THE IMPACT OF THE 2014-2016 EBOLA EPIDEMIC ON SIERRA LEONEAN IMMIGRANTS IN THE UNITED STATES

The 2014-2016 Ebola epidemic represented the largest outbreak in the history of the disease and it took a tremendous toll on the West African countries of Guinea, Liberia, and Sierra Leone who were impacted by a disease that had never been seen in their part of the world. While the epidemic significantly impacted those three nations, reported cases also spread to African countries such as Mali, Nigeria, and Senegal, as well as countries in the western world, such as Spain and the U.S. prior to the West African epidemic. Ebola was perceived in the U.S. as a distant threat dramatized by the media and entertainment industries. However, the introduction of Ebola into the U.S. triggered intense national media attention and widespread public alarm. When the first case of Ebola was diagnosed in a man in Dallas, Texas, the public’s resulting fear was disproportionate to the actual risk of transmission. As fear of exposure increased, stigma affected both returning aid workers and persons from Africa living in or visiting the U.S. The purpose of the present study was to qualitatively explore the experiences of Sierra Leonean immigrants living in the U.S., in order to describe their experiences with Ebola-related stigma and perceived risk for Ebola as part of their ongoing acculturation experiences. The sample comprised of 15 individuals who originally emigrated from Sierra Leone. Individual interviews were used and descriptive content and thematic analysis was utilized in order to guide data analysis. Results revealed that while Sierra Leoneans in the U.S. did experience Ebola-related stigma and heightened perceived risk for contracting the Ebola virus during the epidemic of 2014-2016, it did not impact the participants’ sense of belonging and ongoing adjustment in the U.S.

ix LIST OF TABLES  (CDC, 2014;Rolison & Hanoch, 2015). While the World Health Organization (WHO) deemed the 2014-2016 Ebola outbreak "a public health emergency of international concern" (Alexander et al., 2015;WHO, 2014) the actual risk of contracting the virus in the U.S. was small. Media coverage of the outbreak was high and there were several news reports of African immigrants being stigmatized, negatively targeted and even physically assaulted (Allday, 2014;Brown, & Constable, 2014;Montford, 2014;Muhammad, 2014;Rolison & Hanoch, 2015). While diseaserelated stigma leads to heightened fear, isolation, and mutual distrust, existing research has shown that changing perceptions of Ebola survivors were essential in easing community tensions and eradicating the outbreak (Davtyan, Brown, & Folayan, 2014;Hitchen, 2014).
It is important to note that Ebola-related stigma, much like any other diseaserelated stigma, can lead to negative stereotypes about the groups affected. Such stereotypes and associated maltreatment can represent another barrier of adjusting to life in another country. As existing research on the acculturative experiences of African immigrants in the U.S. is scant (Obasi & Leong, 2010;Orjiako & So, 2014) one must note how benchmark events, such as the Ebola 2014-2016 outbreak, have impacted the complex ongoing acculturative experiences of West African immigrants.
For African immigrants who are adjusting to life in the U.S. it is important to recognize that disease-related stigma may represent another acculturative stressor or barrier to thriving in a host country.

Background of Ebola Epidemic 2014-2016
The earliest cases of Ebola can be traced as far back as 1976 with cases in Sudan (Galas, 2014) and subsequent outbreaks in the Democratic Republic of the Congo and Gabon (Alexander et al., 2015;Galas, 2014). While Ebola is not new to Africa, the West African Ebola outbreak was the largest ever documented. It contrasted dramatically from prior outbreaks in its duration, number of people affected, and geographic extent (Alexander et al., 2015). The West African outbreak started in Guinea in December 2013, and heavily affected the neighboring countries of Sierra Leone and Liberia (Alexander et al., 2015;Centers for Disease Control and Prevention, 2015;Tosh & Sampathkumar, 2014). The Ebola epidemic also spread to other countries such as Nigeria, Senegal, Italy, Mali, Spain, the United Kingdom and the U.S. However, the numbers of cases in those countries were significantly lower.
The Ebola virus disease (EVD) outbreak of 2014 was identified as the worst epidemic in the history of the disease, with a survival rate of only 53% (Davtyan et al., 2014). According to the CDC, there were 3,814 total cases of Ebola in Guinea, 14,124 cases in Sierra Leone, and 10,678 cases in Liberia (CDC, 2016). It is a disease characterized by a hemorrhagic fever and severe illness including multiple organ failure with a high mortality rate (Alexander et al., 2015;Tosh & Sampathkumar, 2014). The first case of Ebola was diagnosed in the U.S. in a patient who had recently traveled from Liberia to Dallas, Texas. He later died due to health complications (CDC, 2014;Tosh & Sampathkumar, 2014). While there were only four reported cases of Ebola in the U.S. and one death, it was very impactful. Studies have noted that even though the risk of contracting the virus in the U.S. was small, the Ebola epidemic received extensive coverage in the U.S. media, with close to 1,000 segments about the virus airing between October 7 and November 3, 2014 on the news (Gertz & Savillo, 2014;Rolison & Hanoch, 2015). Even while the actual risk of contracting Ebola in the U.S. was low, it may come as no surprise that the psychological impact of prolonged news reports could have increased levels of perceived risk of exposure.
Furthermore, existing literature suggests that media focus on emotive topics can give rise to biased public perceptions that exaggerate the risk of rare events (Frost, Frank, & Maibach, 1997;Rolison & Hanoch, 2015).

