what happens in the room stays in the room 3. One person talks at a time  4. Encourage to take leadership roles and participate within the group 5. No forcing, just positive encouragement 6. Supporting each other and not to be afraid to ask questions, ask for clarification, grammar is optional 7. Giving space to others 8. Being self-aware 9. Think before you speak 10. Respect each other by being on time – send a message or email 11. Devil’s Advocate – used with two different opinions 12. Avoid using oppressive language 13. No judgment 14. Patience 15. Feedback 16. Sensitive and empathetic Figure 2. Research collaborators group guidelines Although the initial plan was to meet at the University of British Columbia Point Grey campus, the collaborators found the location of the campus inconvenient and relatively far from where they lived, worked, and went to school. Therefore, our meetings were held in Burnaby, an area that was accessible for the collaborators. Meetings were initially held at a public library in the area. Through the initiative of one of the collaborators, we eventually secured access to the Burnaby Youth Hub, where we held the majority of our meetings. There was strong alignment between the goals of the project and the mandate of the Burnaby Youth Hub, which was to 27  provide “a safe space for youth, providing a variety of programs and services to support, engage, and empower young people in the community” (http://www.burnabyyouthhub.org/). A total of 38 in-person meetings with the collaborators were held between July 2014 and November 2015. Each collaborator was paid $20 CAD per one to two-hour meeting. A major thrust of their work was the New Frames participatory video project, which will be described later in this chapter. 3.2.2 Knowledge Refining  In line with the co-KT framework (Powell et al., 2013), information was gathered to refine what was currently known about immigrant and refugee young men’s mental health. This was done through a scoping review of existing literature on migration and mental health among young people in Canada (Hilario et al., 2015) and by gathering new information, which involved recruiting and conducting interviews with research participants. Details about the methods of recruitment and data collection are provided in Chapter 3.3 Study Site and Recruitment and Chapter 3.4 Data Collection. 3.2.3 Knowledge Interpreting, Contextualizing and Adapting  The third step in the co-KT framework is described as interpreting, contextualizing and adapting knowledge. This involved the analysis of data from in-depth individual and group interviews with research participants. Research findings from the analysis of this data are presented in Chapters 4 and 5 of this dissertation. As part of this iterative process, the collaborators were tasked with designing a mid-project iKT initiative. New Frames, a participatory video initiative, is one of the study outcomes. Details about this process are provided in Chapter 6. 28  3.2.4 Implementation and Evaluation  The fourth phase in the co-KT framework, implementation and evaluation, took the form of several initial screenings of the New Frames participatory video with the advisory committee and with a public audience. The short film was intended to provide opportunities to share the research study and to spark dialogue about the experiences of immigrant and refugee young men in Canada. The initial screening, held at Heartwood Community Café, was followed by a panel discussion with the collaborators and the advisory group. It drew an audience of approximately 80 people, which included immigrant and refugee young men as well as service providers and community leaders with the potential to influence services and policy.  3.2.5 Embedding in Context In the fall of 2016, the project team was approached by a non-profit Canadian organization that wanted to help distribute the New Frames video to educational institutions worldwide. The collaborators and I decided to pursue distribution, as a way to embed the research and facilitate its translation to other contexts, which is the last step identified in the co-KT framework. As a group, the collaborators voted to donate funds from the acquisitions to Fresh Voices, an initiative aimed at enhancing the capacity of immigrant and refugee youth from across British Columbia to engage in dialogue and action toward “improved policies and practices that affect racialized immigrant and refugee youths’ sense of belonging in British Columbia and Canada as a whole” (http://freshvoices.ca/). The work of embedding this initiative in context will continue and will be formally evaluated in my future research.  29  3.3 Study Site and Recruitment Recruitment of study participants took place in Greater Vancouver, British Columbia, a densely populated region located in western Canada. The region was selected because it is home to a large immigrant and refugee population. According to Statistics Canada (2018), about one in five people in Canada were born outside of the country. Similarly, approximately one in five adolescents (age 12 to 19) in British Columbia have reported being born outside of the Canada and, in the Vancouver Coastal region this figure is nearly one in three (Smith et al., 2014). Following approval from the University of British Columbia Behavioural Research Ethics Board, recruitment and data collection were conducted between October 2014 and October 2015. Recruitment was informed by the iKT approach, the advisory group, and the collaborators. Strategies were diverse to ensure the inclusion of young men who were or were not connected to services. Printed recruitment materials were displayed at community centres, libraries, and youth centres. Materials were also circulated via emails and websites with the assistance of the advisory group and collaborators. Young men interested in participating were invited to contact me via email, text message or phone call to learn more about the study. Eligibility criteria included self-identification as an immigrant or refugee young man. Due to practical constraints and cost considerations, only English-speaking individuals were eligible to participate. Having a diagnosis of mental illness was not a requirement to participate. A $20 CAD honorarium for each interview was offered to participants to acknowledge their time and contributions to the study. Participants were provided with copies of the study consent forms, a letter of information for their parent(s) or guardian(s), and a list of local mental health resources 30  and supports (for example, the Kids Help Phone) that participants could access if needed (see appendices A and B for copies of forms).  3.4 Data Collection To address the research questions outlined in Chapter 1, I drew on multiple data collection and analysis methods including in-depth individual and group interviews, field notes, and a reflexive journal. Participants were informed of the study procedures, and they provided written consent prior to taking part in the interview. Participants were offered the option of an individual or group interview and were able to select the interview location. I was responsible for the recruitment processes, and I conducted all of the interviews. Two group interviews (n=4 and n=5 participants), one pair interview (two friends) and thirty individual interviews (including follow-up sessions) were conducted. These interviews ranged from 30 minutes to about two hours; several participants took part in more than one interview format. Interviews were conducted in various locations as per the preference of the participant: community and recreation centres, libraries, public parks, malls, and cafes. Interviews were digitally recorded. Debriefing took place following each interview to allow for additional thoughts or questions from participants.  The interview process was informed by Riessman’s (2008) narrative analysis approach, which is similar to ethnographic approaches that ‘follow participants down their trails’. Participants were encouraged to tell their ‘natural stories’ and to view the interview like a conversation. The interviews were conversationally oriented and the interview guide included broad questions such as, ‘What is a typical day like for you?’ and ‘Can you tell me about a difficult time in your life?’ (See appendix C for interview guide). 31  Field notes were recorded during data collection and a reflexive journal was used to track my thinking process (Emerson, Fretz, & Shaw, 2011). Field notes were also used to document the iKT approach, based on the co-KT framework, and the participatory video processes. This data was used in the reflexive analysis of the New Frames process, described later this chapter. 3.4.1 Research Participants Thirty-three young men, who self-identified as immigrants or refugees, participated in the study. They ranged in age from 15 to 22 years old. The majority were attending secondary school (n= 21) or post-secondary institutions (n= 9). One participant was in an alternative high school; another was working full-time and one was seeking employment. The young men originated from eighteen countries including Afghanistan, Bangladesh, Belarus, Bosnia, Brazil, China, Colombia, Democratic Republic of Congo, El Salvador, Ethiopia, India, Iran, Korea, Philippines, South Africa, Taiwan, Vietnam, and Zambia.  The participants comprised a heterogeneous group, moving to Canada through family reunification immigration channels, government-assisted refugee programs, refugee claimant processes, or through international high school education programs. Length of residence among participants who were born outside of Canada ranged from less than one year to approximately 14 years; the average was seven years. Four participants identified as second-generation immigrants born in Canada to families who had immigrated. The majority of the young men were visible minorities, which refers to "persons who are non-Caucasian in race or non-white in colour and who do not report being Aboriginal” (Government of Canada, 1995). Three participants, one from Bosnia (former Yugoslavia) and two from South Africa, were not perceived as visible minorities. Additional demographic details are included in Table 1. 32   Table 1 Participant demographic data Geographic region of origin East Asia   China  8   South Korea  1   Taiwan  4  Southeast Asia  Philippines 3   Vietnam  1  South Asia  India 2   Bangladesh 1  Central/South America Brazil  1   Colombia 1   El Salvador 1   Eastern Europe   Belarus 1   Bosnia  1  Africa  Congo 1   Ethiopia 1   South Africa 2   Zambia  2  Middle East   Afghanistan 1   Iran 1  3.5 Data Analysis Digitally recorded interviews were transcribed verbatim. The software program, NVivo10, was used to organize and re-aggregate transcribed interview data with broad codes that were inductively derived from repeated readings of the transcribed interviews. These themes were drawn from the data, the research questions, and the goals of the study. Although determining the boundaries of stories was an interpretive process, sequences were preserved as much as possible in initial coding. A reflexive journal was used to track my thinking process during data analysis.  33  Narrative analysis methods (Riessman, 1993; 2008) were used to guide close readings of the data, including the setting, the influence of the interviewer, and the circumstances surrounding the interpretation of the narrative, including my identities and subject positions as the researcher. Drawing on narrative analysis methods, the participants’ narratives were understood not as exact representations but rather interpretations of their experiences and their social worlds. In this way, the meaning-making function of narratives is central to this qualitative research approach. Riessman (2008) maintains that people often use narrative to make sense of disruptions in personal biographies. For Riessman, stories allow us to interrogate, demystify and establish coherence in the wake of ‘discontinuities in expectations’ resulting from unexpected circumstances. Through a narrative analysis approach, I considered how immigrant and refugee young men made sense of ‘interruptions’ or ‘discontinuities’ in their lives – moments that were unexpected and/or unwanted, for example, migration, loss of loved ones, and significant distress.  In particular, I used thematic and dialogic/performance narrative analysis approaches. Using thematic narrative analysis, data were analyzed in light of the themes I developed, which are informed by the data, the research questions, the purpose of the study, and guidance from my supervisory committee. Dialogic/performance narrative analysis facilitated close readings of the contexts such as the setting, the influence of my presence as the researcher, and the social circumstances surrounding the interpretation of the narrative.  Narrative analysis attends to both particularities and context (Riessman, 2008). For Riessman, narratives are “social artefacts, telling us as much about society and culture as they do about a person or group” (p. 105).  In order to have coherence, narratives must connect to a broader ‘community of life stories’. Therefore, it is in the close analysis of stories that the connections 34  between personal biographies and society can be illuminated. In this way, the focus in the analysis of the interview data was not only on the content of the stories but on how they were told and why particular stories were shared. Through these strands of analysis, also interrogated was the agency of the multiple voices in the analytical process. Narrative analysis was used to address two of the research questions identified in this dissertation: (1) what are the linkages between masculine discourses and the narratives of immigrant and refugee young men about distress, and; (2) what are the connections between mental health and the migration and resettlement experiences of immigrant and refugee young men? A reflexive analysis (Finlay, 2002) using field notes and journals was used to address the third research question, (3) how are issues of representation and power experienced in integrated knowledge translation and participatory video with immigrant and refugee young men? Additional details regarding data collection and analysis are presented in Chapters 4, 5 and 6. 3.5.1 Rigour and Validity The frame of reference for rigour in the narrative analysis aspects of this study is qualitative research. Rigour can be evaluated in terms of validity as ethical relationship (Denzin & Lincoln, 2017). I acknowledge the co-construction of the findings from this research in relation to my interactions with the participants as well as with the collaborators and the advisory group. Furthermore, I recognize that the identities and power dynamics between me and the participants shaped the research process and the subsequent findings (Beckman, 2014). While the findings provide only one of many possible sets of interpretations, several processes were undertaken in the study to ensure a high degree of validity and rigour that the research findings can be trusted to provide insight into a consensus reality for the participants in the study. 35  Rigour can be also evaluated in terms of validity, authenticity, and the extent to which the researcher would act on the implications of the research (Denzin & Lincoln, 2017). To enhance rigour in my analysis, I held regular meetings with my supervisory committee, the advisory group, and the research collaborators to discuss analytical insights and themes. An audit trail was kept in the form of meeting minutes and field notes. The collaborators (who were also immigrant and refugee young men) discussed the data and affirmed the emergent themes that reflected their experiences and interpretations. The advisory group provided guidance based on their experiences working with immigrant and refugee youth. 3.6 The New Frames Process As part of the iKT design, the collaborators were engaged in the analysis of data from interviews with research participants and in designing a knowledge translation initiative. The collaborators were provided with training in qualitative research and video production. The KT initiative was called New Frames and was aimed at engaging the collaborators in making sense of the stories told by the 33 research participants. Drawing on participatory video methods (Mitchell, Milne, & de Lange, 2012), the collaborators and I created a 20-minute video based on excerpts of transcribed data from the interviews. The video process took place over a period of six months and followed the five stages of video production: development, pre-production, production, post-production, and distribution (Women in Film and Television Vancouver, 2009). During development, the collaborators discussed and decided on the concept of the film. In consultation with several local filmmakers, the collaborator team and I conceptualized the idea and design with the goal of creating a film for immigrant and refugee young men.  36  The process of selecting the research data or material for the film was based on a practice that the collaborators had established early on in the project: reading excerpts of transcribed interview data out loud together and discussing the stories. The collaborators directed me to select one to two pages from each of the thirty interviews that I had completed and that had been transcribed at the time. I removed identifying information from the excerpts and shared them with the team for discussion. Over several weekends we gathered and read the excerpts out loud over pizza, pastries, and coffee. During this time, we also considered possibilities in terms of the type or style of film. The group consensus was to produce an arts-based initiative that would serve as a vehicle for sharing knowledge from the project. However, there were many possible approaches. For example, one collaborator was a strong proponent of writing a narrative story - either dramatic or action - about one character. Another collaborator suggested adopting a documentary style that would bring in new stories from the study participants or from the collaborators themselves.  The collaborators and I decided to consult with experienced filmmakers to provide some guidance. A local filmmaker and film instructor was asked to facilitate two sessions on screenwriting for narrative short films and ‘writing treatments’ for documentary. He shared several exemplars of his own work with the group, beginning with one called Pirandello, which would, unknown to all of us at the time, strongly influence the direction the collaborators would take in how to represent the excerpts. Our consultant drew on his film Pirandello to show how a documentary treatment could be applied to fictional material, challenging the conventions of film. Following several sessions, one collaborator suggested a similar experimental approach for New Frames: to select six excerpts from the data and to hire actors to re-enact the scenes in a documentary style without initially revealing to the viewer exactly what they were seeing.  37  The research collaborators were responsible for deciding on the style as well as the content of the film, the former through consensus building and the latter by way of individual selection. After consultations with filmmakers and many team discussions, the collaborators decided on the six excerpts of data. Each collaborator selected their top three excerpts from the data, which were eventually narrowed down to one based on redundancies in selections. During this process, each collaborator made a case for his top choice and why it should be included in the film. The collaborators explained to the rest of the team how they interpreted the excerpt, what was poignant or important about it, how it resonated with them, and why it needed to be shared.  The collaborators described the selected excerpts in terms of the following themes: being unique or different, giving space, having faith, awareness, satisfaction, body image and masculinity. These excerpts became the six scenes that comprise the film, scenes that also raised questions, during initial screenings, about many issues relevant to immigrant and refugee young men: transnational migration and the limitations of nationalism; the impact of religion and faith on distress; happiness, anger, and how to deal with frustration; aging out of health and social services; negotiating career paths in rapidly changing economic systems; relationships, sexual practices, and male privilege; masculine ideals; and the need for empathy. Beyond the film these scenes represented the themes that the collaborators deemed were most important to share about the study, especially with other immigrant and refugee young men. Following this decision, a script with six scenes was developed. It was decided that actors would be hired to play each ‘character’ and each would be directed by the collaborator who selected that excerpt of data. Therefore, each on-screen ‘character’ would be co-created based on the words of the study participant who participated in the research interviews, the creative direction of the collaborator, and the re-enactment by an actor.  38  In pre-production, the collaborators trained with professional filmmakers over several sessions in preparation for the production. Since we had a small team and the collaborators would each take a turn at directing a scene, they had to gain proficiency in all of the roles on set, including director, cinematographer, boom operator, sound design, and assistant director. Discussions about funding and budgets took place. Filming locations were secured and clearances obtained. We rented equipment in advance, primarily cameras and sound recording gear, and prepared them for the production days. Auditions were held and actors were casted in roles based on the script. During this period, the collaborators also developed storyboards and notes to guide them in directing the actors and in framing their shots during their turns as directors and cinematographers.  The stage of production encompassed the film shoot. We filmed in a professional studio space and the set was designed to mimic the intimacy of a research interview. In addition, there was one pick-up day that was scheduled a few days later to re-shoot one of the scenes.  Figure 3. New Frames film set 39  The post-production stage spanned several months because the collaborators and I decided that each collaborator would direct as well as edit their scene within the film. We worked with a professional editor who prepared the footage for the collaborators with timecodes to precisely mark the footage. Using the timecodes, the collaborators reviewed the footage and selected the ‘takes’ they wanted to include. They also indicated the sequencing and ‘cuts’ between the different angles used in the shoot. These decisions were communicated to the editor who compiled the footage accordingly to complete the video, which is about 20 minutes in length. In summary, New Frames was part of the iKT design and engaged the collaborators in the analysis and translation of knowledge from the research. It provided a means to highlight the stories and themes that the collaborators felt were important to share with other immigrant and refugee young men and their communities. The process also informed the analysis of data that I was leading in response to the research questions outlined in the dissertation.  