Health and Socio-Cultural Experiences of Refugee Women: An Integrative Review

Suicidal behaviors among refugee women in Jordan: post-traumatic stress disorder, social support and post-displacement stressors

BACKGROUND

This paper examines the frequency of suicidal behaviors (suicidal ideation or attempt) among a sample of Syrian refugee women living in non-camp settings in Jordan. We asked several questions surrounding suicide and examined the associations between post-traumatic stress disorder (PTSD), social connectedness, post-displacement stressors and suicidal behaviors.

METHODS

Participants (n = 507) were recruited using a clinic-based systematic sampling from four health clinics throughout Jordan in 2018. We used a multivariable logistic regression to examine the hypothesis of whether positive screening for PTSD (PCL-5), social isolation (have no friends or family members available to help), and greater number of post-displacement stressors (PMLD Checklist) is associated with suicidal behaviors.

RESULTS

Approximately one-tenth (9.86%) of participants surveyed reported suicidal behaviors (suicidal ideation or attempt) in the past six months. Our hypothesis was partially supported. In the adjusted multivariable analyses, screening positive for PTSD [OR:4.02 (95% CI:1.33, 12.15)] increased odds of suicidal behaviors, while having one friend or family member available to help when in need [OR:0.31 (95% CI:0.13, 0.78)] decreased odds of suicidal behaviors. We did not find any associations between the number of post-displacement stressors and suicidal behaviors in the multivariable model.

CONCLUSION

Agencies and practitioners addressing suicidal behaviors among Syrian refugee women should provide interventions that aim to reduce PTSD symptoms and social isolation. Potential intervention includes screening for mental health symptoms and suicidal behaviors during routine visits with service providers, as well as providing proper mental health and psychosocial support services according to the mapping of available services.

Influence of post-migration living difficulties on mental health among refugees and asylum seekers: A scoping-review on clinical tools

BACKGROUND

The literature indicates an increasing interest in the mental health of refugees (R) and asylum seekers (AS) - particularly how it could be affected by previous exposure to trauma and violence - but less has been written about the issues they are forced to face during the post-migration period and how these also can affect mental health. Research shows that the mental health of R/AS is highly influenced by their post-migration conditions and may deteriorate due to post-migration social health-related determinants; in addition, a lack of language skills, discrimination, separation from family, poverty, and other stressors can contribute to social isolation. The difficulty in asking for help in case of psychological distress and, consequently, in accessing care, contributes to the worsening of their clinical condition.

AIMS

The primary purpose of this study is to identify and provide a review of the clinical tools used to screen migrants (R/AS) at risk of developing psychological distress, identifying post-migration difficulties.

METHODS

We searched studies in PubMed, Embase, Scopus, Cochrane (Central), and Cinahl (ultimate) with the last search on 14 April 2023, using a combination of keywords and Medical Subject Headings (MeSH).

RESULTS

Our systematic search identified 1,878 records. After removing duplicates, we screened 1,238 records by title and abstract, retaining 97 for full text review. Of these, 68 met full eligibility criteria (1995-2023). A total of 30 social scales have been identified, as well as structured or semi-structured questionnaires and interviews. Translated into multiple languages, the tools can be self-administered or administered by trained professionals. PMLD is known for its effectiveness in evaluating the post-migration period and predicting mental health issues.

CONCLUSIONS

Considering the limited number of studies and, consequently, the limited number of tools found, it can be inferred that not enough attention is given to post-migration in the broader sense.

Predictors, barriers, and facilitators to refugee women's employment and economic inclusion: A mixed methods systematic review

Refugee women's employment and economic inclusion have emerged as significant areas of focus, with these women facing unique challenges due to their gender, refugee status, and sociocultural identities. Policymakers and researchers worldwide are giving this issue increased attention. This systematic review uses a mixed methods approach and includes 31 studies to explore the predictors, barriers, and facilitators of refugee women's employment. The results reveal a pooled employment rate of 31.1% among refugee women. It identifies demographic features, language proficiency, education, and family structure as critical determinants of employment. The qualitative synthesis uncovers three key themes: the meaning and significance of employment; barriers to employment; and facilitators and coping for employment. This study underscores the multifaceted influences on refugee women's employment. The findings can inform the creation of more targeted interventions, policies, and practices to support refugee women's employment and economic integration.

Women's experiences of trauma-informed care for forced migrants: A qualitative interview study

Introduction

Forced migration affect the health and wellbeing of millions of women. The aim was to explore experiences of trauma-informed care among women who are forced migrants.

Methods

This was an exploratory qualitative study. Eleven women who had concluded treatment at multidisciplinary trauma centers in Sweden were interviewed, recruited through consecutive sampling. Audio-recorded interviews were transcribed and analyzed with systematic text condensation.

Results

Women dealt with mental and physical manifestations in a challenging psychosocial situation. Various structural and individual barriers were addressed that hindered access to adequate health services. Women appreciated various benefits of the treatment and recalled the care as supportive and compassionate. However, undergoing treatment was considered demanding, requiring significant determination and energy. Participants suggested that peer support could enhance the support.

Conclusions

Migrant women experience a range of health-related burdens and encounter barriers to trauma-informed care. While demanding, treatment has the potential to alleviate symptoms. Health professionals and stakeholders providing trauma-informed care need to ensure that their services are accessible and culturally sensitive towards the unique needs of women. Peer support has the potential to enhance support further, which need further evaluation.