The Impact of Perceived Risk & Disease-Related Stigma
A study by Smith (2006) on the role of the media in risk communication during the severe acute respiratory syndrome (SARS) outbreak mentioned that "the public typically base their decisions on the perceptions of risk rather than actual risk" (p. 3116). This study also noted that even though SARS presented some medical risk, it exerted a large psychological impact on people relative to its low prevalence and mortality rates, partially attributed to rapid transmission of information through the media. (Smith,2006). As Ebola virus disease is known to have very high mortality rate and virtually no identified cure or vaccine, repeated messages about the uncertain course of the epidemic could have easily heightened concerns about it among the general population.
Additionally, existing research has indicated that misperceptions of risk can lead to inappropriate reactions during an epidemic, such as stigmatization of individuals who are perceived as possible sources of infection (Rübsamen,2015). As Ebola is a disease with high fatality rates, existing literature has shown that it is a punishing disease that targets individuals and families. It imposes shame or disgrace on people who are impacted, regardless of whether they are sick, healthy or have recovered (Cheung, 2015). Due to the severity of the disease, any association with the Ebola outbreak whether it is direct, indirect, actual or perceived may present a serious threat. When sources of harm are difficult to identify or understand, fear is easily generalized to any person who falls ill or who has anything to do with anyone who has fallen ill. Their presence alone becomes a threat to one's life and well being which can result in individuals using extreme measures to counter that perceived threat (Garoff, 2015). While there were higher prevalence rates and death tolls of Ebola in West Africa compared to the U.S., it is important to note that misperceptions of risk may lead to the stigmatization and maltreatment of African immigrants residing in the U.S.
As stigmatization continued during the outbreak, more efforts were being directed at speaking up about harassment and working with African advocacy groups in order for individuals to "target Ebola, not Africans" (Crossnan, 2014). As African immigrants faced stigmatization and maltreatment due to Ebola related fears, it seemed to mimic the stigma exhibited towards individuals living with HIV/AIDS. A study by Davtyan and colleagues (2014) noted the similarities between Ebola and HIV/AIDS stating "the idea that EVD only affects certain groups such as poor Africans and African immigrants is comparable to HIV/AIDS as it was attributed to homosexuality in the early days of the epidemic" (p. 2). Furthermore, this study mentioned that communities impacted by HIV/AIDS and Ebola-related stigma have both suffered from isolation and ostracism, physical violence, and diminished quality of life (Davtyan et al., 2014).
Existing research also suggests that during an Ebola outbreak, psychosocial support diminishes as self-protection drives people to a sort of individuality (Garoff, 2015;Paglia, 2013). Weiss, Ramakrishna, and Somma (2006) note that the emotional impact of social disqualification and cultural meanings of illness signify the various ways by which stigma operates. A cultural shift in the context of a historical event such as fear of Ebola is particularly salient among African immigrant populations because individuals from West Africa usually maintain close relationships and alliances. The threat of disease can shatter families and communities (Garoff, 2015;Paglia, 2013). Thus the stigma of Ebola could simultaneously increase stress and decrease social support.

Stigma, Historical Events and The Complexities of Acculturation
Ebola-related stigma is noted to persist in individuals even after treatment (Cheung, 2015). Beyond those actually infected, and troubling for the wider community is the fact that African immigrants without a history of Ebola can be targeted and stereotyped simply on the basis of their cultural background. Research has shown that another concerning aspect of health-related stigma occurs when marginalized groups become more vulnerable to health problems, because they are identified with other targets of stigma, such as poverty, ethnicity, sexual preferences, and other factors that may contribute to social disadvantage or discrimination (Weiss, Ramakrishna & Somma, 2006). Given the number of acculturative stressors that immigrants already have to endure upon resettlement in another country (Lee, Koeske, & Sales, 2004;Mori, 2000), the recent Ebola outbreak and associated stigma represent additional acculturative stressors among African immigrants.
While acculturation has been described as the process of adapting to a culture involving the transition that takes place as a result of contact between two differing cultures (Berry, 1997;Flannery, Reise, & Yu, 2001), other theoretical frameworks note that acculturation is an ongoing, complex and fluid process. Berry's fourfold theory is the most widely used model of acculturation and has received substantial empirical support in various studies; however, existing research notes that it lacks flexibility rendering acculturation a static concept (Amoah, 2014;Bhatia & Ram, 2009). It is important to recognize that the "immigrant identity is one that is negotiated and reconstructed in the market place on varied cultural encounters" (Amoah, 2014, p. 127). In other words, during an ongoing acculturative process, the identities of Sierra Leonean immigrants may be destabilized or even re-negotiated because of Ebola-related stigma.

Other Theoretical Models of Acculturation
As the identities that immigrants construct during their migration experiences are also known to be fluid and complex, additional models of acculturation must be utilized to capture such nuances. According to social identity theory, another concept that has examined immigrant identity behavior is that ''groups will react to insecure social identity by searching for enhanced group distinctiveness'' (Amoah, 2014;Tajfel & Turner, 1986, p. 22). As immigrants come in contact with a new host culture, they attempt to construct their identity by comparing and finding commonalities between cultures. Perceived inconsistencies in both cultures can create suspicion and insecurities for the immigrant, which further creates questions about their own cultural identity and that of the host culture (Amoah, 2014;Cinnirella, 1997). This questioning and renegotiating process is referred to as "identity-differentiation" (Amoah, 2014;Grant, 2007, p.7). Social identity theory further postulates that identity differentiation becomes stronger when a sense of threat and insecurity is suspected.
Other theories such as the self-categorization theory note that immigrants gradually define their identity through self-introspection in relation to the out-group taxonomy (Amoah, 2014;Turner, Hogg, Oakes, Reicher, & Wetherell, 1987;Wyer, 2010). Social rejection of individuals is more likely to recoil in their in-group (Amoah, 2014;Knowles & Garder, 2008). In contrast to psychological models of acculturation, the notion of ''diasporas'' has become increasingly utilized to understand immigrant experiences. Within the last decade there has been an emergence of a distinct area referred to as "diaspora studies" (Bhatia & Ram, 2009). Existing research posits that the idea of the diaspora refers to "immigrant communities who distinctly attempt to maintain (real and/or imagined) connections and commitments to their homeland and recognize themselves and act as a collective community" (Bhatia & Ram, 2009, p. 141). In a study examining acculturation among Indian immigrants, Bhatia and Ram (2009) found that Indian immigrants living in the U.S. renegotiated their acculturation status after the events of 9/11. They noted that culture is often a 'positioning' and the acculturative experiences of immigrants are often shaped by various historical and sociopolitical contexts. However, in order to fully understand this 'positioning' existing literature asserts that researchers must work to understand the contextual factors that influence how individuals enter the acculturation process, what influences their adaptation, and how this process may change over time (Bhatia & Ram, 2009;Cabassa, 2003;Schwartz, Unger, Zamboange & Szapocznik, 2010). It is also important to understand the characteristics of the migrants themselves, the countries from which they originate, and the country and local communities in which they settle (Schwartz et al., 2010). Bhatia and Ram (2009) reported that their study participants who were once well integrated into the life and culture of the U.S. questioned and renegotiated their identities as American citizens after experiences of stigmatization following the events of 9/11. It is important to highlight the context-specific factors that led to a renegotiated identity. As researchers have attempted to expand beyond dimensional frameworks of acculturation, in order to address the additional complexities and context-specific factors that impact the adjustment of migrant groups, it is argued that in order to truly understand acculturation researchers must be open-minded and draw from various epistemological and methodological approaches (Bhatia & Ram, 2009;Chirkov, 2009). Mixed-method and qualitative approaches may create a better   knowledge base for understanding what mechanisms influence the acculturative   process and what factors are uniquely shaped by the process of adapting to new cultural environment (Cabassa, 2003).
The current study aims to expound upon Berry's acculturation theory, by using the conceptual foundations of social identity and self-categorization theories alongside the work of Bhatia and Ram (2009)  Leoneans who are settled in the U.S. As few studies have examined acculturation specifically among people of African descent, it is important to consider culturespecific elements of the acculturative process (Obasi & Leong, 2010;Orjiako & So, 2014).