3.7 Theoretical Framing In designing this study and interpreting the research data, I drew on several theories and concepts to frame the dissertation. Given my focus on young men from immigrant and refugee backgrounds, I drew on critical theories of gender and masculinities in the analysis of narratives to address the first research question, what are the linkages between masculine discourses and the narratives of immigrant and refugee young men about distress? The concept of social context was used to address the second research question, what are the connections between mental health and the migration and resettlement experiences of immigrant and refugee young men? In this section, I describe the theories and concepts used to guide the study and to analyze the data. 40  3.7.1 Gender This dissertation drew on a relational approach to gender (Connell, 2012). In health research, gender has been conceptualized in various ways. According to Connell, three common approaches have been used: a categorical approach, in which masculinity and femininity are viewed as natural opposites, a poststructuralist approach emphasizing the meaning of gender through discourse, and a relational theory approach in which gender is viewed as embodied social structure. From a relational theory approach, gender is multidimensional, "embracing at the same time economic relations, power relations, affective relations and symbolic relations; and operating simultaneously at intrapersonal, interpersonal, institutional and society-wide levels" (Connell, p. 1677).  In this way, gender relations can be understood as historically mediated processes by which social practices are structured (Connell, 2005). Within relational theory, the structures and patterns of social practice that shape the embodiment of gender are amenable to change, given under different social and historical conditions, and are subject to interrogation. According to Connell, gender is plural, dynamic, and linked to a spectrum of relational (hierarchical, hegemonic/non-hegemonic) and constantly shifting masculinities that are constructed vis-à-vis everyday practices. 3.7.2 Critical Masculinities Masculinities can be understood as patterns of social practice that are deployed by men (Robertson, 2007). The early literature on masculinities was largely characterized by psychological approaches, largely based on theories of sex roles, which attempted to measure dimensions of masculinity without accounting for the influence of social structures and power 41  (Connell, 2005). Masculinity can also be understood as “the outward expressions of being biologically male” (Robertson, p. 27). However, this understanding of masculinity, according to Robertson, poses limitations for understanding the linkages between sex, gender, and health. Viewing masculinity as fixed and essential constrains possibilities for understanding health inequalities among men based on social class, geography, and ethnic background.  Postmodern perspectives in the social sciences have argued against the notion of masculinity as an intelligible construct. However, Robertson (2007) has countered, “it is precisely the need to illuminate that which is hidden that makes problematizing men by the use of a theoretical framework (masculinity/masculinities) so important” (p. 31). For Robertson, gendered practices remain invisible so long as the category of ‘male’ is not problematized in the research process and that, in practice, postmodern approaches may actually perpetuate the status quo by conceptualizing masculinities as a collection of incoherent concepts, which may, in turn, conceal relations of power rooted in gendered privilege as it intersects with other forms of power. I drew on critical perspectives on masculinities to examine how negotiations and configurations of social practices shape the experiences and narratives articulated by immigrant and refugee young men about their mental health. Patterns of masculinities develop as “configurations of gender practice, [which]… interact with other areas of social practice such as race, class, sexuality and disability” (Robertson, 2007, p. 33). Among immigrant and refugee young men, gender relations intersect with social structures and discourses linked, for example, to class and race. During migration and resettlement, dimensions of identity must be negotiated and re-negotiated depending on the context, and this process is influenced by the social constructions of masculine identities within particular locales (Hibbins and Pease, 2009).  42  Migration experiences can intersect with class and race in the negotiation of masculinities among immigrant and refugee men. According to Connell (2000), the diversity of masculinities is characterized by a hierarchical system in which men have unequal access to the ‘patriarchal dividend’ with some men marginalized or excluded based on categories of difference such as race, ethnicity, and class. For Hibbins and Pease (2009), “white hegemonic masculinity has dominated the discourse about what it means to be a man” (p. 12). Pease (2012) has drawn attention to “the male privilege that resides behind the emotional inexpressiveness associated with white, Western, heterosexual men” (p. 130). In this way, the area of critical masculinities has highlighted the intersections between gender, race, and class, and the ways in which they shape the experiences of immigrant and refugee young men in relation to mental health and masculinities. 3.7.3 Social Context In this dissertation, the concept of social context was used to examine how mental health is situated within social relations. Social context refers to relations as “local configuration of social relations (comprising social structures such as class, race, and gender; institutional practices, and collective and individual behaviour, and intersecting personal biographies)” (Poland et al., 2006, p. 60). The concept was used to analyze how health is shaped by social structures, including resources and rules within a society, and practices that shape those social structures (Frohlich, Corin, & Potvin, 2001). In this way, social context is distinct from the term ‘social influences’, which has been used to describe the role of parents and peers, attitudes, or environment within ecological and systems theories and research.  43  I drew on the concept of social context to examine how power relations intersect with ‘social cleavages’ – including but not limited to gender, race, and class – through the control of human and material resources and control over ideas (Poland et al., 2006). According to Poland and colleagues, agency and structure operate in a dialectical relationship in which human practices are shaped by and also help reproduce or resist social structures. In this vein, health is shaped by the confluence of social structures, institutional practices, and personal biographies (Frohlich, Poland, & Sareck, 2012). The conceptual lens of social context provided an analytical entry point for examining the ways in which the perspectives of immigrant and refugee young men regarding mental health and their everyday experiences were situated within their biographies as well as institutional practices and social structures. 3.7.4 Summary of Theoretical Framing In summary, this dissertation research was informed by a relational theoretical approach to gender, critical perspectives on masculinities, and the concept of social context. These guided the framing of the study and provided entry points for conducting the narrative analysis of data. The theoretical framing served as a lens for investigating the narratives and for considering the implications of the research in fostering mental health among young immigrant and refugee men.  3.8 Ethical Considerations Ethical approval for this dissertation was obtained from the University of British Columbia Behavioural Research Ethics Board (approval certificate H14-01359; PI: Dr. Joy Johnson) before starting recruitment or data collection. Participants were provided with a copy of the study consent forms as well as a letter of information about the project for the participants’ parents 44  and/or guardians (see appendices A and B for copies of forms). A list of local mental health resources and supports was also compiled and provided to each participant.  The interview participants were informed of the purpose, process, and potential risks and benefits related to their participation in the study. Participants were reminded of their right to decline to respond to any questions during the interview without explaining their reasons and without further inquiries from the researcher on the same topic. They were informed of their right to end the interview session at that time and/or to withdraw from the study at any point during the research and still receive their honorarium.  Several strategies were implemented to protect the identities of the participants and to ensure anonymity. The collection of demographic data during the recruitment process was minimized to contact information and participants were given the option of providing pseudonyms. Hard copies of participant consent forms or notes with demographic data or identifying information about participants were stored in a locked cabinet in the School of Nursing at UBC. Digital audio recordings of the interviews and transcribed interview data were stored on a password-protected computer at UBC and on my personal laptop, which was also password-protected. One master digital file was further protected with a password to open the document since it contained all of the participant names.  Any potentially identifying information was removed in publications, reports of findings, and knowledge translation activities. Strategies to ensure that the identities of the participants remained confidential throughout the research process included removing identifying information from the excerpts in the analysis and in the data shared with the collaborators and providing pseudonyms. Because some immigrant and refugee communities may be tight-knit, 45  there may be some stories that in their uniqueness may potentially lead to the identification of participants. Where some information could potentially identify an individual, I removed these details. In the participatory video project, excerpts from the data were re-enacted by actors. 3.9 Positioning Myself This dissertation has been shaped by my identities and the ways in which I have positioned myself in this work. I am a cisgender woman and I identify as an uninvited guest on the unceded territories of the Musqueam, Squamish and Tsleil-Waututh people in Greater Vancouver, British Columbia. I was born in the Philippines and moved to Canada as a child. The analytical lenses and theories that I am drawn to and that I employ in my work are informed by my experiences spanning three decades, which are related to the land on which I live, work, and play.   My interests in this area of study are grounded in my previous work with immigrant youth. In my master’s research, I investigated the relationships between immigration, gender, and mental health among Southeast Asian youth in British Columbia. Drawing on participatory epidemiology approaches, I worked with an advisory group comprised of folks who identified as Southeast Asian to examine the mental health (self-reported emotional distress, self-harm, and suicide intent) of this sub-group of youth. I used population-based data from the 2008 British Columbia Adolescent Health survey to examine patterns of mental health by gender, immigration-related factors, such as length of residence in Canada, and theorized protective factors, including connectedness to families, schools and cultural groups. Findings from this study suggested gender-related differences in emotional distress, connectedness, and in the relationships between connectedness and mental health (Hilario, Vo, Saewyc & Johnson, 2014). 46  My master’s thesis work strengthened my interests in immigrant health and in research approaches that engage communities in the process. During that research, an advisory group member shared his experiences as a teacher working with boys and young men and questioned the extent to which gender differences in our findings were influenced by the ways in which young men and young women understand and respond to questions, including those on standardized surveys, about mental health. In discussions with other adolescent health researchers, the gender-related differences in our study were described as ‘common’ and ‘what we would expect to see’. The advisory group, however, encouraged me to interrogate these patterns and consider how discourses around gender may shape how young people experience mental health. Another advisory group member encouraged me to question the relationships between mental health and experiences of discrimination faced by minority groups, which were not examined in my previous research. Therefore, my dissertation is a continuation of this work and of my long-standing interests in the health of immigrant and refugee groups. 3.10 Summary of Methodology In summary, this research drew on an integrated knowledge translation design involving an advisory group and collaborators who self-identified as immigrant and refugee young men. Thirty-three young men (15 to 22 years old) took part in the study as research participants. Interviews took place in 2014 and 2015 in Greater Vancouver, British Columbia, Canada. Participatory video methodology was used in the co-creation of an iKT initiative, New Frames, with the collaborators. Interview data was analyzed to address the research questions using narrative analysis and a theoretical framework informed by a relational approach to gender, masculinities, and the concept of social context.   47  Chapter 4: “I Tend to Forget Bad Things”: Narratives of Distress among Immigrant and Refugee Young Men2 4.1 Background Distress among young men has drawn media and research attention in recent years. Media representations have portrayed young men in North America as struggling with difficult thoughts, emotions and experiences, including loneliness, rejection and social isolation (Hamblin, 2016). Findings from previous research raise questions about the extent to which societal and institutional pressures on men ‘to remain silent’ have muted their distress and help-seeking (Ridge et al., 2011). According to Ridge and colleagues, qualitative research on distress from the perspectives of men may help to “open up important insights to ‘invisible’ aspects of [men’s] emotional life” (p.154). There has been little research, in particular, on how masculine discourses shape distress among young immigrant and refugee men. Transnational migration and mass displacements – as a result of human-induced environmental changes, political and economic conflicts, and growing inequities worldwide – are contributing to increasingly diverse societies. Nuanced understandings of distress are needed to inform mental health and public health programming to ensure that supports are relevant to the lived experiences and contexts of diverse young men.                                                2 Chapters 4, 5, and 6 are based on manuscripts submitted for publication in peer-review journals. A version of chapter 4 is under review with the following authors: Carla T. Hilario, John Oliffe, Joy L. Johnson, Josephine Wong, and Annette J. Browne.  48  This chapter addresses the gap in the literature on men’s distress and the first research question in the dissertation: What are the linkages between masculine discourses and the narratives of immigrant and refugee young men about distress? 4.1.1 Mental health and masculinities Previous studies have shown that men are often unwilling to disclose vulnerability or to seek help for mental illness (Riska, 2009), and can use various strategies to conceal their depression (Brownhill et al., 2005; Rochlen et al., 2010). In the context of an online cancer support study, Gooden and Winefield (2007) found that while “women clearly expressed their emotions, men tended to imply emotion” (p. 111). Research suggests that this ‘silent suffering’ of men is shaped by gender socialization, in which men learn to suppress negative emotions that may, in turn, contribute to mental health problems (Addis, 2008). In a meta-ethnography of research on men’s perspectives on mental health, Hoy (2012) found that compromised mental health was linked to masculine norms such as control, stoicism, and emotional suppression, which are often associated with ‘traditional’ or ‘dominant’ forms of masculinity.  Findings from some qualitative research have provided further insights into masculine norms and men’s practices around seeking help for depression. Among men with depression, for example, there is a tendency to reproduce the discourses that contribute to reticence in accessing professional care (Johnson, Oliffe, Kelly, Galdas, & Ogrodniczuk, 2012). At the same time, some men challenged these discourses as well as binary representations of masculine norms regarding men’s use of mental health services. This research has supported upstream mental health promotion strategies that take into consideration the array of masculine discourses and ideals that influence men’s experiences.  49  4.1.2 Men’s distress in context The context of distress among men is an important topic of inquiry. In this study, distress is conceptualized as a spectrum, ranging from situational distress to ongoing experiences of significant distress, and is linked to mental health. For Ahmed (2004), emotions can mediate “the relationship between the psychic and the social, and between the individual and collective” (p. 27). Because masculine practices are shaped by discourses, institutions, and social conditions, new analytical entry points into men’s mental health research can be used to situate their perspectives and experiences in relation to their social contexts. There has been little research from the perspectives of young men without diagnosed or self-reported depression. Most of what is known about distress among men is derived from studies with people living with a diagnosis of mental illness such as depression or men living with a chronic illness (Ridge et al., 2011). Findings from a recent meta-synthesis show that most of the literature on men’s mental health has focused on depression and help-seeking from professionals (McKenzie et al., 2016). Exploring the perspectives of men who may be experiencing distress and who do not describe their experiences in terms of mental illness has the potential to garner new insights to inform mental health promotion efforts.  4.1.3 Focusing on immigrant and refugee young men Intersecting with gender are other aspects of social contexts that shape the mental health experiences of immigrant and refugee young men. According to Statistics Canada (2018), about one in five people in Canada were born outside of the country. In British Columbia, about one in five adolescent men (ages 12 to 19) were born outside of the country; in the area of Vancouver Coastal this figure jumps to nearly one in three (Smith et al., 2014).   50  Nuanced understandings of the narratives young men deploy about distress can inform mental health and public health programming to ensure that services and initiatives are relevant to their lived experiences and contexts. While Canada is home to a diverse population, virtually no studies have focused on distress among immigrant and refugee young men. The majority of immigrant health research with youth has tended to concentrate on acculturation (Salehi, 2010) and on individual or family-related factors linked to mental health (Hilario et al., 2015). There has been little research on the discourses that shape mental health from the perspectives of immigrant and refugee young men. There is a gap in understanding the experiences of this group, and it is likely that displacement, loss, and trauma, which can be part of their experience, may give a different shape to their narratives. Therefore, the goal of this chapter was to answer the first research question in the dissertation: What are the linkages between masculine discourses and the narratives of immigrant and refugee young men about distress?  4.2 Methods 4.2.1 Overview This qualitative study applied narrative analysis methods (Riessman, 2008) and critical theories of gender and masculinities. I drew on Connell’s (2012) relational approach to gender as a social structure that shapes individual and collective identities, institutions, and societal discourses. Gender relations can be conceptualized as socially and historically mediated processes by which practices are structured (Connell, 2005). For Connell, gender is dynamic and plural, encompassing a spectrum of relational (hierarchical, hegemonic/non-hegemonic) and constantly shifting masculinities that are constructed vis-à-vis everyday practices. As patterns of practice, masculinities are shaped by social and historical circumstances and are amenable to change. 51  Critical theories of masculinities were also used to analyze masculinities as social practices linked to male privilege (Pease, 2010). Connell (2000) described the diversity of masculinities in terms of a hierarchy in which men have unequal access to the ‘patriarchal dividend’; some men are marginalized or excluded based on categories of difference such as class and/or race. For Hibbins and Pease (2009), “white hegemonic masculinity has dominated the discourse about what it means to be a man” (p. 12). A critical masculinities lens was useful in examining the experiences described by immigrant and refugee young men, for whom access to male privilege intersects with belonging to visible minority or racialized groups in Canada. Among immigrant and refugee young men, gender relations intersect with social structures and discourses regarding transnational migration and resettlement. During migration and resettlement, dimensions of identity – including but not limited to gender, race, and class – must be negotiated depending on the context, and this process is influenced by the discourses and social constructions of masculinities within particular locales (Hibbins & Pease, 2009). Migration and experiences of marginalization due to ethnicity or race may also intersect with the construction of masculinities among migrant men, especially those belonging to refugee communities and who experience a greater sense of displacement and social exclusion. In this way, critical perspectives on masculinities were used to examine the intersections between race, class, and other dimensions of identity, and the ways in which they shaped distress among young immigrant and refugee young men in relation to masculinities. 4.2.2 Setting and participants This study was conducted with young men living in the Greater Vancouver Region who self-identified as having immigrant or refugee experiences. Thirty-three young men took part in the 52  study. They were between 15 and 22 years old and the majority were attending secondary school (n= 21) or post-secondary institutions (n= 9). One participant was in an alternative high school and another was working full-time.  Length of residence among participants who were born outside of Canada ranged from less than one year to approximately 14 years; the average was seven years. Four participants identified as second-generation immigrants born in Canada to families who had immigrated. The young men originated from eighteen countries including: Afghanistan, Bangladesh, Belarus, Bosnia, Brazil, China, Colombia, Democratic Republic of Congo, El Salvador, Ethiopia, India, Iran, Korea, Philippines, South Africa, Taiwan, Vietnam, and Zambia. They comprised a heterogeneous group, moving to Canada through economic migration, family reunification schemes, government-assisted refugee programs, refugee claimant processes, and through international high school education programs. 