What words can tell us about social determinants of mental health: A multi-method analysis of sentiment towards migration experiences and community life in Lima, Perú

To support resilience in contexts of migration, a deeper understanding of the experiences of both receiving communities and migrants is required. Research on the impacts of migration on community life is limited in contexts with high internal migration (i.e., migrating within one's country of origin). Evidence suggests that cultural similarity, community relationships, and access to resources may be protective factors that could be leveraged to support the mental health of internal migrants. The current study uses data drawn from a sample of pregnant Peruvian women (N = 251), 87 of whom reported being internal migrants and 164 of whom reported being from the locale of the study (Lima, Perú). The aim was to better understand the social experience of internal migration for both local and migrant women. Inductive thematic analysis was used to examine migration experience and perceived impact of migration on community life. Internal migrants discussed three themes relative to their experiences: motivations, adjustment, and challenges. Experiences of women in receiving communities consisted of four themes related to migration: positive, negative, neutral, and mixed perceptions. Linguistic Inquiry and Word Count (LIWC-22) software was also used to assess sentiment towards migration. Across both analytic methods, migration motivations and perceptions were multifaceted and migrants reported a wide range of challenges before, during, and after migration. Findings indicated that attitudes toward migration are broadly positive, and that there is a more positive appraisal of migration's impact on the community life for internal as opposed to international migration.

Support interventions to promote health and wellbeing among women with health-related consequences following traumatic experiences linked to armed conflicts and forced migration: a scoping review

BACKGROUND

Women exposed to armed conflicts and forced migration face significant health-related risks and consequences. Consequently, there is a need to identify and develop effective interventions that provide tailored support for them. The aim of this scoping review was to examine research evaluating support interventions promoting the health and well-being among women with traumatic experiences linked to armed conflict and/or forced migration.

METHODS

A scoping review of empirical studies evaluating non-pharmacologic/non-surgical interventions promoting health and well-being among adult women with traumatic experiences linked to armed, torture, and/or forced migration, identified through systematic searches in February 2022 within five databases (AMED, CINAHL, Cochrane Library, PsycINFO, and PubMed). Methodological characteristics and results were extracted and analyzed with narrative analysis using tabulations, descriptive statistics, text-based summaries, and thematization.

RESULTS

Assessment of 16 748 records resulted in 13 included reports. The methodological approaches were quantitative (n = 9), qualitative (n = 2), and mixed methods (n = 2), with most reports being feasibility/pilot studies (n = 5) and/or randomized controlled trials (n = 4). The most common recruitment strategy was non-probability sampling (n = 8). Most interventions were conducted in North America (n = 4), Asia (n = 3) or Middle East (n = 3). Thirteen intra-intervention techniques and five categories of components utilized within the interventions were identified, the most common being skill building (n = 12). Ten developed the interventions through theoretical frameworks or manuals/therapy, while five developed interventions through public or stakeholder involvement. Eleven studies evaluated outcomes related to psychological health, disorders, or distress. A large proportion of the investigated outcomes showed post-exposure improvements and improvements when compared with controls. Qualitative findings highlighted improved mental and physical health, empowerment and stigma reduction, and enhanced knowledge.

CONCLUSION

Few studies have developed and evaluated tailored support interventions for this population, containing a range of components and intra-intervention techniques. No clear focus was identified regarding outcome measures, and most studies used non-probability sampling. Few developed interventions through public contribution in collaboration with women. While limited studies show promising effects on women's mental health, more empirical intervention research that closely corresponds to women's needs are needed.

The association of neighborhood socioeconomic characteristics with cardiovascular health: A quasi-experimental study of refugees to Denmark

Neighborhood socioeconomic disadvantage is associated with cardiovascular health, although it is unclear which specific aspects of neighborhoods matter most. We leveraged a natural experiment in which refugees to Denmark were quasi-randomly assigned to neighborhoods across the country during 1986-1998, creating variation in exposure to various aspects of neighborhood disadvantage. The cohort was followed through December 2018. Exposures included neighborhood-level family income, educational attainment, unemployment, and welfare transfers measured in the first neighborhood after arrival to Denmark. Outcomes included cardiovascular risk factors (hyperlipidemia, hypertension, diabetes and anxiety/depression) and cardiovascular disease (acute myocardial infarction and ischemic heart disease). Neighborhood-level income and education were most consistently associated with cardiovascular risk factors, whereas welfare transfers were most consistently associated with cardiovascular disease. Addressing these specific aspects of neighborhood disadvantage could therefore lower the risk of poor cardiovascular health among refugees. Future research is warranted to examine if results are generalizable to other immigrant groups, countries or time periods.

Influences on reproductive decision-making among forcibly displaced women resettling in high-income countries: a scoping review and thematic analysis

BACKGROUND

Forced displacement impacts the health, rights and safety of women, which is further compounded by gender inequality. In particular, this has consequences for forcibly displaced women's reproductive health once resettled in a new country. To ensure the reproductive health and rights of forcibly displaced women during and after resettlement, there must be careful consideration of their reproductive decision-making taking into account the context and environment of the host country.