Purpose of Study
The present study used semi-structured interviews to qualitatively explore how the 2014-2016 Ebola epidemic impacted Sierra Leonean immigrants living in the U.S.
More specifically, the study aimed to describe Sierra Leonean immigrants' experiences with Ebola-related stigma and perceived risk for Ebola as part of their ongoing acculturation experiences.
This study addressed the following research questions: 1. How do Sierra Leoneans in the U.S. describe how they were impacted by the Ebola epidemic of 2014-2016?
2. Did they experience and exhibit Ebola-related stigma?
3. Did Ebola-related stigma impact their acculturative adjustment in the U.S.?

Participants
The current study included (n=15) individuals who were originally from Sierra Leone and were recruited through flyers and emails from a community organization. A subset of the participants (n=2) had previously participated in a qualitative research study conducted by the researcher examining their acculturation experiences and psychological adjustment after the civil war in Sierra Leone (Cole, 2015) and expressed interest in the current study.  SD=11.9). Additional demographics can be seen in Tables 1 and 2. The sample size in this study (n=15) is smaller than samples used in quantitative studies. However, it is consistent with the sample sizes usually found in qualitative studies that usually range from 5 to 25 participants (Kvale, 1996).

Measures
The participants were asked to complete a demographic questionnaire and were prompted to respond to questions during the semi-structured interview. A detailed description of the measures used is listed as follows.

Demographics.
Participants were instructed to provide basic demographic information including current age, gender, ethnicity, language(s) spoken, relationship status, education, employment, length of time in the U.S., immigration status, whether or not they had access to healthcare, and if they ever received mental health counseling services (Appendix A).

Semi-structured interview.
A scale (Obasi & Leong, 2010), the short version of the Padilla SAFE acculturative stress measure (Mena et al., 1987), and Bhatia and Ram's (2009) assessment of cultural identity in the context of historical events.
Previous research has shown that utilizing an interview guide assists the researcher in obtaining information from all participants as well as providing some sequencing and guidance without interfering with the flow of the participant's reflection (Polit & Beck, 2008;Seidman, 2006). Throughout the interview process, informal member checking and follow-up questions were used to verify participant responses and validate that the descriptions truly reflected the voice of the participant and were not imposed by the views of the researcher.

Procedure
Following the approval of the University of Rhode Island Institutional Review Board, a non-probability purposive convenience sampling (Polit & Beck, 2008;Richards & Morse, 2007) approach was used to recruit participants. The president of the non-profit organization, Friends of Sierra Leone, assisted with the recruitment process. This organization aims to promote and celebrate African culture and is widely regarded as a major advocate for Sierra Leonean issues. Friends of Sierra Leone is based in Washington D.C. with several chapters and officers throughout the U.S. Flyers along with a copy of interview questions (Appendix C) were distributed via email listserv in the Washington D.C. and Atlanta's metropolitan areas. Participants from a previous study conducted by the researcher (Cole, 2015) were contacted primarily to share the results of that study. Those who met the inclusion criteria for the present study were given a brief explanation of the study and were given the option to contact the researcher at a later time to ensure their participation (Appendix D). Eligible participants were at least 18 years of age, lived in the U.S. for at least 6 months, and were able to understand, read and speak the English language.
From January to early March 2018, follow-up phone calls and email messages were made to schedule interviews. Fifteen face-to-face interviews ranging from 15-to 60-minutes took place in the participants' homes or at mutually agreed upon public locations (e.g., outside patio of coffee shop, bookstore, or restaurant). At the public locations the researcher mindfully chose a quiet location where others could not hear the detailed account of interview responses.
Prior to the interview the purpose and process of the research study as well as the risks and benefits were discussed with each participant. Participants were asked to explain their understanding of the study for clarification and then were asked to sign a consent form (Appendix E). As this study involved the use of audio recorders, participants were also asked to consent to having the interview recorded. They were also asked if they would be interested in participating in future studies conducted by the researcher.
The demographic form was administered first, and then the semi-structured interview was completed. Upon completion of the interview, participants were compensated with a $25 gift card in appreciation for their time.
After all the interviews were conducted, the transcription company, TranscribeMe, professionally transcribed all of the qualitative data. All transcriptions were also edited several times by the coding team in order make sure verbatim responses were accurately captured. Data were also edited to eliminate all possible identifiers, and participants were assigned pseudonyms to ensure confidentiality.
These pseudonyms were then linked to randomly selected ID numbers in order to provide links between interview and demographic data.
Several precautions were taken to safeguard the participation of the individuals within the current study. If the interview proved to be emotionally difficult, a number of identified mental health and support agencies located throughout the metro Washington D.C. and Atlanta, Georgia areas were made available to participants (Appendix F). The list of referral agencies was identified after each site was called and was found to have experience working with African populations. Fourteen participants declined a follow up call for emotional well-being and one participant was called 2-5 days post-interview to "check-in" about her wellbeing and a referral was made to an agency. The participants were asked to provide their contact information for follow up on a separate form (Appendix G) and were assured that any forms with identifying information would be kept completely separate from demographic and interview data. Such efforts were taken as the literature suggests that qualitative researchers should demonstrate another aspect of competence, consisting of having sufficient knowledge of the potential consequences of an intense interview and acting to provide appropriate follow-up support (Haverkamp, 2005;Lowes & Gill, 2006;McCosker, Barnard, & Gerber, 2001).

Benefits of Being a 'Partial' Cultural Insider
Previous research has noted that one of the most important strategies to employ when designing and implementing a study with immigrant populations is working with a cultural insider (Birman, 2005). Existing research also states that studies conducted within ethnically diverse populations should contain cultural norms so that the research might be of benefit to participants and their communities and not cause any harm (Begum, Walsh & Lorenzetti, 2014;Liamputtong, 2008). Moreover, the literature suggests that researchers working with ethnically diverse populations should work towards cultural competence by building rapport with research participants and developing trusting, long-term relationships. Such efforts require researchers to remain in or with cultural communities for extended periods of time (Begum, Walsh & Lorenzetti, 2014;Liamputtong, 2008).