4.2.3 Data collection  Recruitment and data collection took place over approximately one year commencing in October 2014. Approval for the study was obtained from a university behavioural ethics review board. Printed study recruitment materials were displayed at community centres, libraries, and youth centres. Digital recruitment materials were also circulated via emails and websites with the assistance of an advisory group comprised of service providers and program leaders working with young people. Young men interested in participating were invited to contact me via email, text message, or phone call to learn more about the study. I conducted all of the participant interviews and obtained written consent from participants prior to starting the interviews. Two group interviews, one pair interview and thirty individual 53  interviews were conducted. Several participants took part in more than one interview format. Participants were able to select the interview location; interviews were conducted at community and recreation centres, libraries, public parks, malls, and cafes as per their preference. Participants were offered a $20 CAD honorarium for each interview in recognition of their time and contributions, and were provided with copies of the signed study consent forms, a letter of information for their parent(s) or guardian(s), and a list of relevant mental health resources.  The interview process was informed by Riessman’s (2008) narrative approach, which is similar to ethnographic approaches that ‘follow participants down their trails’. While an interview guide was used with broad questions and prompts (including “What is a typical day like for you?” or “Tell me about a bad day?”), young men were encouraged to tell their ‘natural stories’ and to view the interview like a conversation. The interviews ranged from 30 minutes to approximately two hours. Interviews were digitally recorded and transcribed verbatim.  4.2.4 Data analysis Data were analyzed using narrative themes developed inductively through repeated readings of the transcribed interviews. These themes were drawn from the data, the research question, and the goals of the study. Although an interpretive process, interview sequences were preserved as much as possible in initial coding. NVivo 10 software was used to organize the data in response to the research question: What are the linkages between masculine discourses and the narratives of immigrant and refugee young men about distress?   Drawing on narrative analysis methods, the participants’ narratives were not understood to be exact representations but rather interpretations of their experiences and their social worlds. Narrative analysis attends to both particularities and context (Riessman, 2008). Riessman 54  maintains that in order to have coherence, narratives must be able to “mesh with a community of life stories” (p. 10) and it is in the close analysis of stories that personal biographies are connected to society. In this way, the focus was not only on the content of the stories but on how they were told and why particular stories were shared.  Thematic and dialogic/performance narrative analysis approaches were used to guide close readings of the data, the setting, and the circumstances surrounding the interpretation of the narrative. In dialogic/performance narrative analysis, stories as treated as “social artefacts, telling us as much about society and culture as they do about a person or group” (Riessman, 2008, p. 105). Through this analysis I explored how narratives about distress were shaped by masculine discourses in relation to the societal context in which the study was taking place and to my role as the interviewer. In this analysis, I recognized that the content and form of the stories shared by the young men were shaped by what is shared in the interview context, which can enable or constrain the types of stories told. For Riessman (2008), “stories don’t fall from the sky (or emerge from the innermost ‘self’); they are composed and received in contexts – interactional, historical, institutional, and discursive” (p. 105). Since I conducted all of the interviews and I identify as a cisgender woman of colour from an immigrant background, the stories the young men shared were constructed for me. I am not proposing that our study findings exhaust the possible narratives shared by all immigrant and refugee young men; instead I acknowledge, as in many strands of narrative analysis, that the stories in our findings represent simply one set of possibilities among many (Chase, 2005).  55  4.3  Results Through the analysis, three narratives of distress were identified: norming distress, acknowledging distress as ongoing, and situating distress. The narratives were deployed by young immigrant and refugee young men to make sense of distress in their lives and to situate their experiences as nuanced responses to their social contexts. In the first narrative of norming distress, the participants depicted difficult experiences as hypothetical and exceptional, while simultaneously rendering distress as a taken-for-granted norm. In the second and third narratives, distress was acknowledged and situated in relation to discourses that shaped how they could express and understand their distress. All names that appear are pseudonyms; most pseudonyms were selected by the participants. 4.3.1 Norming Distress  In the first narrative, the young men shared accounts that rendered distress as a taken-for-granted norm. Although the majority of the participants switched between the various narratives, this was used almost exclusively in several interviews and was the most common narrative. At the same time, it was used to depict difficult experiences as hypothetical and exceptional, that is, occurring infrequently. The focus in these accounts was on the circumstances that might lead to a bad day rather than on describing an actual experience. For example, in one group interview with four 15-year old high school students, participants took turns describing elements of what would be a bad day for them. In this way, the young men established a degree of distance between themselves and the possibility of experiencing distress. Accounts in this narrative were often limited to the distant past. For example, some participants described events in their early childhood, such as 15-year-old Patrick from South Korea: 56  I guess the worst day I’ve had - it’s probably that day when I went to my friend’s birthday party and cried. Because of the reasons, like I cried there, and it was for the dumbest reasons too so, it’s the worst day because of not actually what happened but rather because of the things that --- it’s kind of like basically I regretted a lot so that makes it a bad day…  Patrick brought up this event several times during his interview, emphasizing and linking his public display of emotions to a sense of regret and shame while avoiding details around the event and the emotions he felt at the time. He maintained the experience of shame as a rare and manageable slip in response to circumstances in his childhood. There was an assurance that difficult experiences were isolated incidents that were unlikely to recur, as Ivan, a 17-year-old high school student who was from Belarus, shared: In grade 10, I failed my math test really badly - like an F kind of fail, you know what I mean? And… I got really really depressed and then I didn’t talk to anyone for like two days. I was like, damn like that’s just that was like the worst day ever. Luke, a 19-year-old international university student from South Africa, felt lonely and “flat” over a period of several months during his first year in Canada. He described how he withdrew from the people close to him and felt isolated. This continued until he sought help from friends and family. At the same time, he situated his experiences in the context of a full recovery from an isolated incident, while distancing himself from those circumstances and emotions: 57   I’m not more susceptible to feeling like that ‘cause, I mean since I’ve been back I’ve never really felt it again… I really doubt that’s gonna happen again, especially the thing that happened in second semester of first year.  This narrative was used by the participants to distance themselves from difficult experiences and emotions. Some accounts focused on perceived inability to express emotions, as explained by 20-year-old Daniel from Brazil, My parents always said I had a hard time showing my emotions – I don’t know why I do that… Maybe I’m afraid – uh, I don’t think that’s it. It’s just hard for me to understand what emotion I’m feeling at that time. In the interview, Daniel attributed his emotional inexpressiveness to difficulties understanding his feelings. This portrayal of himself was set against his account of a classmate: This really weird kid – compulsive liar, he had bipolar disease, but he didn’t get diagnosed until last year – he had a lot of problems with fitting in… I knew that he had like, mental problems… I actually could not understand what was going on in his head, because he was just crazy – like, some moments we were playing a video game – he was fine, and then he would just freak out and just scream at people, try to fight with you. Daniel’s emotional inexpression was linked to an outward display of composure as a masculine norm and contrasted against other young men who did not demonstrate a similar degree of control. The use of medical terminology indicated Daniel’s familiarity with mental illness while distancing himself from the experiences of his classmate. 58  Within the narrative of norming distress, a sense of resilience was emphasized by the participants while talk of distress was at once normed and minimized. For 16-year-old Marcus, a high school student from Taiwan: I tend to forget bad things actually… Let’s say someone did something really bad to me then I would get really mad at the moment but then afterwards I just sit down, watch a movie relax and then just I’m all smiles again. I don’t like to remember bad things. By highlighting his ability to control his emotions and to work toward regaining composure, this young man’s statement conveyed his strategy to move on from difficult experiences and consequently waylay his own distress. In this narrative, distress was downplayed and was unlikely to affect participants again. The narrative indicated a theme of strength in dissipating distress while implying a norm that ‘bad things’ happen.  4.3.2 Acknowledging Distress as Ongoing In the second narrative, distress was acknowledged as an ongoing part of the young men’s lives. Within this narrative, participants detailed the ways and the extent to which they experienced distress, ranging from situation distress to mental health challenges. Accounts connected the present to past events, using terms such as tendencies and triggers.  Rather than focusing on isolated incidents, these accounts situated distress within ongoing circumstances and relationships. For example, Raymond, a 17-year-old high school student from Taiwan, connected his distress to his relationship with his parents: 	Sometimes I don’t get along with my parents and usually when we fight that just makes the whole day bad in a way cause I get into a really bad mood and I just don’t want to do 59  anything after… with my parents it’s very difficult to because we don’t have a very good relationship and I haven’t had a really good childhood with them so whenever I fight with them even if it’s about something minor it triggers all the memories – everything – all the emotions I’ve ever had regarding them and it just makes me very very upset because it reminds me of everything – every problem that hasn’t been solved yet – because we don’t really solve our problems, we just forget about it and even though it’s still there. And when we fight it just makes me angry how I know that this problem isn’t going to get solved either.  Raymond described feeling unsupported and misunderstood by his family, which caused significant distress for him. He expressed his ongoing frustration at a situation he depicted as potentially unsolvable and beyond his control, because of the many conflicts that have happened between him and his parents. Therefore, incidents had a tendency of ‘triggering’ memories of previous conflicts. His account underscored the intensity of his distress and he described resorting to calling a helpline or ‘breaking things’ to relieve his frustration and anger. Several young men drew on medical terminology to emphasize the gravity of their distress. Hedayat, a 19-year-old university student from Bangladesh, explained: I guess I just naturally have that sort of bipolar tendency, not bipolar as a diagnosis, but I have bipolar tendency. I have months or a year and if I were to describe it… I have the day to day or week to week shifts, but then I also have underlying like this is a good year, this is a bad year. This is a good month, this is a bad month, they’re stacked.   The participant described the immediacy of his distress in terms of a rolling pattern interrupted by periods when times were ‘good’. He offered a view of distress and mental health challenges 60  as prolonged, lasting weeks, months or even years. By doing so, there was acknowledgment of uncertainty and instability regarding distress. Some participants described difficult experiences in terms of lack of motivation, energy level, and a sense of numbness. Aaron, an 18-year-old student from Bosnia, also used medical terms such as depressed to explain his experiences:  You’re unmotivated, you’re tired, you don’t want to wake up. You just want to sit around. You just feel sad and pathetic. Um… you’re not necessarily sad but you don’t feel anything… I felt depressed for about three, four years in high school. I didn’t tell anybody just ‘cause I didn’t want to bother anybody… I felt suicidal, I didn’t want to do anything. Getting bad grades in school really got me down.  In contrast to casting distress as insignificant, the narrative of distress as ongoing linked difficult experiences to past and present, including relationships and ongoing circumstances. Within this second narrative, the young men were able to open up and acknowledge distress, in the varied forms it existed in their lives.  4.3.3 Situating Distress  Beyond acknowledging distress as ongoing, the third narrative reflected accounts in which participants situated their experiences in relation to dominant discourses that shape their expression of distress. Distress was depicted as instructive and integral to understanding the circumstances of their lives. Rather than seeing distressing circumstances as something ‘to be dealt with’, their experiences were described as an opportunity to acknowledge pain and to cultivate their sense of empathy as a way to understand their own distress.  61  This narrative was deeply reflective as participants situated their accounts within their views on understanding and responding to their distress. The young men’s acknowledgement of their pain was particularly poignant, as 19-year-old Hedayat explained: By inflicting mutual pain then there’s an understanding – but then that clearly points back to that there’s a pain within you that you haven’t acknowledged - that’s why you’re angry, that’s why you’re trying to inflict it because you’re trying to deal with your own pain, you’re trying to understand your own pain … so then if what that violence is looking for is understanding, then what it needs is not like a violent expunging or an outward subject, but like sympathy, right. We need empathy to be able to understand our anger because that’s what we’re looking for.  The participant critiqued the normalization of masculine discourses of anger and violence as a means to work through mutual pain. In this regard, stoicism is broken in order to release anger through, in Hedayat’s words, a ‘violent expunging’. While anger was acknowledged as the default mechanism for masculine expression of emotional pain, Hedayat noted its limitations in helping young men to actually address their pain.  Participants recounted ways in which they learned to understand and practice empathy. In the words of Nicholas, a 19-year-old student from the Philippines: Well most of the stress I was having back then was my mom kind of like hounding me on my career choices… like you’re not in university where you should be and stuff like that. And then [my counselor] explained to me that my mom is just trying to make sure that I know what I’m doing. And I guess by listening to her I understood what my mom was saying to me and it made more sense…  62  Evident were co-constructions of masculinity wherein hierarchical positions were understood as available to young men who worked hard and were competitive. Herein were patriarchal pressures in the context of claiming dividends linked to hegemonic masculine ideals. At the same time, there was an imperative to acknowledge distress beyond one’s self and to imagine the circumstances that might have influenced another person to inflict disrespect, anger or pain. As 20-year-old Nathan from the Philippines explained: … It takes the focus off of me, right, like sometimes you have to see things from the other person’s perspective and how this person might be feeling, right… It helped me in that way like I can see this person was feeling this, maybe I should approach him like this or maybe I should put it this way or… It’s so hard to explain, but really, really important to have empathy, yeah I don’t know, it’s just a human requirement.  In this narrative, the emphasis on empathy was juxtaposed against dominant masculine discourses in which outward strength, dominance and control are valued. It signaled a form of resistance to expectations for young men to act in particular ways. As Matthew, a 19-year-old university student from South Africa, reflected:  Sounds silly, when I look back at myself like five years ago or something I don’t know why I did the things that I did. I was just so deluded ‘cause I had this idea of what people were supposed to be like and kind of followed that as opposed to doing what I really wanted to do. Just like I wouldn’t cry at movies, I wouldn’t cry, I just tried not to cry, I would like focus on the crying, but crying is good for you, crying feels so good.  63  In contrast to foregrounding the suppression of difficult emotions, Matthew described the sense of relief and release he experienced by acting counter to what he perceived were prevailing instructions to young men ‘not to cry’.  Within the narrative of situating distress, the participants sought to make sense of their experiences of distress. There was explicit acknowledgment of pain and the need for understanding and empathy. This represented a departure from masculine norms that require emotional inexpressiveness, particularly in public spaces, and signaled emergent narratives that challenge the dominant discourses about what it meant to be a young man. 4.4 Discussion This chapter focused on the connections between masculine discourses and distress among immigrant and refugee young men. Informed by gender relations and critical masculinities, the narrative analysis indicated three narratives: norming distress, acknowledging distress as ongoing, and situating distress. The findings indicate, through the narratives, the diverse perspectives of immigrant and refugee young men in Canada. By including both groups in the study, my intent was not to conflate the perspectives of immigrants and refugees; rather the aim was to provide a nuanced analysis of the types of narratives they drew on to describe their experiences in ways that were “consequential for later action and for the meanings that the speaker wants listeners to take away from the story” (Riessman, 2008, p. 3). The narrative presented by many participants was one of norming distress, which is consistent with existing research indicating men’s unwillingness to disclose vulnerability and their efforts to conceal their distress (Riska, 2009). This finding can be interpreted in relation to the performance and embodiment of dominant masculine discourses that affect how young men 64  engage with their world. As Walton and colleagues (2004) have asserted, “…to experience emotions is human; to control their expression is masculine” (p. 413). This narrative may have been deployed by many participants in the study to reassure the researcher that they were generally ‘doing well’.  Much research, particularly with heterosexual men, has focused on constrained emotionality and emotional inexpressiveness and the interventions that could help men overcome ‘emotional illiteracy’, described by Connell (2000) as ‘masculinity therapy’. For other researchers, “generalizations about men being silent about their mental health problems are misleading” (Mckenzie et al., 2016, p. 81). As Gough (2006) has argued, intervening on ‘masculinity’ and organizing services to accommodate hegemonic forms of masculinity may perpetuate a view of masculinity as static and unchanging rather than plural, dynamic, and situated in social and historical contexts.  Pease (2012) has emphasized the need to closely examine the ways in which gendered practices around emotions, including emotional indifference or distance, enhance the capacity of men to control others and to maintain power. Portraying men as victims of constrained gendered practices, therefore, does not take into account the male privilege associated with men’s repression of feelings and desensitization to the emotions of others. Rather than ‘masculinity therapy’, strategies can focus on supporting men to ‘subvert their socialization’, to re-conceptualize their emotions as a way to acknowledge the emotions and the pain of others, and to connect their pain “to their position in the social relations of gender” (Pease, p. 137).  Masculine discourses may also intersect with discourses about immigration and visible minority or racialized groups in ways that shape the experiences of immigrant and refugee young men and 65  the narrative of norming distress. Research with refugee youth in Canada, for example, suggests that they experience discrimination related to language proficiency, newcomer status, and belonging to visible minority groups (Edge, Newbold, & McKeary, 2014). It is possible that ongoing exposure to adversity among immigrant and refugee groups may invite narratives that minimize or normalize experiences of distress since narratives that deny distress cannot easily be used in this context. Therefore, the narrative of norming distress might be constructed in response to experiences of discrimination and racism based on mainstream discourses in Canada about immigration and national identity. While the narrative of norming distress suggests an attachment to masculine norms, the narratives of acknowledging and situating distress suggest a resistance to “the male privilege that resides behind the emotional inexpressiveness associated with white, Western, heterosexual men” (Pease, 2012, p. 130). These narratives challenge dominant masculine discourses and may signal emergent masculinities linked to the unique everyday experiences of immigrant and refugee young men in Canada. Findings from Chapter 5 shed further light on these experiences and the social context of mental health for this group, particularly the realities of working through distress and difficult emotions in the context of marginalization and discrimination. 