AIM

This scoping review aimed to explore the influences on reproductive decision-making among forcibly displaced women resettling in high-income countries.

METHOD

A scoping review was conducted following the PRISMA-ScR for reporting. EBSCO was used to search databases covering global health, health policy, psychology, sociology, and philosophy for articles published from 1 January 2012 to 27 April 2022. Data extracted from each article included author(s), year of publication, publication type, aims/objectives, study design, sampling method, data collection or eligibility criteria, study population (i.e., sample size and characteristics), migration status, country(ies) of origin, host country(ies), key findings and limitations. Two independent reviewers screened all articles against eligibility criteria using Covidence. Data charting and thematic analysis were performed independently by one reviewer.

FINDINGS

Nineteen articles published between 2013 and 2022 mostly conducted in the United States (36.8%) and Australia (21.1%), with the majority reporting on qualitative findings (68.4%), and women from a wide array of countries and cultures (most commonly African countries) were included. Influences on women's reproductive decision-making related to the contexts before displacement, during displacement, and after arrival, with influences on women's reproductive decision-making identified specific to the context. The influences before displacement included conflict; religious beliefs; socio-cultural gendered expectations; and external control over reproductive autonomy. During displacement influences included paternalism and access to education. Influences after arrival included pressure, restriction, coercion; knowledge and misconceptions; patriarchal power dynamics; and seeking empowerment. An adapted socio-ecological model was developed to interpret the findings.

CONCLUSION

This review highlights the complexity and nuances within forcibly displaced women's experiences which influence their reproductive decision-making. Further research may review the evidence base to provide guidance for healthcare professionals and health policies aimed at empowering women to make autonomous reproductive decisions; develop training for healthcare professionals to prevent pressure, restriction and coercion of women's reproductive autonomy; and inform development of policy that takes an intersectional approach to women's health rights and gender equality.

Psychological well-being, mental distress, metabolic syndrome, and associated factors among people living in a refugee camp in Greece: a cross-sectional study

Background

Forcibly displaced people face various challenges and are therefore at higher risk of being affected by mental and physiological distress. The present study aimed to determine levels of psychological well-being, PTSD symptom severity, metabolic syndrome, and associated factors among forcibly displaced people in Greece in response to WHO's call for evidence-based public health policies and programs for forcibly displaced people.

Methods

We conducted a cross-sectional study among n = 150 (50% women) forcibly displaced people originating from Sub-Sahara Africa and Southwest Asia living in a Greek refugee camp. Self-report questionnaires were used to assess psychological well-being, symptoms of PTSD, depression, generalized anxiety disorder and insomnia, perceived stress, headache, and perceived fitness. Cardiovascular risk markers were assessed to determine metabolic syndrome, and cardiorespiratory fitness was measured with the Åstrand-Rhyming Test of Maximal Oxygen Uptake.

Results

The prevalence of mental distress and physiological disorders was overall elevated. Only 53.0% of participants rated their psychological well-being as high. Altogether, 35.3% scored above the clinical cut-off for PTSD, 33.3% for depression, 27.9% for generalized anxiety disorder, and 33.8% for insomnia. One in four (28.8%) participants met criteria for metabolic syndrome. While the prevalence of moderate or severe insomnia symptoms and metabolic syndrome differed little from the global population, the risk of being affected by mental distress was markedly increased. In multivariable analysis, higher perceived fitness was associated with higher psychological well-being (OR = 1.35, p = 0.003) and a decreased likelihood for metabolic syndrome (OR = 0.80, p = 0.031). Participants with elevated psychiatric symptoms were less likely to report high psychological well-being (OR = 0.22, p = 0.003) and had increased odds for higher PTSD severity (OR = 3.27, p = 0.034). Increased stress perception was associated with higher PTSD symptoms (OR = 1.13, p = 0.002).

Conclusion

There is an elevated risk for mental distress compared to the global population and an overall high mental and physiological burden among people living in a Greek refugee camp. The findings underpin the call for urgent action. Policies should aim to reduce post-migration stressors and address mental health and non-communicable diseases by various programs. Sport and exercise interventions may be a favorable add-on, given that perceived fitness is associated with both mental and physiological health benefits.

"Step by Step We Were Okay Now": An Exploration of the Impact of Social Connectedness on the Well-Being of Congolese and Iraqi Refugee Women Resettled in the United States

Little is known about the gendered impacts of the displacement and resettlement process. Women are known to struggle more with feelings of belonging and the creation of social networks to access essential information, resources, and social and emotional support to enhance their overall health and well-being. The purpose of the present study was to qualitatively explore female refugee perceptions of belongingness and social connectedness post-resettlement into their U.S. host community. Conducted between January and June of 2016, through the partnership of multiple governmental, nonprofit, and community-based organizations, two female focus groups were conducted among Congolese (n = 6) and Iraqi (n = 6) U.S. resettled refugees. Descriptive surveys were distributed to participants, providing valuable insights into participant demographics and indicators that could impact the integration process (i.e., age, language, country of origin, ethnicity, education, length of time spent in the U.S., housing). Participants discussed the social connections (individuals, communities, organizations) that acted as facilitators or inhibitors of developing social capital. The importance of building strong transformational bonding (family members, other refugees) and bridging (host community) relationships, alongside transactional ties with linking agencies (resettlement social services), was critical for a positive resettlement experience. The strength of their network ties among these social connections contributed to their perceptions of belongingness and well-being post-resettlement into their host community.