Throughout this project, this researcher benefitted through collaboration with
Friends of Sierra Leone, which aims to promote and celebrate African culture. This organization is widely regarded as a major advocate for Sierra Leonean issues in the United States. This researcher's parents are originally from Sierra Leone and have maintained their cultural identity. As a partial insider this author shared her cultural identity with the research participants and was able to identify Friends of Sierra Leone, as a collaborating agency to work with through existing connections within the Sierra Leonean community.
Moreover, a connection with Friends of Sierra Leone had been established in 2013 for a previous research study (Cole, 2015). At the conclusion of that study, the research participants gave the recommendation to "go to the ground" in order to understand the people of Sierra Leone and their specific needs. This process of "going to the ground" is an important part of building cultural competence within understudied populations as it involves spending extended periods of time with the population as recommended by the literature (Begum, Walsh & Lorenzetti, 2014;Liamputtong, 2008). As a partial cultural insider this author's involvement with Friends of Sierra Leone continued beyond the realm of the previous study. This author became a member of the organization, learned more about issues relevant to Sierra Leone, and met the president of the organization and several board members who assisted with the recruitment of research participants for the current study.
This author was inspired to continue exploring the adjustment of Sierra Leoneans within the U.S. during the Ebola outbreak. Shortly after collecting data from the previous study (Cole, 2015), this author witnessed family members who both experienced and exhibited Ebola-related stigma in 2014. Given the severity of the Ebola outbreak and the historical relevance of this research topic, this author felt called to stay connected "to the ground" by continuing research efforts with the aim of benefitting the Sierra Leonean community in some way.
Additionally, previous research participants were contacted to share the results from the previous study in the form of a brief report. Study results were also shared with Friends of Sierra Leone, members of the Sierra Leonean community and the participants within the current study to demonstrate the importance of conducting research on Sierra Leonean issues and illustrating how research can be translated into ongoing action. This process of sharing qualitative research findings with participants is known as member checking and is noted to increase study credibility and participant involvement (Goldblatt, Karnieli-Miller & Neumann, 2011). Sharing the results from the previous study and continuing the collaboration with Friends of Sierra Leone definitely expedited the recruitment of participants and the data collection process for the current study.
This ongoing connection with the Sierra Leonean community has afforded this author the opportunity to learn about other Sierra Leonean organizations within the U.S. such as Krio Descendants Union. Being embraced as a guest in many of the participants' homes was striking After the interviews were completed, many of the participants (n=11) wanted to share their feelings about the current state of Sierra Leone and urged this author to continue research efforts beyond the current study.
The matched cultural identity of the participants and the researcher proved to be beneficial not only because of the familiarity and understanding of the culture, but also the personal investment to act ethically according to the culture of the research participants and the culture of the researcher (Birman, 2005;Tapp, Kelman, Triandis, Writsman, & Coelho, 1974).
It is important to note that despite a cultural identity with the research participants, this author represents a partial cultural insider. While this author is familiar with the customs, language, and other cultural nuances found within Sierra Leonean culture, she remains an outsider to the experience of adjusting to life in the United States. Additionally, aiming to adhere to assumptions consistent with a constructivist line of inquiry within qualitative research, this author believes that participants have constructed the nature of their reality which is then interpreted by the researcher noticing common threads. These constructivist assumptions posit that "multiple realities exist and data reflects the researcher's and participants' constructions of reality" (Buckingham & Brodsky, 2015, p. 145). This reasoning supports the use of descriptive thematic and content analyses utilized in the current study. The aim was to stay true to what the data revealed because it is important for participants among an unstudied population to convey their story. Being a partial cultural insider provided the benefit of establishing rapport quickly with research participants and a developing a sense of trust that their story would be told to benefit their community.

Data Analysis
Manifest content analysis and thematic analysis were used to analyze the data.
Manifest content analysis is a systematic form of analyzing transcribed interviews and remains close to the text with minimal interpretation (Sandelowski, 2000).
Since this researcher wanted to stay close to the participants' words, this type of analysis was well suited to this study. Once manifest content analysis was completed thematic analysis was done. Thematic analysis involves the detection of patterns and regularities that typically goes right through the data (Polit & Beck, 2008).
Once the transcriptions of the interviews were completed, they were read several times while listening to the audiotapes for accuracy. Six research assistants, trained by this researcher, assisted with the data analysis. They were divided into three teams, with two assistants in each team. Each team was assigned an equal amount of data to analyze.

Data analysis began with open coding of the data which examined units of data (sentences or phrases). Similar codes were then grouped into categories and counted
to determine the number of responses related to that code. Throughout the coding process, memos were written by all coders to capture the formation of initial codes and subsequent revision and refinement of final categories and subcategories. The coding teams engaged in several discussions about the coding process and interpretations until complete agreement was reached. Each coder also independently documented interpretations about the underlying categories and discussed overall potential themes found in the study. The researchers and the six research assistants reviewed all of the potential themes and memos until there was 100% agreement.

Trustworthiness
Trustworthiness in qualitative research is characterized by credibility, dependability, confirmability and transferability (Lincoln & Guba, 1985;Shenton, 2004). Credibility was established through informal member checking during interviews, the use of descriptive codes in the language of the participants, and by double-checking transcripts to ensure that they were verbatim accounts of participant responses. Furthermore, journaling took place throughout data collection and analysis to document and check the biases of the researcher and research assistants.
Transferability, or level generalizability, was supported with the use of thick descriptions of research findings. Generating an audit trail of records produced throughout the study supported dependability and confirmability. All memos, journal entries, interview and coding notes were maintained throughout the study.
Trustworthiness was also supported by maintaining communication with a member of the doctoral committee who is an expert in qualitative research.

Knowledge of Ebola Outbreak 2014-2016
Prior to addressing the three research questions, participants were asked about their general knowledge of the Ebola virus, when and how they heard about the epidemic, and whether they felt well informed. Table 3 represents the eight responses that emerged when participants reported their general knowledge of the Ebola virus. Ebola is deadly. The majority of participants reported that they knew that Ebola was a deadly virus known to kill people rapidly. For example, Brian a 29-yearold participant who formerly worked as a medical doctor in Sierra Leone described the rapid progression of the virus.
"So the initial signs and symptoms that you first see is the ones that I've listed.
And followed by that, you then get diarrhea, vomiting. And you tend to see some rash on your body as well. And this is normally also associated with decreased renal function. That is a decreased function of the kidneys and the liver. Normally, at this stage, that is when some patients they start to bleed, both internally and externally. So, because of that, the Ebola virus disease is actually a very fatal disease. It has a fatal incidence of about 25 to 90 percent meaning the chances of surviving; it's actually pretty slim." Spreads through contamination. Seven of the participants reported that they knew Ebola spread through contamination of bodily fluids such as blood and sweat as well as skin-to-skin contact. For example, Tania a 26-year-old participant stated: "It was something that spread because of contamination, through blood, skin, sweat and things of that nature." Ebola comes from animals. Six participants reported that they knew Ebola was known to come from animals such as monkeys or fruit bats that were usually found in remote areas. Leo, a 32-year old participant stated: "It is transmitted by wild animals, especially chimpanzees, monkeys, and bats." Another participant, 43-year-old Robert reported: "They never found the actual source, but claims are made that it jumped from animals to humans."

