Refugee stigma and its toll on mental health: development and validation of the refugee stigma scale (RSS)

Abstract

Background: Unprecedented, forced displacement, especially from conflict and war areas, requires addressing resultant mental health issues. Aim: Refugees experience mental and physical health problems due to post-displacement stressors, and the pervasive stigma associated with refugee status can exacerbate these difficulties, highlighting the need for a comprehensive assessment tool to understand various facets of refugee stigma. Method: We developed the refugee stigma scale (RSS), consisting of 43 items informed by the literature, qualitative and quantitative data. The scale includes four theoretical dimensions of stigma: perceived community stigma, experienced stigma, anticipated stigma and internalised stigma. To examine convergent validity, validated self-report measures assessing depression, anxiety, post-traumatic stress disorder (PTSD), somatic symptoms (SSs), post-migration difficulties and contact experiences were used. Confirmatory factor analysis (CFA) examined the scale structure, and multiple-group CFA (MG-CFA) was used to assess measurement invariance. Cronbach's alpha was used to test internal reliability, and associations of the stigma dimensions with depression, anxiety, PTSD and SSs were examined to test validity. Results: In a sample of (n=851, 404 Syrian, 63.9% men; 447 Afghan, 67.1% men) refugees in T & uuml;rkiye, the CFA supported the hypothesised four-factor structure of the RSS (fit indices: chi(2)=4051.880, df=1169, p<0.001, comparative fit index=0.99, Tucker-Lewis index=0.99, root mean square error of approximation=0.054). MG-CFA suggested that RSS is invariant across Syrian and Afghan refugees, gender, educational level, length of stay and legal status in the host country. High internal reliability (alpha>0.88) and strong associations of the stigma dimensions with health outcomes support the reliability and convergent validity of the RSS. Conclusion: This study provides robust evidence for the RSS as a scale assessing different dimensions of stigma related to refugee status. The RSS can provide valuable insight into the complex web of refugee status stigma and mental and physical health difficulties.