[Resilience after Flight: Perspectives of Refugees and Supporting Practice Actors]

STUDY OBJECTIVES

The study aims to identify (aim 1) and relate (aim 2) refugees' and practice actors' perspectives on resilience after a flight to broaden the depth of understanding of postflight resilience and to provide insights into relationships between practice actors and refugees.

METHODS

Three guideline-based focus groups with refugees (N=9) and practice actors (N=13) to assess the perspectives of both groups on resilience after flight were conducted in German. They were analyzed iteratively according to Constructionist Grounded Theory.

RESULTS

Refugees and practitioners report the strains of uncertainty and limitation, the adaptation processes of commonality and endeavor, and the adaptation goals of stability, connectedness, and positive emotionality (goal 1). The statements of refugees and supporting practice actors on resilience after flight concur strongly regarding their content and complement each other. Refugees report more individualized and more specifically than practice actors (goal 2).

DISCUSSION

The aspects of resilience mentioned by refugees and supporting practitioners replicate the results of previous qualitative studies on post-flight resilience conducted with refugees. Both the strain of partly not knowing adequate adaptation options locally and attempts to create resilience-promoting conditions seem to be specific to the resilience of refugees. The content-related similarities between refugees and practice actors might stem from experiences of the practice actors in the context of support processes or from similar life experiences of the practice actors. The less individualized approach to post-flight resilience of the practice actors may be caused by a higher level of abstraction, role expectations, or coping with emotional distress.

CONCLUSION

The results of the study suggest that refugee resilience is characterized by universal and population-specific aspects. That practice actors who support refugees and refugees concur on the content of post-refugee resilience validates the findings of previous qualitative studies on post-refugee resilience. The study also identified different approaches to post-flight resilience among refugees and practitioners, whose causes require further research.

Use of participatory action research to support Syrian refugee mothers in the resettlement period in Canada: A longitudinal study

Research has shown that refugees in a foreign country often experience physical and mental health challenges upon resettlement (Ahmad et al., 2021; Salam et al., 2022). In Canada, refugee women experience a range of physical and mental barriers, including poor access to interpreter services and transportation, and a lack of accessible childcare, all of which can negatively affect their successful integration (Stirling Cameron et al., 2022). Social factors that support Syrian refugees to settle successfully in Canada have been unexplored systematically. This study examines these factors from the perspectives of Syrian refugee mothers living in the province of British Columbia (BC). Framed by principles of intersectionality and community-based participatory action research (PAR), the study draws on Syrian mothers' perspectives of social support in early, middle, and later phases of resettlement. A qualitative longitudinal design consisting of a sociodemographic survey, personal diaries, and in-depth interviews was used to gather information. Descriptive data were coded, and theme categories were assigned. Six themes emerged from data analysis: (1) Steps in the Migration Journey; (2) Pathways to Integrated Care; (3) Social Determinants of Refugee Health; (4) COVID-19 Pandemic Impacts and Ongoing Resettlement; (5) Strength-Based Capabilities of Syrian mothers; (6) Peer Research Assistant's Research (PRAs) Experience. Results from themes 5 and 6 are published separately. Data obtained in this study contribute to the development of support services that are culturally appropriate and accessible to refugee women living in BC. Our objectives are to promote the mental health and improve the quality of life of this female population, and to enable it to access healthcare services and resources in a timely manner.

Understanding Mental Health Status of Syrian Refugee and Jordanian Women: Novel Insights from a Comparative Study

(1) Background: War and displacement are well-known predictors of negative mental health outcomes among affected populations. This is especially relevant for refugees of war, particularly women, who often repress their mental health needs due to family responsibilities, social stigma, and/or cultural pressures. In this study, we compared the mental health status of urban Syrian refugee women (n = 139) with local Jordanian women (n = 160). (2) Methods: Psychometrically validated Afghan Symptom Checklist (ASC), Perceived Stress Scale (PSS), and Self-Report Questionnaire (SRQ) examined psychological distress, perceived stress, and mental health, respectively. (3) Results: According to independent t-tests, Syrian refugee women scored higher than Jordanian women on the ASC [mean score (SD): 60.79 (16.67) vs. 53.71 (17.80), p < 0.001], PSS [mean score (SD): 31.59 (8.45) vs. 26.94 (7.37), p < 0.001], and SRQ [mean score (SD): 11.82 (4.30) vs. 10.21 (4.72), p = 0.002]. Interestingly, both Syrian refugee and Jordanian women scored higher than the clinical cutoff in the SRQ. Regression analyses indicated that more educated women were less likely to score high on the SRQ (β = -0.143, p = 0.019), particularly in the anxiety and somatic symptoms subscale (β = -0.133, p = 0.021), and were less likely to exhibit symptoms of ruminative sadness (β = -0.138, p = 0.027). Employed women were more likely to exhibit high coping ability than unemployed women (β = 0.144, p = 0.012). (4) Conclusions: Syrian refugee women scored higher than Jordanian women in all used mental health scales. Access to mental health services and enhancing educational opportunities would help mitigate perceived stress and may enhance stress-coping abilities.