Ebola comes from eating bush meat. While other participants identified that
Ebola is transmitted to humans from animals, three participants stated humans are infected from eating those animals, which is commonly referred to as bush meat.
Sarah, a 29-year old participant stated: "Ebola is a virus that's caused by a bacterium that's found in monkeys. And, for example, back in Africa, when in Sierra Leone people go the bush, it's called bush meat, and they kill these monkeys or these baboons and they eat them, so the bacteria becomes active in the human. So when it becomes active, then the person gets the disease or the virus called Ebola." Has symptoms similar to malaria. Two participants shared that the Ebola virus has symptoms that are similar to the symptoms of malaria. Tania, a 26-year-old participant shared an incident where a prominent ambassador who was infected with malaria was convinced that he was infected with the Ebola virus and was making preparations for his perceived demise.
"But the other one that was actually on the news, when they said the Diplomat, he actually contracted--that one, it was very serious and scary because we were all on the phone because he is a Sierra Leone Ambassador. Participants were then asked when and how they heard about the Ebola outbreak, which is outlined in Tables 4 and 5 below. In 2015 1 (6.7%) Note. Total does not equal 15 (100%) as some participants did not provide an answer to this question. Moreover, the majority of participants reported that they felt they received information from good sources and were well informed about the Ebola outbreak in Sierra Leone. Table 6 outlines the general impressions of all the participants below. Participants were also asked where they would go to get good information about the Ebola epidemic. The following eight responses emerged and are outlined in Table 7. Kenneth: "So those really affected in Sierra Leone. Yeah, and that was us friend because people that survived the disease, and these are the people you need to talk to because they can give you firsthand information about the disease." Tania: "Of course, the Internet. WhatsApp and Facebook, yes."

Research Questions
The purpose of the individual interviews (n=15)  The results are displayed under each research question.

Research question #1 How do Sierra Leoneans in the U.S. describe how they were impacted by the Ebola epidemic of 2014-2016?
Participants' descriptions of how they were impacted by the Ebola epidemic are described under two categories:1) pervasive fear and 2) preventative actions.

Pervasive fear.
The majority of participants (n=13)

Research Question #2 Did They Experience and Exhibit Ebola-Related Stigma?
Participants' descriptions that captured Ebola-related stigma are described under one category microaggresssions.

Microaggressions.
As participants previously reported that they were impacted by discrimination when Ebola cases were found in the U.S., it may come as no surprise that a larger proportion of participants (53.3%) reported they were treated differently because they came from a country that was impacted by the Ebola epidemic. Francis: "Because I did not travel to Freetown years before and after the Ebola, I did not." Sarah:" Not really…I've heard of people who were stigmatized and stuff, but no. I wasn't treated like--people were just curious." Another participant, 28 year-old Lucas reported that he felt that he wasn't outwardly treated differently but stated that he did know of people that made jokes about it.
"I wasn't treated differently. Most of the people that brought up the virus, it was more in a jokey manner. And I had to say something once or twice. But after that, I stopped responding. So she would just whatever, and then she realizes it's not funny and she stops."

Adjustment in the U.S.?
Participants' descriptions related to the impact of Ebola related stigma on their acculturation adjustment in the U.S. are described under two categories: 1) the immigrant identity with six sub-categories and 2) longing for 'Sweet Salone' The Immigrant Identity.
While a notable proportion of the participants did experience Ebola-related stigma and discrimination, the majority of participants stated that such experiences did not impact their sense of belonging in the U.S. This sense of belonging along with descriptions of what they thought it means to be a Sierra Leonean in the U.S. today and their level of community connectedness and involvement encapsulates the category of the immigrant identity with six sub-categories.

Grateful for the land of opportunity. Four participants reported an overall
sense of gratitude to move to the U.S. to pursue their dreams and other opportunities. Leonean, the majority of participants reported that the sense of being a Sierra Leonean in the U.S. had changed due to the political climates of both the U.S. and Sierra Leone. They also reported that this change was impacted by the overall stability of Sierra Leone after the war, Ebola, and the recent mudslide. One participant, Peter, age 61, even reported concern about his status as a dual citizen of the U.S. and Sierra Leone.
"Considering the present circumstances in Sierra Leone, even though it was something they said it was in our constitution back home, by carrying two citizenships, at first we thought that it was okay to have a dual citizenship. you know, so." The majority of participants had mixed feelings about leaving Sierra Leone; some were still currently homesick. Some reported that they didn't do much because they were not homesick because of their connection to Sierra Leone within the U.S. Others stated that they called home or engaged in social media, listened to Sierra Leonean music, ate food, or relied on their faith or connection to family.