4.5 Implications for practice and future research Nuanced understandings of young men’s experiences can inform the development and implementation of programs to address distress, promote mental health, and prevent mental health challenges among diverse young men. Findings from this study may be used to inform initiatives aimed at creating safe and supportive contexts for young men to be able to talk openly about distress and to access the supports they need. Beyond discourses related to masculine 66  norms of stoicism and strength, there were emergent narratives focused on acknowledging distress, engaging with emotions, and situating their experiences within the context of their everyday lives. The unique experiences of this group are further explored in Chapter 5, particularly in relation to marginalization and the social context of mental health.  These findings make contributions to the literature on men’s mental health by offering a nuanced analysis of distress from the perspectives of immigrant and refugee young men in Canada. This study takes up Petersen’s (2009) recommendations to attend to the sociology of emotions and to “shift the focus from changing ‘men’ to changing the discourses, institutions and practices” that give rise to men’s health experiences and behaviours (p. 210). There is much potential for further empirical study of emergent masculinities among young men in relation to distress and mental health. Future research is needed with men who are engaged in practices that support their mental health and to explore how masculinities are negotiated within those contexts.     67  Chapter 5: “Just as Canadian as Anyone Else”: Experiences of Second-Class Citizenship and the Mental Health of Immigrant and Refugee Young Men3 5.1 Background In recent years, the experiences of immigrant and refugee young men have drawn attention worldwide. Human-induced environmental disasters, local and global conflicts, and increasingly inequitable distributions of wealth have shaped transnational migration patterns that require innovative solutions to addressing the health of immigrant and refugee populations. With an estimated 250 million immigrants across the globe (World Health Organization, 2018), and about 60 million refugees displaced from their homes due to conflict in 2014 (United Nations High Commissioner for Refugees, 2016), the world has been witnessing, in the words of the Director-General of the World Health Organization (WHO), “the largest population displacements seen since the end of the Second World War” (2015). Canada is home to a large immigrant and refugee population, particularly in its urban areas. People born outside of Canada represented over 20 percent of the country’s population, according to 2016 census data (Statistics Canada, 2018). The growing population of immigrant                                                3 A version of chapter 5 is in press: Hilario, C., Oliffe, J., Wong, J., Browne, A., & Johnson, J. (in press). “Just as Canadian as anyone else”: Experiences of second-class citizenship and the mental health of young immigrant and refugee men in Canada. American Journal of Men’s Health. Advanced online publication, doi: 1557988317743384. 68  and refugee groups in Canada raises a unique set of considerations with regards to designing and implementing effective mental health initiatives and conducting research to inform programs and services (Mental Health Commission of Canada, 2012). Mental health promotion has been identified as a key priority in supporting immigrant and refugee populations. According to the WHO, mental health is “a state of well-being in which every individual realises his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community” (2014b). Beyond the absence of mental illness, mental health is understood as fundamental to individual and collective capacity for thought, emotion, and interaction. In this vein, mental health promotion is conceptualized as an approach that acknowledges determinants of mental health, comprises strategies across health and social services that foster supportive environments, and involves populations in the context of everyday life (Joubert, Taylor, & Williams, 1996). Taking an upstream mental health promotion approach, this study addressed the second research question in the dissertation: What are the connections between mental health and the migration and resettlement experiences of immigrant and refugee young men?  5.1.1 Frameworks for Immigrant and Refugee Health Increasingly, there has been a call for a broader analysis of immigration that takes into account the social and institutional contexts in which people resettle (Castañeda et al., 2015). Most of the research with immigrant young people has tended to concentrate on familial or cultural values, intergenerational conflicts, and acculturation (Salehi, 2010). In general, there has been an emphasis on individual and family-level factors and less attention to social structures and relations (Hilario, Oliffe, Wong, Browne, & Johnson, 2015).  69  In-depth analysis of how structural factors related to inequalities shape immigrant health outcomes are needed (Viruell-Fuentes, Miranda, & Abdulrahim, 2012). The reliance on cultural and behavioural frameworks, in which culture is narrowly defined and individual health behaviours are the primary unit of analysis, have led to studies that “revert back to an apolitical and ahistorical understanding of differences between populations that eschews social inequalities and social determinants of health” (Castañeda et al. 2015, p. 380).  For example, empirical evidence suggests that that social support and stable resettlement have protective effects on the mental health of young people (Fazel, Reed, Panter-Brick, & Stein, 2012). Similarly, research in Canada has shown linkages between supportive environments and the health and wellbeing of refugee youth (Edge, Newbold, & McKeary, 2014). However, virtually no studies have focused on mental health from the perspectives of immigrant and refugee young men in Canada. 5.1.2 Mental Health of Immigrant and Refugee Young Men  Canada is home to a large immigrant and refugee population, particularly in its urban areas. According to 2016 census data, people born outside of Canada represented over 20 percent of the country’s population (Statistics Canada, 2018). In recent years, the top three source countries for permanent immigration in Canada have been China, India, and the Philippines (Immigration, Refugees and Citizenship Canada, 2016).  Research has shown that first-generation immigrant youth in Canada experience higher psychological distress compared to second or third-generation immigrant youth (Hamilton et al., 2009). Similarly, a study using population-based survey data found that Southeast Asian youth who have been in Canada for 5 years or less were more likely to report emotional distress (Hilario et al., 2014). Furthermore, research in Australia suggests higher odds of depression 70  among immigrant men from non-English speaking backgrounds compared to their Australian-born counterparts (Straiton, Grant, Winefield, & Taylor, 2014). Researchers in the field of men’s health have noted the need to examine the intersection of gender and diversity in seeking help (Galdas, Cheater, & Marshall, 2005). For example, immigrant men in Canada have been found to under-utilize health services for psychological distress (Kirmayer et al., 2007). Research has also found that mental health services for immigrant youth in Canada have been sidelined and grounded in charity-based rather than rights-based frameworks (Ngo, 2009). Barriers to accessing services for newcomers include limited language proficiency, lack of cultural safety, difficulties navigating the system, fear of accessing services, and being seen as a burden on the system (Gagnon, 2002).  The literature points to a gap in effective, relevant, and accessible mental health-promoting services and programs for immigrant young men. To my knowledge, the empirical research on men and mental health has yet to focus on the perspectives of immigrant and refugee young men. In Canada, as other researchers have previously noted (Edge & Newbold, 2013), there is scant information about this group. Therefore, this study addressed the second research question in the dissertation: What are the connections between mental health and the migration and resettlement experiences of immigrant and refugee young men? 5.2 Methods The conceptual lens of social context guided the study. Social context refers to relations “comprising social structures such as class, race, and gender; institutional practices, and collective and individual behaviour, and intersecting personal biographies” (Poland et al., 2006, 71  p.60). Within this lens, mental health is shaped by the confluence of social structures, institutional practices, and personal biographies (Frohlich, Poland, & Sareck, 2012). The concept of social context provided an analytical entry point for examining the ways in which the narratives of immigrant and refugee young men, pertaining to their day-to-day experiences, were situated within personal biographies, practices, and social structures linked to power and privilege within specific socio-historical contexts.  5.2.1 Recruitment The study was conducted in Greater Vancouver, a metropolitan region located in western Canada. Following approval from the University of British Columbia Behavioural Research Ethics Board, recruitment and data collection were conducted between October 2014 and October 2015. Recruitment strategies were diverse to ensure the inclusion of young men who were or were not connected to services. Flyers were distributed at youth and community centres, libraries, and on websites. A project advisory group assisted with posting notices in addition to word of mouth recruitment by a team of youth research collaborators who were also immigrant and refugee young men. Those who were interested in participating were instructed to contact the lead author via email, phone or text message.  5.2.2 Participants Thirty-three young men, who identified as having immigrant or refugee backgrounds, participated in the study. They ranged in age from 15 to 22 years old. The primary activities of the participants included attending secondary school (n = 21), alternative school (n = 1), attending college or university (n = 9), working full-time (n = 1), and being unemployed (n = 1). The participants originated from 18 countries and comprised a heterogeneous group, including 72  those who had immigrated through family reunification programs, government-assisted refugees, refugee claimants, and international students temporarily residing in Canada.  Several young men (n = 4) identified as second-generation immigrants born in Canada to families who had immigrated. Length of residence among those born outside of Canada ranged from less than one year to approximately 14 years (average = 7 years). The majority of the young men were perceived by the interviewer and lead author as visible minorities with the exception of three participants (two participants South Africa and one from the former Yugoslavia). In Canada, the category of visible minority refers to "persons who are non-Caucasian in race or non-white in colour and who do not report being Aboriginal” (Government of Canada, 1995).  5.2.3 Data collection Recruitment, data collection, and analysis were led by the lead author who identifies as a cisgender visible minority Filipina woman who immigrated to Canada as a child and racialized settler through the family reunification scheme and was in her 20s at the time of data collection. The co-authors include four people who identify as an Australian immigrant to Canada; a visible minority Chinese woman born in the British colony of Hong Kong and immigrated with family to Canada at age 16; a Euro-Canadian woman; and a white, Canadian-born, lesbian woman. All authors have established strong track records of conducting research with marginalized communities with the goal of promoting health equity. Data were collected through individual and group interviews. The lead author conducted all of the interviews. Participants were informed of the study procedures, and they provided written consent prior to taking part in the interview. All participants were offered the option of an individual or group interview. As part of the process, participants were able to select the 73  interview location. The interviews were conversationally oriented and the interview guide included broad questions such as, ‘What is a typical day like for you?’ and ‘Can you tell me about a difficult time in your life?’  Interviews were digitally recorded and transcribed verbatim. The interviews ranged from 30 to 90 minutes in length and were conducted in various locations as per participants’ preference: community and recreation centres, libraries, public parks, malls, and cafes. Debriefing between the interviewer and interviewee took place following each interview to allow for additional thoughts or questions from participants. This step was documented in field notes but not recorded as part of the interview. Participants were provided with copies of the study consent forms, a letter of information for their parent(s) or guardian(s), and a list of relevant mental health resources. A $20 CAD honorarium for each interview was offered to participants to acknowledge their time and contribution to the study.   5.2.4 Data analysis  The software program, NVivo10, was used to organize and re-aggregate transcribed interview data with broad codes that were inductively derived from repeated readings of the transcribed interviews. Thematic narrative analysis was used to examine the coded data (Riessman, 2008). Data were examined not as exact representations but rather to elicit the young men’s interpretations of their experiences and their social worlds. The focus of the narrative analysis was on the connections between mental health, social context, and experiences linked to migration and settlement. Drawing on the concept of social context as an analytical entry point, thematic narratives were identified through dialogue and building consensus among the authors. Throughout the analysis, 74  the authors engaged in dialogue on the convergent and divergent interpretations and the collective intellectual contribution stemming from their epistemological perspectives as well as scholarship standpoints. All names that appear in the findings are pseudonyms; most pseudonyms were selected by the participants. 5.3 Findings Within a study focused on the social context of mental health, the participants described their everyday experiences as immigrant and refugee young men in Canada. The analysis revealed three prevailing narratives: a better life, living the (immigrant) dream, and starting again from way below. These narratives were interconnected and underpinned by a central theme of negotiating second-class citizenship.  5.3.1 A Better Life  In describing their experiences, there were many references made by the participants to a narrative of searching for a better life. Their pre-migration aspiration for a better life was often framed in terms of physical, political, economic and social safety and security in Canada. During one group interview, several participants echoed similar reasons for migrating: the possibility of “a new life”, “more security”, and “better opportunities”.  Daniel moved to Canada to study as an international student and, in his interview, highlighted the stress he experienced on a daily basis in his home country,  Everything is so dangerous… I was robbed twice – people would just take a knife or a gun and just, you know, “Give me your wallet,” – that’s pretty common, you know?    (Daniel, age 20, Brazil, international student) 75  He recounted how he avoided particular neighbourhoods and exercised vigilance to avoid being robbed and/or assaulted. He perceived that community violence and crime only occurred in his pre-migration country, and was likely not aware that Canadian youth in marginalized neighbourhoods also experience similar violence.  In addition to physical safety, participants referred to a better life as the hope for political stability and security as an impetus for migrating. For some young men, moving to Canada came with the promise of refuge from war, as one participant explained, “Here [in Canada] there’s more security, some countries have war”. Nabhan, a young refugee, recounted some of his experiences growing up in Afghanistan: That time the Taliban – they just came to Afghanistan and attacked the entire country. So, they had really strict rules – like, really strict, like woman shouldn’t go outside from house, not at all, they have to put the cover… and I respect my religion, and it was really strict, like we are human, everyone does mistake… but back in the day – you have to do it or you have to die. Killing humans for them was like killing – not even killing, it’s just cutting the bread, you know? Like pieces of bread… (Nabhan, 18, Afghanistan, refugee) Nabhan recalled the physical danger as well as human rights infringements that he and his family experienced. He shared that his parents experienced ongoing struggles in ensuring the safety of all their children and that when he reached the age of 16, his family sent him to Canada alone to seek asylum. For other participants, a better life meant economic security and prosperity in Canada, which was often portrayed as ‘a land of opportunity’. One participant who immigrated with his family explained his parents’ reasons for moving to Canada: 76  They thought that moving to Canada would be a better option for me ‘cause it’s just a better country overall you know what I mean with uh all the corruption going on in Russia and the president and stuff and… ‘cause like if I’m being honest Russia is not that much of a wealthy country. (Ivan, 17, Belarus, immigrant) Ivan’s dissatisfaction with his perceived social and political corruptions in Russia shaped his perspectives of hope for a more prosperous life in Canada.  A better life also signified social safety and the freedom of movement, as Luke, an international university student, described,  Being on a South African passport, travelling is impossible, like I need a visa for everywhere… This is really kind of like my ticket out of all of that. (Luke, 19, South Africa, international student) In this regard, moving to Canada and the possibility of becoming Canadian citizens provided a way to navigate a global class system that allows or restricts the mobility of some groups based on citizenship to specific nation-states. A South African passport, for example, did not afford Luke the same right to travel to different countries as a Canadian passport. This aspiration constructed their expectation of Canada as “a better country overall”. The pre-migration construction of a better life influenced the range of stories the young men shared regarding the places they knew as home or where they were living before they moved to Canada. Despite the diversity of national and regional contexts from which the participants and their families have migrated from, this narrative of a better life was pervasive across the young men’s accounts; they were intertwined with the hope for safety, security, rights, and prosperity. 77  At the same time, this narrative reinforces a broader discourse in Canadian society whereby low-income and middle-income countries are often constructed as problematic or inferior societies, but the complicities of Canadian foreign policies remain invisible. 5.3.2 Living the (Immigrant) Dream In this second narrative, social context was linked to living the (immigrant) dream in Canada. The young men described the attributes that positively influence their mental health, including the proximity of the city to mountains and forests, better air quality compared to their pre-migration countries, and the relative accessible public transportation. Living the (immigrant) dream also referred to the prevailing portrayal of Canada as an economically prosperous, inclusive, and fair nation where everyone has an equal opportunity to pursue their dreams and achieve upward class mobility.  Within this narrative, the young men saw themselves as agents for fulfilling their dreams, as well as the aspirations of their families. Education was recognized as requisite for securing jobs, and therefore depicted as the key to a hopeful future. In this vein, academic achievements, such as a good mark on an exam, were often featured in accounts of positive emotions such as excitement and feeling “pumped up”. Conversely, failures related to academic performance were described in accounts of significant distress:  A really bad day for me is when some of my teachers got mad at me when I forget to do homework or I couldn’t answer the questions… And, even though they might not notice it, it will make me depressed for the whole day. (Peter, 16, Taiwan, immigrant) 78  In this and other stories, the young men alluded to self-blame, disappointment and shame. As another participant shared, “I got [my] report card like yesterday and [was] very upset… I feel like how should I explain it to my parents?” (James, 17, Taiwan, immigrant). Within these accounts, self-talk was interjected as if to reveal that the young men knew that they were expected to work harder and ‘be better’.  The fear of failure was aggravated by the young men’s worries over disappointing their parents together with the desire to realize the collective family aspirations. One young man who immigrated with his family explained: Well like it was kind of the whole thing of we came to this country and… it’s like, “Are you just going to go to [college]? You could’ve made it to [university]. But you were just too lazy.” (Nicholas, 19, Philippines, immigrant) He alluded to a sense of shame in his perceived inability to exert the effort and focus required during a window of opportunity for upward social mobility.  For several participants, the amount of effort required of them at times exceeded their physical and mental capacity to juggle multiple responsibilities: I’m just overloaded, just boom. Sometimes I gotta work like 16 hours… the homework, the school, a pretty tight schedule every day, just got to manage it and… there are chores around the house, homework, and all that kind of just piles up on you, weight on your shoulders, you know.  (Ivan, 17, Belarus, immigrant) These participants emphasised the stress and emotional toll of financial hardship on their families and the significant pressure it generated for the young men to succeed in school. The 79  constant stress and pressure to achieve was a trigger for negative thoughts, which, for one young man, led to several years of suicidal ideation: I’m not forced by my parents to do anything, but I know I’m obligated to them just ’cause I feel like I owe them that much at least - so when I do poorly… it really stresses me out and um it kind of just gets all the bad thoughts coming…you just want it to end and how else is it going to end, right? There just doesn’t seem like any… other solution… ’cause you can’t just put a pause on everything, right? (Aaron, 18, Bosnia, immigrant)  When the young men observed the difficulties faced by their parents during settlement, they felt a sense of responsibility and family obligation that weighed heavy on them.  Their attempts to meeting family expectation were often accomplished at the expense of not being able to explore or focus on what they truly wanted for themselves.  At the same time, more tensions and internal struggles unfolded within a context whereby a good education no longer translated into secure employment. In one young man’s words: Coming towards the latter half of my university degree, it’s like, “Hey, what am I going to do?” I started to get that malaise where, you know, I just stay at home and I start to fuse with my bed and become not a person anymore… where you’re just wandering around, you have no idea what the f--- you’re doing or what the f--- anything is.  (Hedayat, 20, Bangladesh, immigrant) For Hedayat and his peers, the portrayal of Canada as essentially egalitarian was seen as a benchmark or starting point against which achievements and their families’ struggles were evaluated. As a result, the young men who framed their struggles through this narrative spoke 80  about failures of individuals rather than the failure of institutions, systems, and policies that were supposed to support them.  5.3.3 Starting Again from Way Below  In the third narrative, the young men focused on nuanced stories about mental health and what it was like for them and their families to leave their home countries and resettle in Canada as immigrants or refugees. The theme of starting again from way below grappled with the mental health implications of the distress the young men experienced in striving to integrate. These experiences included learning a new language, trying to understand mainstream ‘Canadian’ culture and humour, and navigating the education system. For some participants, this narrative also referred to resisting stereotypes about their people, countries and cultures and negotiating systemic discrimination vis-à-vis institutionalized de-skilling practices and unconscious biases, which produce and perpetuate barriers to advancement for members of minority groups. Limited ability to communicate in Canada’s official languages of English and French was a recurring feature of accounts of distress. As language and culture are intricately intertwined, many of the young men experience the common phenomenon of knowing the English words but not the contextual meaning that was culture-bound.  This challenge came up often regarding experiences of distress and anxiety as well as difficulties around establishing social connections, as one young man who immigrated with his family shared: What caused the stress was when I was communicating with my classmates. Now I still couldn’t really understand what they said to me back then … sometimes it felt like they were joking but sometimes it didn’t quite feel like it and I didn’t really know where to go. (Joseph, 17, China, immigrant) 81  The challenge of understanding the contexts specific to everyday conversations with others rendered a sense of social isolation.  When confronted with experiences of marginalization, the young men shared that at times they were forced to respond in ways that were considered to be anti-social. In Kavan’s (age 18, India, immigrant) words, “I didn’t really understand how to make friends in Canada so… I was just getting into fights with the other kids in elementary school and… just not really understanding their humour”.  The young men also spoke about their frequent encounters with stereotypes about people from their countries of origin, and misinformed presumptions about their cultures. Nabhan, a refugee from Afghanistan, described the discomfort he felt whenever his fellow students at school asked him or spoke about ‘his people’:  My friends were just kind of – “Oh, you guys just wanna –,” like in Afghanistan and Iraq, and Gaza and those places, there was lots of fighting and he was like then, “Why you guys don’t want peace in your country?” – I was like, “Well, you can’t just describe the whole country by one or couple people”  Underpinning Nabhan’s experiences are practices of stereotyping, profiling, and discrimination in Canada based on generalizations about the people in specific regions in the world. Hedayat described similar experiences outside of school:  “The most overt kinds of racism that I’ve gotten is generally because of my last name – when we go through borders or airports or whatever security like that, just because it always sets off the flags” (20, Bangladesh, immigrant).  82  These ‘flags’ referred to increasing national and international surveillance of particular groups who fit a hypothesised profile of danger, which functions to sustain the mainstream discourses in Canada about national identity. Within the school system, the young men described feelings of distress in experiencing or witnessing particular circumstances that seemed unfair to them. For example, Joey, a high school student (16, China, immigrant), described how he saw his friend being held back in a class: “…the teacher was being biased… it’s just that the way he talks or like the tone of voice, it changes when he speaks to different people”. Prompted to clarify Joey offered, “Perhaps um race? I don’t know. Race or gender.”  Immediately following this, he scanned the café in which the interview was taking place and continued: I don’t know if I’m supposed to say this but he [the teacher] is nicer to girls in general and he’s nicer to non-Asian, I mean non-Chinese people. I don’t know why. Like other students told me about this too - I’m not the only one who thinks that. But then he’s not the only teacher who does that. (Joey, 16, China) What began as Joey’s response to an interview question about a difficult day and his distress in seeing his friend being unfairly treated in class led to guarded disclosure of instantiations of discrimination, in which the work of immigrant or refugee students were discounted.  The only recourse for Joey was to “just put up with him [the teacher], not argue with him … just study hard, prove that I spent a lot of effort”. Despite being a second-generation immigrant young man, Henry (22, China) expressed concern or worries about his future based on his parents’ experiences, 83  It was really hard to find jobs, especially when you’re Asian at that time, because… they were more or less really focused on Caucasian people… [and] because [my parents’] credentials from their birthplace weren’t really transferable to here.  Other participants described their parents’ experiences of downward mobility vis-à-vis practices and policies that shape the recognition of international credentials, a process also referred to as de-skilling. In the words of Matthew, an international student in Canada: “[My parents] lost most of their degrees and reputations– so they were reduced pretty far down and had to start over again with their lives basically” (19, South Africa, immigrant). These accounts illuminate the realities faced by immigrant and refugee families who experience de-skilling, difficulties finding adequate and equitable employment, and financial hardship. These experiences also reflect institutionalized devaluation of education and professional credentials from particular countries.  The challenges faced by their families once moving to Canada exacerbated the pressures experienced by the young men to fulfill the dreams of academic success and financial security. In Henry’s words (22, China, immigrant), “It used to be like, do we have enough next month to pay for everything and to eat… so that led to more pressure growing up”. Aaron’s experiences were similar (18, Bosnia, immigrant): It was hard, we didn’t have a lot of money – we never really had a lot of money. My dad always worked as a truck driver so he was always away for long amounts of time. So he was never really present. My mom’s always had a pretty hard time just managing money and everything.  Aaron described his mother’s recent diagnosis of cancer and the resulting financial and emotional impact on the family. He emphasized a strong sense of responsibility for his ill mother 84  and younger brother, and how he strived to fill the shoes of an absent father while also longing for his mother’s support. For the young men, financial support for the family was understood and accepted as a collective undertaking by both parents and children, which was particularly challenging when their parents took ill. However, illnesses in the family were often tied to complex social determinants that posed challenges that were not easily resolved, as Henry (22, China, immigrant) explained,  A long time ago, my mom told me – my dad – he has, like, a depression disorder kind of thing, so he was basically on meds for a few years until he secured a job… Maybe the reason why he felt that way was he thought that when he came here with his previous degree and work experience, he could be really prospering in a new country – but maybe when he found out it doesn’t work that way, then that might have been the point where he couldn’t handle that – he couldn’t face that he needed to start over and basically re-do everything and start from way below.  Henry’s account of his father’s depression illustrated the potential impact of ‘broken’ immigrant dreams, which shape the experiences of immigrant and refugee fathers in Canada.  Henry recalled his mother saying, “If you want things to get better, you and your brother will have to do well in school and get a degree and not be like us”. When immigrant fathers were not able to meet the ideal of prosperity and success, the pressures to alleviate the family’s economic and social hardship were passed down to their children.  For Nabhan (18, Afghanistan, refugee), education meant much more than personal gain; the survival of his family was intricately connected to his achievements:  85  I kept telling [my lawyer] that I want to bring my family… I know their life is in danger. He told me, all you have to do is focus on yourself… just stay away from trouble, always try to get a good education, be a nice citizen – if you do all those rules, then you might possibly, there is more chances to bring your family… you have to be good citizen, you have to have a good income, support them – because government, they don’t want to take care of other people, you know?  In a neoliberal society such as Canada, the young men encounter an implicit but strong directive to be ‘good’ citizens. In Nabhan’s words, “they [the Canadian government] don’t want to waste their money on you if you’re just a useless person”. Thus, the ability to demonstrate being a ‘useful’ person in Canadian society was deemed a priority by the young men in their journey of settlement and integration. At the same time, the participants experienced a hyper-awareness that they were viewed as ‘different’. As Raymond who was born in Canada to parents who had moved from Taiwan explained,  Even though I grew up here I always knew that I was different because of my race and I think a lot of times Asians were viewed as foreigners even though we’ve been here for a really long time. And I think there’s sometimes a glass ceiling for Asians in terms of opportunities. Which is difficult because we’re just as Canadian as anyone else here but we’re not treated like one… And that’s frustrating because you know we’re here and yet we don’t have the opportunities sometimes. (17, immigrant, Taiwan) Raymond used the metaphor of the glass ceiling to refer to institutional practices that prevent those who are perceived as foreigners in Canada from full inclusion and access to opportunities. 86  Hedayat (20, Bangladesh, immigrant), who referred to himself as ‘Brown’ several times during his interview, described how difference can operate through mainstream popular culture:  Super heroes…are meant to be our role models and… That’s how kids learn their lessons better than they ever will from school… but then what if there’s just the kids that can’t take these lessons from them because of that disconnect – that you have to turn yourself White to be able to learn these lessons.  He explained how these media discourses shape the experiences of racial minority young men in Canada by telling them that, “to be heroic or to be cool or to be attractive or to be any of these things that you aspire to from the media was also simultaneously to be White”.  Starting again from way below positioned the young men in relation to a benchmark of institutional practices and discourses that often rendered them and their families as second-class citizens. In this social context, immigrant and refugee young men are also marginalized from participating in conversations about mental health. As Hedayat explained,  For immigrants and people of color there’s specific issues, just specific emotions that are hard to deal with… anger and pain and things that you’re not really allowed to show in the context of being vulnerable. (20, Bangladesh, immigrant) While the young men strived to be ‘just as Canadian as anyone else,’ they also recognized the glass ceiling that held back visible minority communities from realizing their dreams of a better life. The narrative of starting again from way below characterizes the realities faced by some immigrant and refugee young men in Canada. Within a context of marginalization and vulnerability, the distress of immigrant and refugee young men is disallowed. 87  5.4 Discussion The aim of this qualitative study was to explore the social context of mental health among immigrant and refugee young men in Canada, with a focus on their migration and resettlement experiences. Informed by the concept of social context as an analytical entry point, the analysis revealed three thematic narratives: a better life, living the (immigrant) dream, and starting again from way below. The narratives characterized the social context for immigrant and refugee young men and were connected by a central theme of negotiating second-class citizenship.  The first narrative provides insights into the migration and resettlement experiences of the participants and the search for a better life. Despite experiences of loss and trauma, the stories were largely underpinned by a strong sense of hope, which was often constructed in juxtaposition to negative portrayals of their countries of origin. Perhaps it was this strong sense of hope for a better life that influenced some of the young men to paint a picture of dire situation of their pre-migration countries. The narrative of a better life also implicated the young men in the production of a broader discourse of Canada as a morally superior society, which makes invisible the ways in which the actions, practices, and policies of Canada are intertwined with the actions, practices, and policies of other nation-states to impact the lives of people within and across nations. It may also be that the young men deployed these portrayals in order to adhere to the expectation for newcomers and second-class citizens to perform public gratitude to Canada through speech acts.  The second narrative focuses on living the (immigrant) dream. Within this narrative, Canada is portrayed as an economically prosperous, inclusive, and fair nation where everyone is given an equal opportunity to excel and succeed. The narrative imposed a persuasion for the young men to 88  recognize immigration as a benefit, if not a reward. Despite the dominant discourses of multiculturalism and social inclusion in Canada, the everyday realities of the young men reflected a mixed narrative of hopefulness as well as a broken dream. The third narrative, starting again from way below, refers to the ways in which immigrant and refugee young men respond to difficulties after moving to Canada and the impacts on their mental health. This narrative suggests a social context in which immigrant and refugee groups, particularly those who are visible minorities, experience marginalization and discrimination through institutional practices and mainstream discourses. It sheds light on the connections between the immigrant dream and the neoliberal ideologies in which resilience and failure are individualized. Furthermore, the notion of citizenship as tied to nation-states is troubled in accounts of institutional discrimination. Canadian practices of deskilling and denial of international credentials are shaped by structural racism, which is intertwined with visible minority status. Across the three narratives, the findings from this study highlight the diverse experiences of immigrant and refugee young men in Canada. The authors acknowledge the strengths as well as potential limitations of including a diverse group of participants who identified as immigrants or refugees in one study. In doing so, the intent was not to conflate the experiences of these young men or to claim an exhaustive analysis of all experiences shared in the interviews. Instead, the aim was to provide a focused and nuanced analysis of their social context through detailing patterns and diversity in their narratives.  Although the young men’s everyday experiences were different based on their ethnic backgrounds and current life circumstances, many shared the common experiences of 89  marginalization. For example, the accounts of the young men who were from the Middle East and/or were Muslim suggested instances of Islamophobia, whereas the accounts of several Asian young men referred to anti-Chinese sentiments in Canada. A study with refugee youth in Canada reported similar findings regarding intersecting forms of discrimination related to language proficiency, newcomer status, and being part of a visible minority or racialized group (Edge, Newbold, & McKeary, 2014).  Among immigrant youth in Canada, research has shown that inclusion is linked to exclusionary factors such as ‘us/them’ constructs, aversive and color-blind racism, racialized habitus, and notions of ‘worthiness’ (Naffi, 2016). A recent article reported a public discourse in Canada of racial minority immigrants and refugees being so rich that they are contributing to the affordability crisis and so poor that they are draining the system of services, supports, and resources (Ball, 2017). This discourse demonstrates the biases in Canadian society that construct and justify the exclusionary practice of placing White Canadians into the category of true, first-class citizens and placing racial minority immigrants and refugees into the category of not-quite-Canadian second-class citizens.  The findings from this study contribute to the literature on the mental health of immigrant and refugee young men. There is a paucity of research focused on the perspectives of young immigrant and refugee men, particularly regarding their everyday experiences of mental health. The findings point to the importance of mental health promotion initiatives that address the social determinants of mental health inequities by using frameworks that go beyond a focus on culture to examine the social contexts, exclusionary processes, and everyday discrimination that shape the mental health experiences of immigrant and refugee populations in Canada and worldwide. This study makes important contributions to the literature on men’s health by 90  offering nuanced narratives regarding mental health from the perspectives of young men who identify as immigrants and refugees in Canada.  Fostering the mental health of immigrant, refugee and racialized populations (Mental Health Commission of Canada, 2012) can be tied in with committed efforts to allocate financial and human resources to address social determinants of mental health (WHO, 2014c). Networks and knowledge-sharing platforms offer a way to exchange promising practices. Promising practices include collaborations between mental health services and resettlement programs, local community centres, and school systems wherein many immigrant and refugee young men pass through. Evidence-informed resources such as the Canadian Pediatric Society Caring for Kids New to Canada (Hilario, Vo, & Pottie, 2015) provide guidance for service providers working with immigrant and refugee young men. 5.5 Implications for Future Research The findings from this study indicate the viability of social context as a conceptual lens in studies with immigrant and refugee young men. Future research in this area may also draw on an intersectional approach as a way to focus on the social determinants of mental health and to provide nuanced insights into the experiences of immigrant and refugee young men at the intersection of gender, immigration, and race (Viruell-Fuentes, Miranda, & Abdulrahim, 2012; Griffith, Ellis, & Allen, 2013). The results of this study also suggest that the concept of minority stress (Meyer, 1995) may provide further analytical insights in future research with immigrant and refugee young men. Drawing on the minority stress model, future research could explore the impacts of racism - in the forms of interpersonal violence, socioeconomic marginalization, and institutional discrimination - on mental health indicators (Karlsen & Nazroo, 2002). 91  Future research could further explicate the relationship between mental health and social citizenship. Social citizenship can be understood as a space in which different actors negotiate individual and collective rights within the context of intersecting social divisions and relations (Koopmans, Statham, Giugni, & Passy, 2005). According to Young (1989), the dominant ideal of citizenship, based on universality as equality, has led to “laws and rules that are blind to individual and group difference…[in which] some groups still find themselves treated as second-class citizens” (p. 250).  Addressing health and social inequities in relation to global migration and citizenship therefore requires transforming not only exclusionary discourses and structures that contribute to inequities but also interrogating dominant understandings of citizenship. Dominelli (2014) proposes a re-negotiation of the relationship between the nation-state and individuals that would allow for “new citizenship practices that transcend the nation-state by being collectively guaranteed, inalienable, globally portable and attached to the person” (p. 15). This view would advance initiatives and policies that re-define citizenship based on inalienable rights and respect for human dignity. As the WHO Director-General recently acknowledged, “The world is experiencing the largest population displacements seen since the end of the Second World War. The scale of anti-migrant sentiment is equally unprecedented” (WHO, 2015). Innovative solutions, therefore, are needed to effectively address the mental health needs of immigrant and refugee men within the current social climate worldwide. Health and social policies that are informed by a view of citizenship as ‘institutionalized fairness’ (Young, 1989) may contribute to shaping the types of practices that will strengthen the fabric of Canadian society by supporting members to live to their fullest potential and, ultimately, foster better mental health for all.  92  Chapter 6: Representation and Power in Integrated Knowledge Translation and Participatory Video with Immigrant and Refugee Young Men4 6.1 Background In recent years, the ‘knowledge translation turn’ within health research has promoted approaches designed to increase the uptake and relevance of research evidence to practice and policy. Within the field of knowledge translation (KT), there has also been increasing dialogue around the models and levels of participation that take place within studies aimed at bridging the gap between what is known and what is done through enhanced engagement with ‘knowledge users’, defined as groups who are well-positioned to be able to use research evidence to change practice. This dialogue has led to delineations between KT and approaches including participatory research and to experimentation with methods that foster engagement with groups, including participatory visual methods. Bowen (2015) distinguishes between different approaches to KT in relation to approaches used in participatory research and engaged scholarship. In traditional (end-of-project) KT approaches, for example, there is little emphasis on partnership; researchers and knowledge users have distinct roles; and power imbalances are not addressed. Integrated KT (iKT) approaches, in contrast, aim to engage knowledge users as partners in the process and issues of power are addressed through pre-negotiated expectations. In this way, iKT reflects similar principles to                                                4 A version of Chapter 6 has been submitted as a sole-author publication. Revisions were invited and submitted on 11/27/2017. It is currently under review. 