Foreign Nationality, Family Psychiatry History and Pregestational Neoplastic Disease as Predictors of Perinatal Depression in a Cohort of Healthy Pregnant and Puerperal Women during the COVID-19 Pandemic

Background: Perinatal depression (PND) represents one of the most common mental disorders in the pregnancy and/or postpartum period, with a 5-25% prevalence rate. Our aim was to investigate predictors associated with PND in a cohort of pregnant and puerperal women based in an Italian setting during the COVID-19 pandemic. Methods: We retrospectively recruited 199 (55 pregnant and 144 puerperal) women, afferent to our Perinatal Mental Outpatient Service of Ancona (Italy). Participants were administered an ad hoc case-report form, Whooley Questions (WQ), the General Health Questionnaire-12 (GHQ-12), the Stress Holmes-Rahe scale (HR) and the Edinburgh Postnatal Depression Scale (EPDS). Results: Around 10% of the sample had a confirmed PND. Being a foreigner woman (RR = 3.8), having a positive psychiatric family history (RR = 5.3), a pre-pregnancy medical comorbidity (RR = 1.85) and a comorbid medical illness occurring during the pregnancy (RR = 2) were much likely associated with PND. Multiple linear regression analysis demonstrated that GHQ, medium- and high-risk at the HR, foreign nationality, positive family psychiatric history, and neoplastic disease before conception significantly predicted EPDS [F(1, 197) = 10.086, R2 = 0.324, p < 0.001]. Limitations: The sample size, poor heterogeneity in terms of socio-demographic, clinical and gynecological-obstetric characteristics, the cross-sectional design of the study. Conclusions: Our study showed a set of predictors associated with a higher risk for the PND onset, including gestational and pregestational medical disease. Our findings outline the need to screen all fertile women, particularly in gynecological and medical settings, in order to identify at-risk women for PND and promptly suggest a psychiatric consultation.

Peer Mentoring Programs for Culturally and Linguistically Diverse Refugee and Migrant Women: An Integrative Review

Refugee and migrant women experience personal, cultural and structural challenges as they adapt to new lives in host countries. Peer mentoring programs are used to facilitate resettlement, build empowerment and improve job-readiness for refugee and migrant women; however, the effectiveness of these programs is not well understood. A systematic search of five databases, plus grey literature from January 2005 to December 2020, was undertaken, resulting in 12 articles. A narrative synthesis using thematic analysis identified the key components and outcomes of effective programs. Most mentoring programs were co-designed with community-based service providers, using participatory approaches to ensure cultural acceptability. Communication and sharing were facilitated using workshops and individual in-person or telephone mentoring. The training and support of mentors was critical. However, differences in expectations between mentors and mentees at times resulted in attrition. Qualitative evaluation revealed enhanced social support, greater empowerment and confidence for the women. There was improved access to the social determinants of health such as education, but limited success in obtaining employment. Mentoring programs can enhance refugee and migrant women's wellbeing and social connectedness in resettlement contexts. However, it is unclear whether these benefits can be sustained over the longer term. Future programs should be rigorously evaluated through qualitative and quantitative analyses to generate conclusive evidence for best practice.

Experiences of armed conflicts and forced migration among women from countries in the Middle East, Balkans, and Africa: a systematic review of qualitative studies

Background

A significant proportion of the global population is displaced, many being women. Qualitative studies can generate in-depth findings that will contribute to an understanding of their experiences, but there is a need for further synthetization efforts. The aim was to provide a comprehensive perspective about adult women’s experiences of armed conflicts and forced migration, focusing on women in or from countries in the Middle East, Balkans, or Africa.

Methods

Systematic review of English reports presenting empirical qualitative studies published in scientific journals 1980 or later, utilizing searches performed in September 2021 within three databases combined with manual screening. Of the 3 800 records screened in total, 26 were included. Methodological details and quality were appraised using pre-specified extraction and appraisal tools. The findings within the included reports were analyzed with thematic analysis.

Results

Most reports utilized interviews, including in total 494 participants, and were appraised as having insignificant methodological limitations. The first theme concerns changed living conditions, involving reduced safety, insufficient access to resources meeting basic needs, forced migration as a last resort, and some positive effects. The second theme concerns the experienced health-related consequences, involving psychological distress, risks during pregnancy and childbirth, exposure to violence and discrimination as a woman, as well as a lack of adequate healthcare services and social support. The third theme concerns the resources and strategies that enhance resilience, involving social support and family life, as well as utilization of internal resources and strategies.

Conclusion

When experiencing armed conflicts and forced migration, women face significant challenges related to changed living conditions and are exposed to health-related consequences. Consistently, women are targets of severe structural and personal violence, while lacking access to even the most basic healthcare services. Despite facing considerable hardships, these women display extraordinary resilience and endurance by finding strength through social support and internal resources. Synthesized qualitative research illustrates that women value social support, including peer support, which is a promising intervention that needs to be evaluated in future experimental studies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13031-022-00481-x.

Chronic pain, mental health and functional impairment in adult refugees from Syria resettled in Norway: a cross-sectional study

BACKGROUND

Limited research exists on pain and especially the co-occurrence of pain and mental ill health in general refugee populations. The present study aimed to approximate the prevalence of chronic pain (CP) among adult refugees from Syria resettled in Norway; investigate the association between CP and mental ill health; and explore how CP and mental ill health associate with both perceived general health and functional impairment. Gender as potential effect modifier in these associations was also examined.