Emergent Theme: Sierra Leone was Neglected
A general sense that Sierra Leone was a nation that was neglected clearly surfaced from the data as a central and pervasive theme. Across several interviews (n=10) there was a general sense that Sierra Leone was neglected because the Ebola epidemic initially wasn't taken seriously by the government of Sierra Leone and the international community until campaigns were created to spread awareness that Ebola cases reached the U.S. Furthermore, this sense of neglect also emerged as participants Tina: "There was more money over the health because when the epidemic did start a little bit, I mean, questions were brought to the health department and people would say, "Oh, something is going on right there in the provinces." And they're like, "Oh, it's just in the provinces. Oh, it's just one person." Leo: "I wasn't happy that Americans were not treating this disease seriously, so when there was one outbreak, one person also came in with the pain they started putting it on the news." And that's when people was asking, "Whoa. This thing is a little serious?" Peter: "I think Sierra Leone was neglected because some of these doctors were there. They had no vaccine, no type of prescribed medication by then.
But when it happened to an American, they flew that person over here, he was taken in a sealed vehicle, everything was in place. Unlike over there, people were going to help Ebola victims with bare hands. The facilities were not there. So because of that, I thought that even though I'm in America, I saw it, what the CDC did. And it came to Atlanta, we saw it on television the way they protected the American then I say, I don't know why this would not happen in Sierra Leone. So that's how I felt a little bit neglected, being from a third world." Moreover, across several interviews it appeared as if participants felt that the government in Sierra Leone was not equipped to handle the severity of the outbreak and many attributed the spark of the Ebola outbreak in Sierra Leone to research studies that were being conducted at the time. Several participants shared their thoughts below.
Tina: "Nothing was done. Nothing was done. They were notified months.
They were notified months. But again, like I said, when you have a nonfunctioning ministry, and that's why a lot of people thought they were part of the deal to bring it as a biological weapon other than a disease. Because you were so nonchalant to your own people so people started thinking, well you all must have been part of this research. You must have given consent to them to bring--because I worked research before. I know what happen in research.
You have a lot of people here when you do research. There's a lot of consent form for you to sign. There's a lot of process when you go through as a trial candidate and all. Over in Sierra Leone, that's not it. You're basically signing a consent form just for some other researcher to bring back, not a consent form Lucas: "Some people have described it as man-made, and some people think it just appears. Nobody really knows where it comes from. It was mentioned that it started at a lab or somewhere around the Mano River union, which is closer to the border of Guinea, Liberia, and Sierra Leone. So since we're now getting word that this is not natural, it was man-made, or it was brought there to be studied up on, so the people that brought it there, what are they doing about it? So, I mean, me personally, I read the document from Tulane University that mentioned that they were in the region doing study on Lassa fever. And then they stumbled on the Ebola virus as they were doing their research. So, I mean, it just happens that the time that they were there doing that, out of nowhere, there was an outbreak in that region. And there was also rumor, which I don't know what the facts are on that, but the U.S. government and some of these other facilities sponsored some of these local government to build a laboratory that was located within that region where this took place." Overall, this sense of neglect along with the various theories and controversies related to what caused the epidemic in Sierra Leone and what prolonged it reveals a sense of disappointment in the political climate within Sierra Leone and the initial international response to a serious and unexpected virus. However, several participants believe that there is still hope for Sierra Leone. With the right leadership, adequate resources, vital partnerships, and the lessons learned from the Ebola epidemic of 2014-2016, Sierra Leone can actualize it's potential. Two participants Brain, age 29, and Robert, age 43, echoed these sentiments.
Brian: "But one thing about the whole Ebola outbreak in Sierra Leone. One thing that we definitely learned is that there's still so much that needs to be done in the healthcare process or management back home. And I'm sure, definitely, if there's another outbreak in Sierra Leone, the government won't take that long much time than it did the last time. A lot of people back home have now been trained on how to do the prevention parts. And how to tackle a community-based level and also, any treatment process. So I think we might be better equipped to face it in the future." Robert: "I'm fully confident that Sierra Leone will rise to the top, certainly to the top. I'm very confident of that. And it'll take both connecting Sierra Leoneans and Sierra Leoneans in the diaspora. And I believe that once you get all of the energy, resources, and expertise of people who are on the ground and people whom they choose not to go but still have a passionate connection for that we'll truly realize our potential. But I'm fully confident that Sierra Leone, and Africa as a whole but I can definitely say definitely Sierra Leone, will realize its potential. A lot of people count them out, but Sierra Leone has one thing that most other countries don't have and that is it's got the largest young population. And at the end of the day, the future is with the youth."

Researcher Recommendations
At the conclusion of each interview, all participants were asked "If you had the chance to talk to a group of people who would like to help other immigrants from Sierra Leone what would you like them to know?" The majority of participants reported that they felt Sierra Leone needs help after all it has endured during the differently. And you don't just go and impose on them Sierra Leoneans are the type of people--they're loving and stuff, but if you go and be boss over their heads, they will not take your advice. You have to make yourself available and be around them so they think we're one. And then when you talk, they listen. When you go and be like, "Oh, because I'm from United States, I have seven masters and five PhDs, and I'm a doctor," they look at you in their snobbish way. Okay, so you have all these--what's that going to do for me?
When you come in, blend with them, even though they know you have all these papers and stuff. Then when you say something, they listen to you, because they know, there's a word in Krio 'rub skin'. You've mingled with them when they sit down to eat and they call you, you eat. You don't be like, "Oh, I don't eat that because I'm from--" So they take you as family." The importance of education was also underscored by some participants who reported on the high rate of illiteracy in Sierra Leone. They also mentioned the importance of specifically educating and empowering young girls and women in Sierra Leone. Two participants, Leo age 32 and Kenneth, age 32, shared their thoughts on providing education in Sierra Leone.
Leo: "For me, education is the key. They must be in school. In my country, the illiteracy rate is so high, so I would tell them about the benefits of education, especially the girl child. They are the most vulnerable people back home." Kenneth: "Well, if I had an opportunity to tell them most of this stuff, they need to create series of awareness to our people. The illiteracy in Africa, in Sierra Leone is so high, so they need to embark on so many advocacy group to educate them, to give them awareness. Because mostly in Africa, the women and children when it comes to issues like violence, they are always affected.
You have child abuse, sexual harassment, or something like--they also do it to pregnant women and something. They keep on dying. They keep on--so obviously this are the areas they need to focus on--like help more women to empower women. Before in Africa, they see women, they're only supposed to be in the kitchen, whereas in America you guys work together." Two participants highlighted the importance of not only investing money into Sierra Leone but also investing time to make sure your efforts are reaching the target population. Lucas, age 28, and Tina, age 56, shared their thoughts on investing in Sierra Leone.
Lucas: "Unfortunately, we lack leadership, and we lack professionalism. And if anybody who's thinking about doing something to help Sierra Leone, don't do it through money. Do it through your time and your experience or your knowledge to transfer into the people. Because I think the more people we can touch, they'll be able to handle situations like this when it comes back.
Because, God knows, the government was not prepared for this, and they would never be prepared for this, I hate to say it, because, until this day, even the money and stuff people were sending back to help these people, they still don't account for millions of dollars. And these people, they help their immediate family, and they do whatever they want with this money. So I encourage anybody who's thinking to help Sierra Leone in any way, if you can mobilize and actually go there and do it, do not give money to people who says, "I'm going to do it on behalf of you." If you can go there and do it personally, it will create more impact and it will reach the people who actually need the aid that you're providing." Tina: "That they have to be in control of whatever funds and whatever changes at the beginning. They could engage other Sierra Leoneans but when it comes to funds, they have to be in control to make sure that it is reaching the target person. It's reaching the target group. Because you could be away trying to help somebody and you think you're sending funds and it's never getting to them. You think you're helping them and it's never getting to them. that Sierra Leoneans are very hospitable and will embrace outsiders. "But people will know because when they go, people are surprised when they go to Africa to see that Africa has a good side. You see, nobody talks about the culture, the good culture.