93  engaged scholarship, which focuses on engaging groups who can contribute greater understanding to an issue, and to participatory research, wherein partnership with community groups is central to the co-production of research.  To enhance engagement, there has been increasing integration of arts-based methods into KT research frameworks (Kontos & Poland, 2009), particularly in qualitative health research focused on knowledge mobilization (Boydell et al., 2012). For Parsons and Boydell (2012), innovative arts-based KT strategies, including drama, photography, and video, are an opportunity to “put the art back into healthcare in a robust, scientific way” (p. 3). While arts-based methods have been found to offer a degree of usefulness in KT (Fraser & al Sayah, 2011), the impact of these methods within KT research remains understudied. Beyond the KT literature, innovations using arts-based methods including the use of video have spanned several decades. Participatory video can be defined as a visual methodology that builds on “a set of practices and relationships that are used to identify and address community needs or social problems” (Mitchell, Milne, & de Lange, 2012, p. 1). Principles of participatory video, sometimes referred to as community video, have been used in community development projects as far back as 50 years ago (Braden, 1999). A defining characteristic was the use of moving images as a catalyst for community development (White, 2003). Across various disciplines, it has been advanced as a practice to “destabilize hierarchical power relations and create spaces for transformation by providing a practice of looking ‘alongside’ rather than ‘at’ research subjects” (Kindon, 2003, p. 142). Despite its history in other fields, there has been little critical engagement with participatory video as an emergent methodology in health research. 94  The purpose of this chapter is to address the third research question in the dissertation: how are issues of representation and power experienced in integrated knowledge translation (iKT) and participatory video with immigrant and refugee young men? This analysis focuses on the use of participatory video as an arts-based approach within an iKT study aimed at exploring the social context of mental health among immigrant and refugee young men. I used a reflexive analysis of the iKT and participatory video processes to examine issues of representation and power in co-producing the short video, New Frames, with a group of immigrant and refugee young men. In this chapter, I provide a brief summary of the iKT and New Frames participatory process. I present findings from the reflexive analysis of the processes undertaken within an iKT study using participatory video, and discuss implications for future research using this methodology. 6.1.1 The iKT Design and New Frames As previously described in Chapter 3, this research took place in Greater Vancouver, British Columbia, Canada. The study received ethical approval from the University of British Columbia. I used an iKT design to engage various groups in the study (see Figure 4). New Frames refers to the iKT initiative produced as part of this dissertation. I drew on the co-KT framework (Powell et al., 2013) to engage an advisory group, which was comprised of service providers and program leaders, and a team of research collaborators, which was comprised of young men who self-identified as immigrants and refugees. The advisory group and collaborators were engaged in all stages of the research, from recruitment through to developing the iKT initiative and informing data analysis. Research participants were also recruited to take part in individual and group interviews. Therefore, three groups were engaged in the study: the collaborators, the advisory group, and the participants. 95    Figure 4. iKT groups 6.1.2 The Collaborators While the participants were recruited to take part in interviews during data collection, the collaborators were engaged over a period of over one year to shape the research process and the iKT initiative. As descripted in Chapter 3, the collaborators ranged in age from 15 to 20 years, at the time the study began. I met with the collaborators 38 times between July 2014 and November 2015. They developed a set of community guidelines based on their goals, vision and values, and worked from these guidelines to move forward while maintaining an open, iterative plan for action. They also identified their goals for participating in the project: “to know more about young guys and about ourselves too”; “to create something we can share back to the community”; “to become a reason why each of us would want to become better people”. Each collaborator was paid $20 CAD per meeting. 96  6.1.3 The New Frames Process As part of the iKT design, the collaborators were engaged in the analysis of interview data and to represent themes that resonated with them using arts-based methods. The collaborators were provided with training in qualitative research and video production. New Frames refers to the video produced as an iKT initiative. Drawing on participatory video methods (Mitchell, Milne, & de Lange, 2012), the collaborators and I co-produced a 20-minute video based on excerpts of transcribed interview data. The video production process took place over six-months, which encompassed five stages of video production: development, pre-production, production, post-production, and distribution (Women in Film and Television Vancouver, 2009). During development, the collaborators discussed and decided on the concept of the video in consultation with professional filmmakers. The collaborators decided on the concept of portraying six segments of transcribed interview data that the collaborators deemed as important themes to share. Following this decision, a script with six scenes was developed. Actors were casted to play each ‘character’ and that scene was directed by the collaborator who selected that theme. In this way, each on-screen ‘character’ was based on the words of the interview participant, the direction of the collaborator, and the re-enactment by an actor. In pre-production, preparations for the shoot were completed. We filmed in a professional studio space and the set was designed to mimic the intimacy of a research interview and post-production processes was facilitated by a professional editor who worked with the collaborators to edit the scenes they directed. Additional details about these processes are provided in Chapter 3.6. 97  In summary, the New Frames process was part of the iKT design and engaged the collaborators in the analysis and translation of knowledge from the research. The video was intended to provide opportunities to spark dialogue about the experiences of immigrant and refugee young men in Canada using an engaging medium. It provided a means to highlight the stories and themes that the collaborators deemed important to share with other immigrant and refugee young men and their communities. The New Frames process also informed the analysis of data that I was leading in response to the research questions outlined in this dissertation.  6.2 Methods Reflexivity can be understood as “thoughtful, conscious self-awareness [and] continual evaluation of subjective responses, intersubjective dynamics, and the research process itself” (Finlay, 2002, p. 532). Reflexive analysis is grounded in a view of knowledge as actively constructed and provides a tool for examining the relationships between the researcher, the ‘researched’, and the research process. Through a reflexive analysis, I examined the processes that unfolded within this study, focusing on how issues of representation and power were experienced in an iKT study using participatory video with immigrant and refugee young men. I analyzed ethnographic field notes (Emerson, Fretz, & Shaw, 2011) that I created to document the study processes, including materials from the video production, meeting minutes, emails, text messages, and journals. 6.3 Findings  The findings from this reflexive analysis are organized according to issues pertaining to representation and power. I focus on the representations of the ‘researched’, the research, and the 98  researcher. In the remainder of the section I present insights regarding issues of power in the context of a collaborative iKT study with immigrant and refugee young men. 6.3.1 Representation of the ‘Researched’ In this project, the research collaborators assumed the role of videographers and were responsible for representing the narratives of the research participants who, like the collaborators, were young men who identified as immigrants or refugees. How did the collaborators arrive at the many creative and pragmatic decisions that eventually led to the moving images and sounds that now represent a segment of the research data in the final version of the New Frames film? Despite the collaborators’ role to inform the study design and to produce the iKT initiative, the young men insisted on practices and processes that allowed them to go into the subject position of the research participants. For example, while conducting the interviews with research participants, I shared short excerpts of data (removed of any identifying information) with the collaborators and explored emerging themes. At the outset, the team suggested and maintained the practice of reading the interview excerpts aloud, taking turns re-enacting the interaction. I documented these processes in field notes and in a journal. As described in detail in Chapter 3.6, the iterative process culminated in portraying six excerpts of transcribed interview data that the collaborators deemed as important themes to share. The collaborators described the themes in the excerpts in terms of being unique or different, giving space, having faith, awareness, satisfaction, body image and masculinity. These excerpts became the six scenes that comprise the video, scenes that also raised questions, during initial screenings, about a range of issues relevant to immigrant and refugee young men: transnational migration and the limitations of nationalism; the impact of religion and faith on distress; happiness, anger, 99  and how to deal with frustration; aging out of health and social services; negotiating career paths in rapidly changing economic systems; relationships, sexual practices, and male privilege; masculine ideals; and the need for empathy. Beyond the film these scenes represented the themes that the collaborators deemed were most important to share about the study, especially with immigrant and refugee young men, their families, and communities. The casting of the actors for the six different ‘roles’ was also decided based on open majority vote and the collaborators were adamant that the roles be played by racialized young men from immigrant or refugee backgrounds, given the underrepresentation of visible minority groups in the arts and media. However, an ongoing question and concern for me was: What might be the implications of these representations for immigrant and refugee young men? For example, what if the scene about young men using sex as catharsis were misconstrued and appropriated to serve agendas that construct racialized immigrant men as more exploitative of women compared to men of dominant race and class?  In representation lays considerations regarding how knowledge can and ought to be presented about a group without potentially reifying negative representations and stereotypes. These concerns of misrepresentation were particularly salient, in my view, during a climate of growing xenophobic and anti-immigrant sentiments in North America, Europe, and other parts of the world. These concerns have implications for the research participants, the collaborators, and the research itself.  6.3.2 Representation of the Research  The findings from this dissertation were primarily communicated and represented via two mediums: written text and film. The representation of the research study in the film, as partly 100  described in the previous section, was shaped largely by the iterative process in which the collaborators decided on how to move forward with the arts or media-based initiative. Even when they decided on using the medium of film or video, there were still creative choices to be made regarding the style and genre (e.g., drama, action, comedy, etc.). When the collaborators chose to experiment with the conventions by re-envisioning and re-creating the excerpts from the research interviews, again they needed to decide on how to approach the script, for example, monologues versus dialogue or group discussion, and the location or setting of the film – indoor or outdoor, or returning to the actual research sites. In the same vein as others have argued that storyboards should be seen as data (Gubrium, Harper, & Otañez, 2015), the script used in the production of New Frames also served as data in addition to the film to help illustrate the types of creative decisions that need to be made in participatory video. For example, I asked the collaborators, apart from casting the actors to play the specific ‘roles’, to also create character sketches for them in the script, that is, to describe their posture, mannerisms, way of speaking, etc. This is a standard technique used in film and video production to help guide the director when providing direction to the actor. These were included in the copies of the collaborators’ scripts in addition to their ‘shot lists’, a series of visual depictions of how they wanted to frame the actors in the shots during filming. Visually, the setting of the film would also contribute to the ways in which the research would be represented. Initially some of the collaborators were adamant about filming at several outdoor locations. Following discussions of the logistics involved in doing so, in addition to a review of our budget and resources for obtaining clearances to use public spaces, it was decided as a team that we would film at one location. We also had to consider potential noise at that location and how it would impact the quality of the audio for the film. These considerations led to decisions to 101  use an indoor studio for our film location and, furthermore, to emplace the scenes directly in the research interview context.  6.3.3 Representation of the Researcher The New Frames film features stories shared by interview participants, selected by the collaborators, and re-envisioned by actors (also young men from immigrant and refugee backgrounds) under the direction of the research collaborators. The film is also about the interview encounter and the researcher within the interview. The creative decision to include the researcher in the film was seen by the collaborators to be a natural one, stemming from the team’s practice of reading the excerpts out loud and always including the words of the interviewer, albeit in their own renditions of my voice. Among the collaborators, there was an emphasis on acknowledging and giving recognition to the contributions of the participants and the researcher (that is, the author) a practice that would eventually influence the final film. Throughout the process, I was in the script, in the storyboard, and in the shot lists. I was also in the studio during the filming and kept the crew on time and on track, in addition to driving actors to and from the location and ensuring that there was food for everyone throughout the day. On the set, in my place, was my sister, who read my lines with a nearly identical voice. Although the interviewer was on the set, it was another creative decision that she would not be seen in the film. The primary angle of the camera was set up to mimic her gaze, as per the conventions of most documentary filmmaking, and to maintain the focus of the frame and of the film on the young men. Therefore, the audience is given the opportunity to situate themselves into the interview as the person answering questions or as the researcher asking them.   102  In the performing arts, the metaphor of the ‘fourth wall’ is often used to describe the invisible wall that separates actors from the audience. The last scene in New Frames, in which an actor is depicted as reading a script outside, reveals that the film is not a documentary and, in doing so, signals a potential fall of a fourth wall in research that often separates researchers from the audience. In this case, the breakdown of this wall reveals not the researcher – since the collaborators ensured the presence of the interviewer in the film – but rather the presence and the roles of the research collaborators as the ones behind the cameras, the lights, and the microphones, and who were responsible for creating this particular representation.  6.3.4 Power: Performance and Agency  Power operated in my role as the lead researcher, a position I at times downplayed and at times actively assumed during the project. In addition, my capacity to assume power was shaped by the actions of the collaborators. For example, one collaborator who was a student at the high school I had attended brought an old yearbook during the second meeting. He had borrowed it from one of the teachers to support his point that I looked the same as I did when I was in high school. This gesture served to establish rapport between me and the collaborators, on the basis of ‘looking young’, and also functioned to remind me, even if not the intent, that the collaborators and I were on equal footing with one another, with shared power within the study based on our similar experiences. A tension I had not foreseen arose during data collection and analysis when interview questions and short excerpts of research data were shared with the group. When some of the collaborators responded to the questions and data by sharing their personal stories with the group, my initial reaction was to interrupt that process. Through this reaction, my intent was at once to clarify and 103  distinguish the roles of the collaborators from the participants, the latter tasked with sharing their perspectives and ‘providing the data’ and the former tasked with guiding the project and creating a video interpretation of the study data, and at the same time to ‘protect’ the collaborators from exposing themselves to each other and from ‘writing themselves in’ to the project. The need to ‘protect’ the collaborators from the data arose again when I found myself struggling with whether or not to share excerpts from the data that I considered might be ‘difficult’ for them to hear. I realized that I was acting on the assumption that I was better positioned to be able to hear these stories (because of my age, research training, professional background as a registered nurse) regardless of the lived experiences of the collaborators. Eventually the young men asserted their need to be trusted and respected as equal members and I shared the excerpts.  The processes of making these decisions illustrated that power is embedded in the role of a researcher and I could have exerted a certain degree of authority and control over the project. In addition, it indicated my initial attachment to an understanding of ‘clear and defined’ roles as defined by prevailing views on rigour and ethics in health research and the power underpinning these conventions to shape my methodological decisions, that is, to adhere to these roles and rules, as a doctoral trainee. Although these tensions were eventually resolved, it took time for me to recognize the inextricable linkages between knowledge and power, and the unique contributions of all groups engaged within a collaborative study. At the beginning of the project I dedicated a great deal of time and energy toward creating a safe space for the collaborators, for example, encouraging them and maximizing opportunities for them to voice their ideas and opinions. I assumed a facilitator role focused on listening. Later in the project, I began to take a stronger leadership role in order to ensure that the meeting 104  discussions were on track and on topic, and that everyone was getting a chance to speak. In reflecting on the project, I have come to appreciate the extent to which the young men were able to collaborate was premised on my performance as the project leader. Beyond these explanations, my commitment to ensuring the emotional safety of the group, over and above the goals of the study, could be explained as a performance of feminine ideals of nurturing. At the same time, the collaborators exercised a degree of agency and negotiated power in their co-production of a video that challenged conventions around fictional frameworks and documentary treatments. As Gubrium and colleagues (2015) have considered, “which stories to tell and how to tell them?” (p. 23). Yet what do these conventions and representations mean for the knowledge produced in participatory video projects such as New Frames? What counts as knowledge and whose perspective(s) matter the most? Whose knowledge is produced and disseminated in the film?  A crossroad in the process was when the collaborators made the decision to tailor the film for themselves and for other young men, rather than for those traditionally ‘in power’ (researchers, stakeholders, service providers). I was faced with a tension between my commitment to the advisory group to deliver a product that would be relevant and useful in their work and to my commitment to the collaborators to allow them full creative license over the project. I asked myself, “What good is it? Who is it good for? And who determines what good it is for?” (Gubrium et al., 2015).  In the end, I followed through on my commitment to the collaborators and supported them in exercising their agency by foregoing revisions to the film and determining for themselves what and who the film is good for as well as who determines these decisions.  105  6.4 Discussion Participatory video may be seen as a way to contribute to ‘knowledge democracy’ (Tremblay & de Oliveira Jayme, 2015). It also has the potential to contribute toward collaborative practices in iKT designs and processes. In the New Frames process, it facilitated the methodological latitude to innovatively represent research/er/ed and the knowledge produced through these relationships from the perspective of immigrant and refugee young men, a group in Canada that has often been marginalized in research about them and their communities. Despite the goal of participatory work to alter uneven power relations, however, “it is important to enter the game with eyes wide open to the ways that positionality continues to affect power and agency” (Gubrium, Harper, & Otanez, 2015, p. 20). While participatory video continues to be seen as a method ‘to empower’ and “to uncover the perspectives of marginalised members of the community such as children and young people” (Canosa, Wilson, & Graham, 2016, p. 1), there has also been considerable dialogue on the complexities and dilemmas encountered in working with young people in participatory research (Dentith, Measor, & O’Malley, 2009; 2012). Researchers have emphasized the need to examine “performances of power” within these methodologies (Fox, 2013, p. 986) and “to be more cautious of claims about participatory video’s emancipatory possibilities” (Kindon, 2016, p. 496).  