METHODS

Cross-sectional, postal survey questionnaire.

INCLUSION CRITERIA

≥ 18 years old; refugee from Syria; and arrived in Norway between 2015 and 2017. Study sample was randomly drawn from full population registries, and n = 902 participated (participation rate ≈10%). CP was measured with 10 items on pain lasting for ≥ 3 consecutive months last year. Symptoms of anxiety, depression and PTSD were measured with the HSCL and HTQ scales, respectively. Ordered and binomial logistic regressions were used in analyses. Gender was tested as effect modifier with Wald test for interaction.

RESULTS

In the sample overall, the proportion of participants who reported severe CP was 43.1%. There was strong evidence that anxiety, depression and PTSD were associated with higher levels of CP. In fully adjusted regression models, including both CP and mental health variables, CP was strongly associated with poor perceived general health whereas mental health showed much weaker associations. The association between mental health (anxiety and PTSD) and functional impairment was highly gender specific, with strong associations in men but not in women. CP was strongly associated with functional impairment with no difference across gender.

CONCLUSION

The study shows a high burden of CP in a general population of adult refugees from Syria with likely substantial adverse consequences for daily functioning. The strong association between CP and mental ill health suggests personnel working with refugees' health should be attuned to their co-occurrence as both problems may need to be addressed for either to be effectively mitigated. A clear mismatch exists between the burden on health caused by pain in general refugee populations and the amount of available evidence to guide mitigating strategies.

TRIAL REGISTRATION

NCT03742128.

Effects of Trauma and Postmigration Stress on Refugee Women's Health: A Life Course Perspective

Trauma exposure and postmigration stress are associated with adverse health outcomes among refugees, yet the relative effect of these factors for subgroups of refugees and those resettled long-term remains unclear. Drawing on life course theory, this study evaluated the associations between war trauma, postmigration stress, and health among Southeast Asian refugee women in the United States, and whether these patterns differ across the life span. A community sample of Vietnamese and Cambodian refugee women aged 30-72 years (N = 293) reported mental and physical health outcomes, conflict-based trauma exposure, and postmigration measures of discrimination and community violence. Both trauma exposure and discrimination were associated with mental and physical health problems, with the relative effect of each stressor varying across specific health outcomes; community violence was associated with poorer mental health. Age moderated the effect of trauma exposure across health outcomes, with stronger associations between trauma and health for older women in particular. Findings provide support for the influence of trauma exposure and the importance of postmigration stressors on health across the life span for refugees. Attending to age group differences in the effects of these stressors, and to subgroups such as women, has implications for interventions addressing the long-term health of refugee populations.

Displacement and Isolation: Insights from a Mental Stress Survey of Syrian Refugees in Houston, Texas, USA

(1) Background: Syrians are the largest forcibly displaced population in the world. Approximately 20,000 Syrian refugees have resettled in the United States (US) since the civil war in Syria began in 2011, with an estimated 130 families resettling in Houston, Texas. We conducted a pilot study with the objective of examining the physical and mental well-being of the Houston Syrian refugee population. (2) Methods: Online surveys were conducted using psychometrically valid instruments including Afghan Symptom Checklist (ASC), Refugee Post-Migration Stress Scale (RPMSS), Perceived Stress Scale (PSS), and Self-Report Questionnaire (SRQ) (3) Results: According to independent t-tests, Syrian refugee females scored higher than males on ASC (37.78 vs. 31.64, p = 0.0446), particularly in the subscales of sadness with social withdrawal (28.89 vs. 24.31, p = 0.0495), and stress-induced reactivity (6.56 vs. 4.86, p = 0.0004). Similarly, females scored higher than males in RPMSS (60.54 vs. 45.15, p = 0.0022), including the social strain domain (8.08 vs. 5.18, p = 0.0204). In PSS and SRQ, Syrian refugee females reported comparable stress and distress scores as males. (4) Conclusions: Syrian refugee females reported higher stress and distress than males. Displacement from their home country and social strain were the major sources of stress in Syrian refugee females, as indicated in RPMSS.

The mental health and well-being of internally displaced female Yazidis in the Kurdistan Region of Iraq: a realist review of psychosocial interventions and the impact of COVID-19

BACKGROUND

Yazidis in the Kurdistan Region of Iraq have been exposed to recurrent traumatic experiences associated with genocide and gender-based violence (GBV). In 2014, ISIS perpetrated another genocide against the Yazidi community of Sinjar. Women and girls were held captive, raped and beaten. Many have been forced into displacement. Rates of post-traumatic stress disorder (PTSD) and suicide are high. Limited research has evaluated interventions delivered to this population.

METHODS

This review explores how the global evidence on psychosocial interventions for female survivors of conflict-related sexual violence applies to the context of the female Yazidi population. We used a realist review to explore mechanisms underpinning complex psychosocial interventions delivered to internally displaced, conflict-affected females. Findings were cross-referenced with eight realist, semi-structured interviews with stakeholders who deliver interventions to female Yazidis in the Kurdistan Region of Iraq. Interviews also allowed us to explore the impact of COVID-19 on effectiveness of interventions.