DISCUSSION AND IMPLICATIONS
As existing research on the acculturative experiences of African immigrants in the U.S. is scant (Obasi & Leong, 2010;Orjiako & So, 2014), this study aimed to qualitatively explore the salient acculturative process of an understudied group within the context of a global health epidemic.  (Karamouzian & Hategekimana, 2014;Mitman, 2014).
Given the unknown course of the virus at the time of the epidemic, the limited amount of surveillance within Sierra Leone due to a damaged health infrastructure (WHO, 2015), and some of the participants' probable exposure to the virus through travel, it is safe to say that such heightened fears are plausible. Existing research suggests that fear reactions in response to infectious disease are considered normal and potentially adaptive or protective (Shultz et al., 2016). The fear reactions of the participants influenced them to alter their behaviors in response to the Ebola epidemic and engage in preventative measures that could serve them well in the case of another outbreak. Furthermore, the results of this study underscore the participants' strong and ongoing ties to Sierra Leone within the context of a global emergency. For many of the participants, Sierra Leone is home no matter how many years they have been away.
It is likely that whenever significant historical events impact the nation of Sierra Leone, Sierra Leoneans in the U.S. and throughout the diaspora will also be impacted in some way.
The underlying theme of participants believing that Sierra Leone was a neglected nation vulnerable to the influence of political controversy and misguided research is not a new concept. The participants' ideas about the spark of the Ebola epidemic in Sierra Leone and subsequent mistrust of vaccine developments, mimic remnants of the yellow fever epidemic that occurred in Liberia back in 1926 (Mitman, 2014 (Mitman, 2014).
The results of this study also revealed that participants did experience Ebolarelated stigma and differential treatment. Work colleagues made jokes about Ebola, travel plans were significantly delayed, family members and neighbors distanced themselves, and those traveling to the U.S. were forcibly monitored for 21 days.
While these precautions were established to contain the spread of this deadly epidemic, it negatively impacted some of the participants as they were targeted and stereotyped simply on the basis of their cultural background.
One would posit that as immigrants already face a number of acculturative stressors upon resettlement in another country (Mena, Padilla, & Maldonado, 1987), Ebola-related stigma would represent another acculturative stressor for Sierra Leoneans in the U.S. While the participants within this study did experience stigma and were treated differently due to their connection to Sierra Leone, it appears as if such experiences did not have a long-term effect on their acculturative process. A large proportion of participants reported they continued to integrate balanced aspects of American and Sierra Leonean culture in their lives or they simply continued to embrace Sierra Leonean culture within the U.S.
While Bhatia and Ram (2009) note that that acculturation is an ongoing, complex and fluid process, the varied experiences of the participants' connection to others and their sense of belonging in the midst of the Ebola outbreak reveals the complexity of the acculturation process. The participants' strong connection to Sierra Leone in the midst of an uncertain political climate coupled with the opportunities they have received in the U.S. seems to have maintained their acculturative statuses as either "integrated" and/or "separated" individuals (Berry, 2003;Bhatia & Ram, 2009;Schwartz et al., 2010). It appears that experiencing Ebola-related stigma did not lead to a change in acculturative status for the study participants. However, when a neighbor who has known you for several years suddenly refuses to let their children play with your children or when coworkers begin to ask you if you've recently traveled to an Ebola-infected zone because of your background, one may wonder if the participants internally questioned their identities as American citizens and residents. Bhatia and Ram (2009)  influences their adaptation, and how this process may change over time (Bhatia & Ram, 2009;Cabassa, 2003;Schwartz et al., 2010 All in all, due to the complexity involved with the acculturative process, it is important to highlight that even as some participants experienced Ebola-related stigma, perhaps there are other factors that helped them mitigate the effects of that acculturative stressor, such as a sense of pride in their Sierra Leonean identity, the drive to succeed in the face of adversity, community connection, or the general hope that conditions will improve for Sierra Leoneans across the diaspora.

Limitations
There are several limitations to address when interpreting the findings of the current study. First, the participants represented a convenience sample and likely represented sub-populations of Sierra Leoneans located in the Washington D.C. and Atlanta metropolitan areas of the U.S. Therefore the findings of this study may not be applicable to the general population of Sierra Leoneans in the U.S. or other immigrant populations who were significantly impacted by this global health emergency.
Furthermore, this qualitative study primarily relied on interview data, memo writing, and demographic information from the participants. Although efforts were made to support the ideals of trustworthiness, a multi-method approach would likely bolster trustworthiness through triangulation.

Future Directions
Given the limited amount of research on the acculturative processes of African immigrants within the U.S., working with these participants has revealed the importance of openly talking to immigrants about their experiences in different countries and sociopolitical contexts to create a clear picture of how complex the acculturation process can be. Findings shed light on the salient issues faced by Sierra Leoneans in the U.S. and throughout the diaspora and also allude to the pervasive impact of global infectious disease epidemics. As mentioned by many of the participants, when working with vulnerable understudied groups, it is important to be flexible, remain open-minded, and follow the cultural guidelines of that population to gain a better understanding of their realities. Essentially this research represented another opportunity for the researcher to 'go to the ground' as a partial cultural insider (Cole, 2015) in order to understand the unique triumphs and challenges of Sierra Leoneans within the United States. It is this author's hope that this study will bring her closer to the shores of Sierra Leone in order to directly make a difference in the lives of Sierra Leoneans after the experiences of war, the Ebola epidemic and the recent natural disaster.
Future studies would benefit from examining the effectiveness of utilizing cultural insiders to conduct ongoing research with understudied populations.
Qualitatively exploring the realities of an understudied group may also serve as a foundation for developing nuanced theories of acculturation on African immigrant populations. stated that they miss Sierra Leone and want to go back to visit or live. Some were disappointed when they came to live in the U.S. 5. Many people used faith, family, and resources they had to overcome hardships of war. Faith, family, friends, and a sense of community also helped people adjust to life in U.S. Most said that they gained something by coming to the U.S. 6. Recommendations: All participants recommended going straight to source for information, by directly talking to Sierra Leoneans. They also said a lot of work still needs to be done to help Sierra Leoneans in U.S. and especially in Sierra Leone.

APPENDIX B
I'm currently in the process of trying to publish the results of the study in a journal for psychology. Your help was greatly appreciated and can spread awareness about the unique challenges and experiences of Sierra Leoneans.