In recent years the dialogue around the ‘participatory turn’ has begun to yield nuanced analyses of the potential and the limitations of participatory methodologies with regards to their underlying goals, that is, social action versus knowledge production, and the discourses behind notions of ‘empowering communities’, including “the assumption that providing visual media opportunities to groups of people automatically gives them a ‘voice’ that will be heard and acted 106  upon” (Pauwels, 2015, p. 108). It would be naïve and patronizing of me to claim that the New Frames process ‘gave voice’ to the young men who participated so that they could tell their most ‘authentic stories’. I did not ‘give voice to the voiceless’; rather, I passed the microphone and camera with the understanding that the collaborators, through New Frames, were trying to do something with these representations. Blazek and Hranova (2012) have called attention to the range of relationships and diverse motivations between and among all involved in the video-making process, including research participants, researchers, and videographers. As Mitchell and colleagues’ (2012) have questioned, “How can we not be there if we are there?” (p. 6). I am careful, as others have counselled, not to romanticize the collaborative research process, to lay bare issues of power with respect to collaboration and representation, and to avoid “appropriating the vision of the less powerful while claiming to see from their positions” (Haraway, 1988, p. 584)   For Pauwels (2015), there is a difference between participatory visual research that supports community members to address concerns in their communities and research that involves members in the creation of visual products primarily for the purpose of scientific research. Although social action and scholarly knowledge production are not necessarily mutually exclusive, the implications of the methodologies and the work based on these goals necessitate clear explication. ‘Giving voice through visuals’, Pauwels cautions, does not sufficiently address the issue of who ultimately stands to benefit from the outcomes of the project nor the need for critical evaluation of the real impacts of the work for the people involved. Short-term individualistic approaches within participatory video work, according to Walsh (2016), can shift toward longer-term movements that move beyond managing social conflict and 107  effect change. Walsh has argued that relations of power in participatory video have often been overlooked because of ongoing emphasis on individual voice and empowerment as the site of social change and as abstracted from social and political conditions: “it is also a dangerous, if optimistic, denial of reality to believe that by telling stories of injustice, justice will be served… if voice and representation are so important, who is this representation for and why” (p. 407, emphasis in the original). In this vein, Walsh also critiques the politics of reception in the common practice of creating and showing participatory videos to people in positions of ‘power’. New Frames provides one example of an iterative participatory video process with a group of immigrant and refugee young men who created a KT initiative as part of a research process. During the development of the video, they chose to focus on immigrant and refugee young men and their families as the intended audience. This shift in the target audience and reception of the New Frames film from those ‘in power’ toward other immigrant and refugee young men might be viewed as subverting the prevailing notion that “the goal of participation for marginalized communities is to make themselves more intelligible to those in power” (Low, Brushwood Rose, Salvio, & Palacios, 2012, p. 57).   The aim of this chapter was to examine issues of representation and power in a collaborative study using an iKT design and participatory video with immigrant and refugee young men. The findings contribute new insights about power and representation in participatory video research. These contributions can inform the practices of KT and qualitative health researchers intending to use participatory video in their future work.   108  Chapter 7: Conclusion 7.1 Overview The research conducted for this dissertation provides the first in-depth analysis of mental health and distress from the perspectives of immigrant and refugee young men in Canada. It addresses gaps in the literature on men’s health and masculinities, immigrant and refugee youth mental health, and integrated knowledge translation using participatory video. In this concluding chapter, I summarize the main findings from the dissertation, outline key contributions, and highlight implications for public health practice, policy, and future research.  7.2 Summary of Findings This dissertation addressed gaps in the empirical literature regarding the linkages between masculine discourses and the narratives of immigrant and refugee young men about distress; and the connections between mental health and their migration and resettlement experiences. The mental health experiences of immigrant and refugee young men are contextualized within masculine discourses and within narratives about citizenship and inclusion in Canada. Findings regarding citizenship and inclusion are especially salient amid ongoing mass transnational migrations of people and global responses to migration and asylum seekers. The findings in Chapter 4 revealed that the young men’s narratives can be interpreted as nuanced responses to masculine discourses that distanced them from difficult experiences while rendering distress a norm. This narrative reflects previous research suggesting men’s reticence to acknowledge and disclose symptoms of mental illness (Seidler et al, 2016). At the same time, the findings revealed narratives in which distress was acknowledged and situated in relation to their 109  relationships and to masculine discourses that shaped their expressions of distress. These findings help to address prevailing assumptions about men being silent about their mental health challenges (Mckenzie et al., 2016, p. 81). This can inform programs and initiatives that provide spaces for young men to acknowledge their distress and mental health challenges as a step toward seeking supports and resources. Narratives that connected the young men to their experiences of distress and pain suggested, as Pease (2012) has described, a subversion of masculine socialization linked to “the male privilege that resides behind the emotional inexpressiveness associated with white, Western, heterosexual men” (p. 130). From this stance, it is possible that the perspectives of immigrant and refugee young men, who are often marginalized in Canadian society, are contributing to the resistance of hegemonic masculine discourses, which emphasize stoicism, strength, and self-reliance. As Walton and colleagues (2004) have argued, “to experience emotions is human; to control their expression is masculine” (p. 413). This narrative may also be linked to media and social discourses portraying young men, especially those who are racialized, as fitting a hypothesized profile of violence and danger, which may be linked to the findings described in Chapter 5. The findings in Chapter 5 demonstrate a social context of ‘second-class citizenship’ for immigrant and refugee young men in Canada. The findings illuminate the discourses and biases in current Canadian society that construct and justify the practice of placing racialized or visible minority immigrants and refugees into the category of second-class citizens in relation to white Canadians as true, first-class citizens. Previous research has found similar discriminatory practices towards recent immigrants in Canada, who were members of visible minority groups (Edge, Newbold, & McKeary, 2014). The findings reveal the unique difficulties of experiencing distress and mental health challenges in the context of discrimination. These experiences and 110  perspectives may also be linked to emergent masculinities that emphasize understanding and empathy, as indicated in narratives in Chapter 4, based on the young men’s experiences as racialized immigrants or refugees.  The findings of Chapter 6 contribute to the literature on issues of representation and power within integrated knowledge translation (iKT) study designs and participatory video processes. My dissertation shows that participatory video can enhance engagement and build research capacity among young immigrant and refugee men toward their inclusion in health research. The findings also highlight the complexity of arts-informed iKT and the dynamic processes of co-producing KT products, whereby multiple groups holding varying degrees and types of power must work together. While my research demonstrates the viability of iKT and methodologies like participatory video, my analysis also indicates that participatory approaches – even those drawing on arts-based methods - do not entirely ‘take care’ of the historically produced unequal power relations between the academics and the communities engaged in the research. 7.3 Key Contributions At the time of conducting this research, there were virtually no empirical studies within the literature that focused on distress and mental health from the perspective of immigrant and refugee young men in Canada. This dissertation is the first study of its kind to focus on the perspectives and experiences of this group and to engage them in the research process with a view to share knowledge co-produced from the study. The research conducted for this dissertation provides key contributions to three bodies of literature: men’s mental health and masculinities, immigrant and refugee youth mental health, and integrated knowledge translation using participatory video methodologies.  111  First, there has been limited empirical research on the meanings young men give to distress, particularly those from marginalized populations such as immigrant and refugee groups. This study makes important contributions to the literature on men’s health and masculinities by offering nuanced understandings of distress. This research provided an analysis of the intersecting aspects of social contexts that shape mental health in this group, including the masculine discourses that shaped immigrant and refugee young men’s distress. In this way, the findings can contribute to efforts aimed at “changing the discourses, institutions and practices” (Petersen, 2009, p. 210) that shape the narratives and experiences of diverse young men. Second, with regards to the literature on immigrant and refugee youth mental health, there is a paucity of qualitative research on mental health from the perspectives of young immigrant and refugee men. In particular, the findings suggest that visible minority young men may experience unique triggers for stress and mental health challenges, including marginalization and racism, which has been suggested in previous literature (McKenzie et al., 2016). The findings point to the importance of mental health promotion initiatives that address mental health inequities and extend beyond a focus on culture toward examining the social contexts, processes, and everyday experiences that shape the mental health of immigrant and refugee populations in Canada. Third, integrated knowledge translation (iKT) is a nascent area of research and practice, and the use of innovative participatory video methodologies have not been fully explored. In particular, the strengths and limitations of iKT studies using participatory approaches with marginalized groups has warranted investigation. This study demonstrated the strengths of iKT in optimizing the inclusion of different perspectives and in building capacity with research collaborators who self-identify as part of the study population. In addition, the research brought together practitioners and program leaders from different sectors, organizations, and types of services - 112  from youth mental health services to resettlement services for newcomers - who may not have collaborated together on a project otherwise. Furthermore, the use of participatory video methodology contributed to a highly innovative iKT initiative that engaged immigrant and refugee young men in the research process, in the making of the video, and in the reception of the video during its initial launch. Although beyond the scope of this dissertation, the production of the New Frames short film provides an alternative dissemination strategy that can be tracked and evaluated in future work. 7.4 Limitations Specific limitations to the study and the analyses were detailed in the three findings chapters. In the following section, I present additional overarching limitations.  First, I acknowledge the limitation of including both immigrants and refugee young men in the same study. In making this conceptual decision, the intent was not to conflate the experiences of these young men or to claim an exhaustive analysis of all experiences shared in the interviews. Instead, the aim was to provide a focused analysis of their social context through detailing patterns and diversity in their narratives. Second, in drawing on a narrative analytic approach to interpret the data, I recognize that the content and the form of the stories shared by the participants were shaped by what is rendered possible to share in the interview context. I agree with Riessman (2008) that “stories don’t fall from the sky (or emerge from the innermost ‘self’); they are composed and received in contexts – interactional, historical, institutional, and discursive” (p. 105). In this vein, the interview context may have enabled or constrained the stories the participants shared with me.  113  I conducted all of the interviews; therefore, the stories the young men shared were constructed especially for me. Because I was older (in my late 20s at the time of the interviews) than the participants, I may have been perceived as a ‘figure of authority’ to which they should not disclose certain information. For example, one young man initially hesitated in telling me that he used marijuana occasionally to help him ‘relax’ when he was stressed or upset. Furthermore, as a woman I experienced tensions between ensuring a safe interview context with the young men and adhering to my values and goals to challenge heteronormative discourses and male privilege. The findings presented in the dissertation are based on data constructed for a particular listener and do not represent an exhaustive analysis of all of the possible experiences and narratives of immigrant and refugee young men; instead, the findings are offered as one set of findings among many possibilities. 7.5 Recommendations for Practice, Policy and Research The findings of this study can inform mental health programming to support immigrant and refugee young men across various levels of government and different sectors. First, municipal governments serve an important role in fostering inclusive civic and community engagement to mitigate the experience among some immigrants and refugees, as this study suggests, of second-class citizenship. Promising practices include collaborations between departments and agencies. For example, resettlement programs that connect new immigrants and refugees to services and supports such as the Immigrant Services Society of British Columbia can further collaborations with programs in the school system such as the Engaged Immigrant Youth Program and with community-based equity-oriented mental health programming such as the Opening Doors Project in Ontario, which provides resources for addressing the ways in which discrimination and stigma affect the mental health of newcomers and refugees. 114  Second, the findings of this research can inform provincial government policies regarding health care and social services, education, and youth employment. There is a need for inter-ministry collaboration to support mental health programming and social services that acknowledge diversity and are inclusive of immigrant and refugee groups in Canada, particularly young men who are reticent to seek help. The findings suggest that the school system is a key site of intervention since it is where newcomer young men pass through and where broader discourses in Canadian society regarding immigrants, refugees, and racialized people are constructed, reproduced, and acutely experienced. In this vein, school-based mental health programs that acknowledge experiences of discrimination within the education system may help to address social isolation and distress among immigrant and refugee young men. At the national level, the federal government serves a role in addressing structural determinants of mental health through public policies that are responsive to the experiences of the participants and families in this study. The findings also suggest the importance of advancing public policies that account for the impact of neoliberal contexts on health and social inequities. There are opportunities for the federal government to advance policies that foster social equity through living wages and affordable housing. While Canadian immigration policies have been used as a strategy to fill gaps in its labour market, the education and knowledge of many immigrants and refugees are often devalued, leading to what is known as ‘de-skilling’ and to downward social mobility. Migration policies can support the civic and economic inclusion of immigrants and refugees by helping to ensure the proper acknowledgment of their education and knowledge in hiring and employment practices. Open dialogue can address prevailing discourses pertaining to immigrant and refugee groups, particularly with regards to responses to asylum seekers, and the meaning of citizenship 115  and national identity in Canada. Within healthcare practice and policy, new frameworks are needed that account not only for culture but also for the social contexts and exclusionary processes, such as everyday discrimination, that negatively affect mental health of racialized immigrants and refugees. These frameworks can increase awareness among health care providers about the relationships between health and context, and to help them develop strategies for recognizing discourses that shape discriminatory practices. One example of these frameworks is anti-oppression, which has been explored in disciplines such as social work (Razack, 1999). Anti-oppression frameworks have been leveraged toward improving community health work (Windsor, Pinto, Benoit, Jessell, & Jemal, 2014) and facilitating systemic change within child welfare systems (Yee, Hackbusch, & Wong, 2015). Corneau and Stergiopoulos (2012) have recommended further study of anti-oppression frameworks to address racism and other forms of oppression within mental health and social services in Canada, and to help reduce their impact on health outcomes. Further study is needed to explore the use of anti-oppression frameworks in nursing and health care provider education. Beyond practice, anti-oppression principles can be used to inform policy and to guide organizational structures and processes in systems such as healthcare. In this vein, anti-oppression strategies can be adopted in healthcare settings, within the public education system, and in other institutions and systems that are pertinent to the everyday life of immigrant and refugee young men and their families. These strategies can be used to inform processes aimed at unpacking assumptions based on gender, race, immigrant or refugee status, and other dimensions of these young men’s identities. It can also be used to develop initiatives that decrease the polarization of views and that facilitate difficult discussions about differences. 116  Mental health programs and services for immigrant and refugee young men can take into account their unique experiences and the context of these experiences. At the same time caution is required in designing services that accommodate hegemonic forms of masculinity as these may perpetuate a view of masculinity as static and unchanging rather than plural, dynamic, and situated in social and historical contexts (Gough, 2006). It has been argued that some masculine norms may enhance the capacity of men, particularly heterosexual men, to control others and to maintain power inequities; therefore, strategies that allow young men to ‘subvert their socialization’ and to connect their pain “to their position in the social relations of gender” (Pease, 2012, p. 137) offer a promising way forward. Findings from this study can inform mental health promotion programs and services by creating safe and supportive spaces for immigrant and refugee young men to be able to talk openly and to connect with peers about mental health.  The salutary benefits of social connection have been well-established (Smith et al., 2014; Whitlock, 2007). The findings of this study underscore that there are possibilities to connect across differences. These connections can lead to opportunities for establishing empathy based on initial engagement at the level of personal stories. Although collective values and goals are linked to structural forces, they are also linked to needs that are grounded in personal biographies. In the interviews conducted in this study, these included the need to feel worthy, to be treated with dignity and fairness, and to belong. By focusing on shared needs, emotions, and experiences, this approach may contribute to greater possibilities for actions that will foster equity in health outcomes, health-promoting resources, and determinants of health.  117  7.5.1 Implications for Men’s Health and Research With regards to research implications, there is much potential for further empirical study of emergent masculinities among young men in relation to distress and mental health. While individual interview and focus group methods were utilized in this study, the majority of the data was collected from individual interviews with participants. It was clear that many of the young men enjoyed the opportunity to connect with others. The use of focus groups and participatory approaches may yield additional insights about mental health and masculinities, particularly if conducted among young men from similar migration journeys, for example, resettling through family reunification or government-assisted refugee programs, and from similar geo-political regions or the same country.  Future research with visible minority or racialized men and across different age groups may offer valuable insights into potential generational differences in their experiences and in their engagement with mental health-promoting services and programs. Existing research suggests that visible minority immigrants with poor levels of perceived mental health and high levels of perceived life stress were less likely than Canadian-born counterparts to report using mental health services (Ip, 2016). Future research could also focus on men who are engaging in practices that support their mental health (Mckenzie et al., 2016) and to explore how masculinities are negotiated within those contexts, while at the same time avoiding the potential for this work to perpetuate heteronormative practices, discourses, and structures that can further marginalization, exacerbate inequities, and prevent the transformation of this field into new strands of scholarship. 