RESULTS

Seven mechanisms underpinned positive mental health outcomes (reduced PTSD, depression, anxiety, suicidal ideation): safe spaces, a strong therapeutic relationship, social connection, mental health literacy, cultural-competency, gender-matching and empowerment. Interviews confirmed relevance and applicability of mechanisms to the displaced female Yazidi population. Interviews also reported increased PTSD, depression, suicide and flashbacks since the start of the COVID-19 pandemic, with significant disruptions to interventions.

CONCLUSION

COVID-19 is just one of many challenges in the implementation and delivery of interventions. Responding to the mental health needs of female Yazidis exposed to chronic collective violence requires recognition of their sociocultural context and everyday experiences.

Professional mental health support seeking in Women of Refugee Background resettled in Australia: An exploratory study of facilitators and barriers

The present study is the first to investigate factors influencing professional mental health support seeking in Women of Refugee Background (WoRB) in Australia. WoRB are a vulnerable population with a range of complex mental health needs. Despite this, research has indicated that WoRB are an underrepresented population in the utilisation of mental health support services. This is a particular concern in Australia, due to an increasing number of WoRB being resettled. A multivariate logistical regression was conducted on a sample of 450 WoRB resettled in Australia from the Building a New Life in Australia (BNLA) data set to investigate factors associated with seeking professional mental health support. Several factors were identified as being significantly associated with professional mental health support seeking in WoRB resettled in Australia, including age, resettlement location, marital status, prearrival trauma involving violence against women, language barriers and health-related variables, including mental distress and long-term disability. The current study provides a unique insight into professional mental health support seeking from a gendered perspective in WoRB resettled in Australia. Insights into factors that influence seeking professional mental health support in this highly vulnerable population must inform mental health practice, service delivery and policies.

Spatiality of Social Stress Experienced by Refugee Women in Initial Reception Centers

This study takes an interdisciplinary approach to understanding the multi-dimensionality of social stress within the spatiality of initial refugee reception centers in Berlin. By focusing particularly on the experiences of women who fled from Syria and Afghanistan, it situates this humanitarian issue within an analytical framework of gender-sensitive and culturally sensitive research and policymaking. Through qualitative interviews with 11 refugee women, the connection between the spatiality of initial reception centers and social stress is explored. This is done by thematically coding the data collected in the context of nine different initial reception centers across various districts in the city of Berlin. The study shows that in terms of the intercultural needs and practices of these women, social stress is triggered by a lack of essential privacy within the spatiality of these structures. However, privacy is not limited to a physical enclosure—it is about having control/freedom over different aspects of everyday life. This article highlights intercultural gaps in gender-sensitive and protection considerations during humanitarian responses.

A qualitative investigation of mental health in women of refugee background resettled in Tasmania, Australia

Background

Women of Refugee Background (WoRB) are a highly vulnerable population with complex going mental health needs following resettlement. In Australia, there has been a substantial increase in WoRB being resettled in rural and regional locations. Despite this, no research to date has specifically focused on factors contributing to mental distress in WoRB in regional resettlement locations. The current study aimed to address this gap in literature.

Methods

21 semi-structured qualitative interviews were conducted with WoRB and service providers in regional locations of Tasmania, Australia. Interviews were audio recorded and transcribed verbatim. Transcripts were analysed utilising Braun and Clarke (Qual Res Psychol 3(2):77–101, 2006) framework for conducting thematic analysis.

Results

Thematic analysis revealed that WoRB conceptualised mental health as a pathogenic entity, which significantly influenced their mental health help-seeking behaviours. The findings also highlighted how resettlement to a rural and regional location of Australia may exacerbate many of the factors which contribute to ongoing mental distress in WoRB.

Conclusions

The findings of the current study build upon existing research which indicates the adverse impacts post-migrations stressors can have on the mental health of individuals of refugee background. Furthermore, this study suggests that the current services and supports available to WoRB resettled in regional locations of Australia are inadequate, and under-resources. These findings are discussed in regard to practical and policy implications which should be addressed to better support the mental health of WoRB resettled in rural and regional locations of Australia.

Health promotion focusing on migrant women through a community based participatory research approach

Background

Migrants are often more vulnerable to health issues compared to host populations, and particularly the women. Therefore, migrant women’s health is important in promoting health equity in society. Participation and empowerment are central concepts in health promotion and in community-based participatory research aimed at enhancing health. The aim of this study was to identify conditions for health promotion together with women migrants through a community-based participatory research approach.

Methods

A community-based participatory research approach was applied in the programme Collaborative Innovations for Health Promotion in a socially disadvantaged area in Malmö, Sweden, where this study was conducted. Residents in the area were invited to participate in the research process on health promotion. Health promoters were recruited to the programme to encourage participation and a group of 21 migrant women participating in the programme were included in this study. A qualitative method was used for the data collection, namely, the story-dialogue method, where a process involving issue, reflections and actions guided the dialogues. The material was partly analysed together with the women, inspired by the second-level synthesis.

Results

Two main health issues, mental health and long-term pain, were reflected upon during the dialogues, and two main themes were elaborated in the process of analysis: Prioritising spare time to promote mental health and Collaboration to address healthcare dissatisfaction related to long-term pain. The women shared that they wanted to learn more about the healthcare system, and how to complain about it, and they also saw the togetherness as a strategy along the way. A decision was made to start a health circle in the community to continue collaboration on health promotion.