If participant is eligible continue:
After completing that study, I became interested in following up with you about your experiences in the U.S. during the 2014-2016 Ebola epidemic. Participation in this new study will involve completing an audiotaped interview lasting about 30 minutes to 1 hour. Your responses to all study questions will be kept confidential. At the end of the interview you will receive a $25 gift card for your participation. I'm in the process of recruiting for this study, so if you are interested in participating feel free to give me a call at 404-964-4605 or email me at Djcole@my.uri.edu.
Thanks again for your time! You have been invited to take part in a research project described below. The researcher will explain the project to you in detail. You should feel free to ask questions. If you have additional questions at later time, please contact Dr. Paul Florin, 401-277-5302, or Daphne Cole, M.A., 404-964-4605, Djcole@my.uri.edu. Daphne Cole, the person responsible for carrying out this study, will discuss them with you. You must be at least 18 years old to participate in this research project.

Description of the project:
The purpose of this study is to better understand the experiences of Sierra Leoneans in the U.S. during the 2014-2016 Ebola epidemic.

What will be done?
If you decide to take part in this study this is what will happen: You will be asked to participate in an interview which will last approximately thirty minutes to an hour and will be audio recorded. You will be asked some questions and can discuss these questions and your answers with the interviewer. All identifying information such as individual names will be removed. In appreciation for your time, you will receive a $25 gift card after completing the interview. You will receive a phone call 2-5 days after the interview, which will last no longer than 10 minutes. The purpose of this call is to briefly check in with you to see how you are doing and to answer any questions or concerns you may have about the study.

Risks or discomfort:
Answering questions about your experiences during a global emergency can be difficult. If you experience any distress, a list of agencies that have counselors who are experienced working with immigrants will be given to you.

Benefits of this study:
It is possible that you will receive no specific benefits from participating in this study. A potential benefit of this project is to provide a greater understanding of the experiences of Sierra Leoneans who come to the U.S. Some people, however, report feeling relieved to share their experiences with others.

Confidentiality:
Your participation in this study is confidential. Any forms with identifying information, such as this consent form and the follow up contact form, will be kept completely separate from interview materials which will use special codes that are not linked to your name. You will also be asked to choose a pseudonym, or false name, at the beginning of the interview and that name will be used on the audio recording. To keep your information confidential, the audio recording of the interview will be placed in a locked file cabinet until a written word-for-word copy of the interview has been created. All typed versions of interviews will be kept on a computer that is password-protected and uses special coding to protect confidential information. All study materials will be destroyed three years after the completion of this study.
Decision to quit at any time: The decision to take part in this study is up to you. You do not have to participate. If you decide to take part in the study, you may quit at any time without penalty. If you wish to quit, simply inform Daphne Cole of your decision during the interview or by calling her at 404-964-4605.

Rights and Complaints:
If you are not satisfied with the way this study is performed, you may discuss your complaints with Dr. The researcher will use a digital recording device in order to audio record the full interview between the participant and the researcher. Please indicate your decision to be recorded by placing an "X" on one of the lines below followed by your signature.
I agree______ or I decline______ to be recorded ________________________

Signature of Participant
Are you interested in participating in future research studies focused on the experiences of Sierra Leoneans?
Please indicate your decision by placing an "X" on one of the lines below followed by your signature.
I agree______ or I decline______ to be contacted for future research studies.

Signature of Participant
Please sign both consent forms, keeping one copy for yourself.
This is a non-governmental human rights organization committed to healing the wounds of torture and stopping torture worldwide. We rebuild lives by providing healing services to survivors of political torture and their families. Our staff has extensive training and experience in providing culturally competent services within an inter-disciplinary model. Our Atlanta clinic provides psychotherapy, social services, and care coordination at no cost to qualified clients. Website: www.cvt.org/ where-we-work/Georgia 2295 Parklake Dr., Suite 434 Atlanta, GA 30345 470-545-2776

Access Mental Health
This agency provides a range of community-based services ranging from individual and group counseling, behavioral health assessments, crisis intervention, psychological testing, nursing, pharmacy and lab services, and community support. Licensed therapists provide a range of therapeutic intervention services for a variety of mental health concerns.

African Immigrant & Refugee Foundation (AIRF) Mental Health Program.
This organization uses a network of African-born mental health professionals to provide assessments and counseling that is linguistically and culturally appropriate for each client. Counseling uses a traditional African framework based on age group, gender and extended family groups.

Community Connections
This organization is the largest private, non-profit provider of behavioral health, residential services, and primary health care coordination for communities in the District of Columbia who are coping with mental illness, addiction, and the aftermath of trauma and abuse.

Catholic Charities: Archdiocese of Washington
This organization is the social ministry outreach agency that houses a number of services to refugee and immigrant populations. The Refugee Center offers case management and employment service support to recent refugees and asylum seeker living in DC as they seek to make a new start in the US. Assistance is offered in job searching, interviewing, benefit enrollment, workplace ESL classes, immigration legal services and all facets of the employment process.

Torture Abolition and Survivors Support Coalition (TASSC):
TASSC is a non-profit organization that provides a range of support services for survivors of torture such as free counseling, free housing on a temporary basis, free legal representation for those who are seeking asylum, medical referrals, employment related assistance and other services.

Advocates for Survivors of Trauma (ASTT):
This organization is a part of the National Consortium of Torture Treatment Centers, a network of service providers who specialize in the care of torture survivors. It provides free psychological and case management services in order to address survivor's needs in a culturally responsive and holistic way. This organization is an independent advocacy and action organization that offers a Refugee Protection Program is that committed to advancing the rights of refugees, including the right to seek asylum. This agency advocates for access to asylum, for fair asylum procedures, and for U.S. compliance with international refugee and human rights law. Legal services are offered to refugees through a pro bono Asylum Legal Representation Program.

The Washington Pastoral Counseling Service
This is an interfaith, non-profit organization with a mission of providing low-cost mental health services to children, individuals, couples and families in the DC metropolitan area. Counselors work with children and adults struggling with a range of issues including early childhood trauma, separation and divorce, spouse abuse and battering, depression, behavioral and substance addictions, communication skill deficits, grief and abuse recovery.

APPENDIX G Follow-up Contact Form
Thank you so much again for the taking the time to talk with me about your experiences.
We have discussed many topics today and I would like to briefly follow up with you in a few days just to see how you are doing and to answer any additional questions you may have.
Please provide your contact information below: Name: _____________________________________ Telephone #:________________________________ Best time to reach you: ________________________