118  7.5.2 Implications for iKT Research and Practice There has been little investigation of participatory video methodologies within iKT research. The insights offered in this dissertation can inform the practices of researchers in their future work as well as the discussions that ought to take place with the groups and communities that participatory video methodologies purport to serve. Further study, however, is needed to develop methods for evaluating the processes undertaken within iKT research, including the challenges that arise in participatory methodologies. The task of scaling up interventions and developing strategies to assess the potential impacts of KT initiatives, particularly those that draw on video, will require methodological and conceptual innovation within the complex designs and processes of iKT. New collaborations across disciplines and sectors are needed to encourage the innovation required in addressing challenges within the fields of mental health promotion and public health. 7.6 Conclusion The mental health of young immigrant and refugee men is a significant public health concern in Canada. 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Ethics, 99(2), 250-274.     137  Appendices Appendix A: Participant Consent Forms    School of Nursing 302-6190 Agronomy Road Vancouver, B.C. Canada V6T 1Z3  (  (604) 822-7435 2   (604) 822-7869 -  joy.johnson@ubc.ca  Title of Study: Influences of social context on mental health among immigrant young men: A collaborative integrated knowledge translation study  Principal Investigator: Joy L. Johnson and John Oliffe, Professors, School of Nursing, University of British Columbia  Co-Investigator: Carla T. Hilario, Graduate Student, School of Nursing, University of British Columbia   Purpose The purpose of this study is to better understand the challenges faced by immigrant young men and how these experiences affect their mental health. We are interested in learning about your experiences in order to better support young men. Ultimately, we hope that this research will improve mental health among young men in immigrant communities in Canada.  Study Procedures We are asking young men between the ages of 15 and 19 who identify as immigrants and who have experienced difficult emotions (e.g., stress, sadness, anxiety, anger) to participate in this study. You do not need to have a diagnosis of mental illness to be included in the study.   Participation in the study is voluntary, which means that it is entirely your decision whether or not you want to participate. If you decide to participate, you can also leave the study at any time. You will still receive your honoraria even if you do not complete the study.  If you decide to participate in this study and provide consent, you will be asked to meet for a one to two-hour interview with the student researcher (Carla Hilario). You will meet face-to-face with the researcher in a location that is convenient for you. You will be asked to talk about difficult experiences, coping with tough situations, and what helps you to deal with emotions like 138  stress, sadness, anxiety, and anger. You will also be asked questions about your neighborhood, school and work, friends, and family, as well as other factors you would like to share.   Risks  Some of the questions during the interview may be upsetting to you because they ask about difficult experiences. If you are not comfortable answering any of these questions, you can ask us to skip the question and we will move on to another question. If you wish, you can also end the interview at any time.   Benefits  Although you may not receive any direct benefits from participating in this study, your participation will help us better understand the experiences of immigrant young men in Canada and the challenges they face in their everyday lives. With this knowledge we can improve services or create better programs that address the needs of young men.  Confidentiality We will not share your name with anyone and your identity will be kept strictly confidential – unless you give us written to release this information. Recordings of your interview will be labeled with a false name and we will keep the files in a locked filing cabinet. All computer files will be stored on password protected computers and a secure network. Records that identify you by name or initials will not be allowed to leave the research team’s offices. You will not be identified in any reports of this research and we will not use your name in any presentations or publications. The only instance that we will need to share your information is if you tell the interviewer about abuse to a minor (a young person under 18 years of age) or harm to yourself or to others. In this case, we have a legal obligation to notify the Ministry of Child and Family Development. Let the interviewer know if you have any questions about this.   Available Services Because of the study topic, you may experience uncomfortable feelings or memories. If this happens, let the interviewer know and she will help you find someone who can help.   Remuneration To thank you for your participation in the study, you will receive a $20.00 honorarium.   For More Information If you have questions or would like more information, please call or send a text message to [study cellphone] or send an email to [email address].   Who can you contact if you have complaints or concerns about the study? If you have any concerns or complaints about your rights as a research participant and/or your experiences while participating in this study, contact the Research Participant Complaint Line in the UBC Office of Research Ethics at 604-822-8598 or if long distance e-mail RSIL@ors.ubc.ca or call toll free 1-877-822-8598  139  Consent  • I have read and understood the consent form.  • I have had sufficient time to think about the information provided and to ask questions, and have received satisfactory responses to my questions. • I understand that my participation is voluntary and that I can refuse to participate or to leave the study at any time. • I understand that all of the information will be kept confidential and will only be used for the purpose of this research study. • I understand that this study will not provide any direct benefits to me. • I understand that I am not waiving any of my legal rights as a result of signing this consent form. • I have been given a copy of this consent form. • I have read this form and freely consent to participate in this study.       _________________________ ______________________  __________ Printed Name of Participant  Signature    Date    ¨ Check this box if you would like to be contacted at a later date to review the accuracy of your transcribed (typed out) interview.  ¨ Check this box if you would like to receive a summary of the study findings. If yes, please print your contact information in the space below.   If you do not check any of these boxes, you can still participate in the current study. You can also check these boxes off but decide later on that you do not want to participate.     E-mail Address (please print): _______________________________________  Mailing Address:    ____________________________________________        ____________________________________________  Telephone # (or where we can leave a message): ________________________ 140      School of Nursing 302-6190 Agronomy Road Vancouver, B.C. Canada V6T 1Z3 (  (604) 822-7435 2   (604) 822-7869 -  joy.johnson@ubc.ca   Title of Study: Influences of social context on mental health among immigrant young men: A collaborative integrated knowledge translation study  Principal Investigators: Joy L. Johnson and John Oliffe, Professors, School of Nursing, University of British Columbia  Co-Investigator: Carla T. Hilario, Graduate Student, School of Nursing, University of British Columbia  Purpose The purpose of this study is to better understand the challenges faced by immigrant young men and how these experiences affect their mental health. We are interested in learning about your experiences in order to better support young men. Ultimately, we hope that this research will improve mental health among young men in immigrant communities in Canada.  Group Interview Study Procedures We are asking young men between the ages of 15 and 19 who identify as immigrants and who have experienced difficult emotions (e.g., stress, sadness, anxiety, anger) to participate in this study. You do not need to have a diagnosis of mental illness to be included in the study.   Participation in the study is voluntary, which means that it is entirely your decision whether or not you want to participate. If you decide to participate, you can also leave the study at any time. You will still receive your honoraria even if you do not complete the study.  If you decide to participate in this study and provide consent, you will be asked to meet with the student researcher (Carla Hilario) and a small group of four to six other young men who will also be participating in the study. You will meet face-to-face with the group in a location that is convenient for you. The group interview will last approximately one to two hours.  You will be asked to talk about difficult experiences, coping with tough situations, and what helps you to deal with emotions like stress, sadness, anxiety, and anger. You will also be asked questions about your neighborhood, school and work, friends, and family, as well as other factors you would like to share.  141    How will your information be used? The information you provide in the focus group will be analyzed by the researchers and summarized into key themes. These themes will be discussed with members of organizations in Greater Vancouver and with a team of immigrant young men who are helping us with different ways of sharing the information, such as through video. Themes from the data will also be used to write reports and papers on this topic.  Privacy and Confidentiality We will request that all participants refrain from disclosing the contents of the discussion outside of the focus group. For instance, participants will be asked not to discuss each other’s identities or responses outside the group. However, we cannot control what other participants do with the information discussed.    We will not share your name with anyone and your identity will be kept strictly confidential – unless you give us written to release this information. The research team will keep your responses and whatever you say during the focus group confidential. Recordings of your interview will be labeled with a false name and we will keep the files in a locked filing cabinet. All computer files will be stored on password protected computers and a secure network. Records that identify you by name or initials will not be allowed to leave the research team’s offices. You will not be identified in any reports of this research and we will not use your name in any presentations or publications.   The only instance that we will need to share your information is if you tell the interviewer about abuse to a minor (a young person under 18 years of age) or harm to yourself or to others. In this case, we have a legal obligation to notify the Ministry of Child and Family Development. Let the interviewer know if you have any questions about this.  Risks  Some of the questions during the interview may be upsetting to you because they ask about difficult experiences. If you are not comfortable answering any of these questions, you can ask us to skip the question and we will move on to another question. If you wish, you can also end the interview at any time.  Benefits  Although you may not receive any direct benefits from participating in this study, your participation will help us better understand the experiences of immigrant young men in Canada and the challenges they face in their everyday lives. With this knowledge we can improve services or create better programs that address the needs of young men.  Available Services Because of the study topic, you may experience uncomfortable feelings or memories. If this happens, let the interviewer know and she will help you find someone who can help.   142    Remuneration To thank you for your participation in the study, you will receive a $20.00 honorarium.  For More Information If you have questions or would like more information, please call us or send a text message to [study cellphone] or send an email to [email address].    Who can you contact if you have complaints or concerns about the study? If you have any concerns or complaints about your rights as a research participant and/or your experiences while participating in this study, contact the Research Participant Complaint Line in the UBC Office of Research Ethics at 604-822-8598 or if long distance e-mail RSIL@ors.ubc.ca or call toll free 1-877-822-8598   Consent  • I have read and understood the consent form.  • I have had sufficient time to think about the information provided and to ask questions, and have received satisfactory responses to my questions. • I understand that my participation is voluntary and that I can refuse to participate or to leave the study at any time. • I will refrain from sharing what is discussed outside of the focus group. • I understand that the researchers cannot control what other participants do with the information discussed. • I understand that the researchers will strive to keep all of the information confidential and used for the purpose of this research study. • I understand that this study will not provide any direct benefits to me. • I understand that I am not waiving any of my legal rights as a result of signing this consent form. • I have been given a copy of this consent form. • I have read this form and freely consent to participate in this study.       _________________________ ______________________   ______________ Printed Name of Participant  Signature    Date    143  ¨ Check this box if you would like to be contacted at a later date to review the accuracy of your transcribed (typed out) interview.  ¨ Check this box if you would like to receive a summary of the study findings. If yes, please print your contact information in the space below.   If you do not check any of these boxes, you can still participate in the current study. You can also check these boxes off but decide later on that you do not want to participate.     E-mail Address (please print): _______________________________________  Mailing Address:    ____________________________________________      Telephone # (or where we can leave a message): ________________________    144  Appendix B: Information Letter for Parent/Guardian   School of Nursing 302-6190 Agronomy Road Vancouver, B.C. Canada V6T 1Z3  (  (604) 822-7435 2   (604) 822-7869 -  joy.johnson@ubc.ca    Dear Parent/Guardian,   Your child will have the opportunity to consent to participate in a research project about immigrant young men’s mental health. We are a team of health researchers from University of British Columbia (UBC) and we are interested in understanding young men’s everyday experiences, how these affect their mental health, and how to improve mental health promotion for this group. We are currently recruiting immigrant young men living in Vancouver, British Columbia and hope to speak with about 20 youth over the course of the next few months.   What does this project involve?  • Individual interview and/or group interview lasting about one to two hours. • Interview questions will focus on participants’ experiences of challenging situations, their feelings, emotions and actions during these experiences, and their perspectives on what could be done to improve mental health among young men in immigrant communities. • Participation in this study is entirely voluntary and your child is free to quit at any stage of the research process. • Participants do not have to have mental illness to participate in the study.   How are students being recruited? Young men will be invited to participate through a general call for participants by the Vancouver School Board’s Engaged Immigrant Youth program and advertisements at community centers, neighborhood houses, and malls as well as online through a project Facebook page and a Twitter account. Interested youth will be able to contact the research team directly through the information provided on the advertisements should they wish to know more about the study.    145  How will your child’s information be used? The information provided in the focus group will be analyzed by the researchers and summarized into key themes, which will be discussed with local organizations and with a group of immigrant youth who are working with the research team. This information will be used to write community reports and research articles.   What are my child’s rights as a research participant? Participation is voluntary, which means that your son/daughter has the right whether or not to participate. Your child may withdraw from the study at any stage of the research process without any consequences. Participants also have the right to refuse to answer any questions they do not feel comfortable answering.    How will my child’s privacy and confidentiality be protected? The researchers will ensure that all information collected for this study is kept confidential. Identifying information will not be collected (i.e. full name, date of birth). Transcripts of the interviews and other documentation will be identified only by code number and will be kept in a locked filing cabinet. Participants will not be identified by name in any reports of the completed study. All documentation will be stored on password-protected computers and a secure network, which can only be accessed by the research investigators.    Your child may participate in a one-to-one and/or a focus group interview. If he is participating in a focus group, we will request that all participants refrain from disclosing the contents of the discussion outside of the focus group. However, we cannot control what other participants do with the information discussed.   Are there any risks associated with my child’s participation? Your son/daughter may find it upsetting to answer some of the questions in the study. For this reason, participants can skip any questions they do not want to answer and/or can end the interview at any time.    What are the benefits of participating? Although your child may not directly benefit from participating in the study, the information gained from the research will help us better understand how to improve services, programs, and policies that improve young people’s mental health. By hearing from youth directly, we will learn what works and what does not work in the context of their everyday lives. A summary of the results – removed of any identifiers – will be made available to participants as well as to parents/guardians upon your request.     146  Who can you contact if you have complaints or concerns about the study? If you have any concerns or complaints about your rights as a research participant and/or your experiences while participating in this study, contact the Research Participant Complaint Line in the UBC Office of Research Ethics at 604-822-8598 or if long distance e-mail RSIL@ors.ubc.ca or call toll free 1-877-822-8598.   If you have any concerns about your child’s participation in this project or would prefer that your child not participate, please contact Carla Hilario, study co-investigator, at [study cellphone] or send an email to [email address].     Yours sincerely,      Professor Joy Johnson, PhD, RN   147  Appendix C: Interview Guide   Influences of social context on mental health among immigrant young men:  A collaborative integrated knowledge translation study    Introduction  The purpose of this research project is to learn from young men in immigrant communities how to improve mental health promotion initiatives for youth. We want to understand what mental health means to guys like you and how/whether you feel supported in your communities.   We are interested in ‘tough’ experiences, how you feel when times are ‘rough’, and what helps with those tough (painful, upsetting) experiences – how do you deal with these emotions (stress, anxiety, anger)? Importantly, we want to hear your perspectives on how things can be improved as well as what is working, particularly in the context of where you live (in Vancouver, BC). I’ll begin with asking questions about what you do on a regular day, what’s it like to live here, and then I’ll ask you to describe to me a really difficult day that you’ve experienced and what happened.   The interview will take about one or two hours. We are really interested in your thoughts and in your experience and while there are some questions I want to ask you, the interview is really meant to be more informal, like a conversation, so please feel free to interrupt me and ask questions anytime. If a question doesn’t make sense to you, let me know and I’ll try to explain in a different way. Do not worry about talking too much – if we get off-track, I might jump in a question, but there are really no right or wrong answers to these questions. Also, I want 148  to emphasize that this interview is really a ‘safe place’ where you will not be judged based on anything you say or based on your identity.  Lastly, I want you to know that this interview is completely confidential and what you share with me will remain private. What this means is that your name or personal information will not be used in anything we share with the public, like reports or articles. Your name will not be linked to anything you say and your interview will not be shared with anyone outside of the research team. The only exception is if you tell me about issues of abuse or harm – then I have a legal obligation to tell someone to make sure that you, or whoever is being harmed, is safe.   Does this make sense? Do you have any questions before we begin?   Interview Questions  1. The everyday –does a typical day look like for you? What do you do on a typical day? Probes: What’s home like? Who do you live with? What’s school like? Do you work? What’s that like?   2. Social context – Probes: If I had just moved to Vancouver, how would you describe this place to me? If I were a new immigrant, what would you tell me about Vancouver? What would be the first thing you would tell me about? Tell me about where you like to spend time or interesting places to see. Why? Can you describe the people who live in Vancouver? [We can go back to these questions during our walk later.] 149   3. Mental health stressors – Probes: When I say ‘mental health’, what does it make you think of? What does it mean for you? I’m going to ask you to think about a really bad day – might be recent or might be a while ago. A day that was difficult, tough. What happened? What did you do? Did you talk to anyone? Was there anyone you could talk to? What could have helped you? Do you think other guys have these experiences? Do you think these experiences are different or the same among immigrants? How do you think things are like for girls?  4. Mental health promotion – What can be done to better support guys when they are dealing with difficult situations? Probes: What actions are needed to help guys around here? What message would you give other guys? Where would guys go if they needed help? Where would they look for information or resources or someone with whom to talk? How would they talk about their mental health challenges?  5. Is there anything else you would like to say? Are there questions we should have asked?   		 	150  Appendix D: Honorarium Form           Study Title: Influences of social context on mental health among immigrant young men: A collaborative integrated knowledge translation study.   I have participated in the project and received $20 honorarium for my participation.  Received by (Initials): ___________________  Date: ___________________   Given by (name):  ___________________ Given by (signature):   ___________________    

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