Conclusions

The community-based participatory research approach and the story dialogues constituted an essential foundation for the empowerment process. The health circle provides a forum for further work on conditions for health promotion, as a tool to support migrant women’s health.

Post-migration Stressors and Subjective Well-Being in Adult Syrian Refugees Resettled in Sweden: A Gender Perspective

A number of post-migration stressors have been shown to adversely affect mental health in refugees resettled in high-income countries, including poor social integration, financial difficulties and discrimination, and recent evidence suggests that these effects are gender specific. Social support has been found to buffer against post-migration stress in some studies on refugee populations, though the evidence on this is mixed. The present study used cross-sectional survey data from a nationwide, randomly sampled group of adult refugees from Syria resettled in Sweden between 2008 and 2013 (N _sample = 4,000, n _respondents = 1,215, response rate 30.4%) to investigate gender-specific associations between post-migration stressors and subjective well-being (SWB) and whether these associations were modified by social support. SWB was measured with the WHO-5 Well-being Index (scaled 0-100), dichotomized into high (≥50) and low (<50) SWB. Main analyses were stratified by gender, and regressed SWB on four domains of post-migration stress (financial strain, social strain, competency strain and discrimination) using logistic regression, adjusting for sociodemographic variables and traumatic experiences. Social support was tested as an effect modifier. In fully adjusted models, main risk factors for low SWB were high financial strain, especially in males (OR_{high vs. low strain, males} = 10.30 [4.91-21.6], p < 0.001 vs. OR_{high vs. low strain, females}= 3.84 [1.68-8.79], p = 0.002), and high social strain, only in males (OR_{high vs. low strain, males} = 9.21 [3.96-21.4], p < 0.001 vs. OR_{high vs. low strain, females} = 1.03 [0.40-2.64], p = ns). There was some evidence that social support buffered the adverse association of financial strain with SWB. In conclusion, the present study found clear support of gender-specific effects of post-migration stressors on SWB. Mitigation strategies and interventions should be aware of and sensitive to these potential gendered effects, and future research exploring mental health in the context of resettlement stress should have a heightened focus on the important role of gender.

Exploring Resilience, Coping and Wellbeing in Women of Refugee Background Resettled in Regional Australia

This study aimed to address a significant gap in the literature by investigating how Women of Refugee Background (WoRB) conceptualise resilience and identify factors that WoRB endorse as contributing to their wellbeing and coping during resettlement. Qualitative interviews were conducted with a group of 21 individuals (nine WoRB and 12 service providers). Thematic analysis identified that WoRB struggled to define resilience, with endorsed factors not fitting with current hegemonic Western understandings and theoretical understandings of resilience. The findings also highlighted how religious practice, finding a community and having a sense of meaning and contribution in their daily life were significant coping and wellbeing factors during resettlement, however, were difficult to access in regional resettlement locations. Results of the current study are discussed regarding theoretical and practical implications, taking into consideration the unique vulnerabilities experienced by WoRB resettled in regional locations of Australia.

Evidence from a Longitudinal Photovoice and Interview Assessment with Congolese Refugee Women in the Midwestern United States

Purpose: Refugees from the Democratic Republic of Congo have rapidly increased since 2016 and are growing to represent one of the top refugee groups in the United States. They are at high risk for health inequities, yet, there is limited qualitative research exploring the health needs, assets, and experiences of this group and even less longitudinal research. In addition, women refugees are understudied across all global contexts. Therefore, the purpose of this study was to conduct longitudinal qualitative research to provide rich contextual data on health and integration experiences of Congolese refugee women when they were newly resettled in 2016 and 3 years later in 2019. Methods: We conducted photovoice and interviews with 16 women in March through May of 2016 and 10 of the same women in March and April of 2019. Results: Women chose and discussed photos revealing a multitude of assets and needs spanning 2016 and 2019. Experiences with nutrition and food security were illuminated and are the focus of this article. Two major themes were access to food in contrast with availability of abundance of food in the United States and concern about what constitutes healthy food in the United States contrasted with accessing healthy and culturally appropriate food in the United States. Findings highlight strength bases of nutritional knowledge, attitudes, and skills as well as a strong social network aiding food security demonstrated by the Congolese refugee women in the study, offering an opportunity to shift to an assets and strength-based approach. Findings also note risk of food insecurity linked to barriers to employment and sociohistorical reflection on living with food shortages before migration to the United States that should be considered as providers strive to provide culturally relevant care. Conclusion: Findings offer contextual data for health care providers and public health professionals to improve nutritional health promotion and food security support for this population. Overlooking nuanced structural barriers may lead to providers perpetuating health inequities for this population.

Mechanisms Explaining the Relationship Between Maternal Torture Exposure and Youth Adjustment In Resettled Refugees: A Pilot Examination of Generational Trauma Through Moderated Mediation

The intergenerational effects of trauma resulting from torture and war are complex and multi-faceted and have important implications for the family system. The current study aimed to identify key relationships between refugee maternal caregiver exposure to torture, mental health, and physical health with maternal-reported youth adjustment. Ninety-six Karen maternal caregivers originating from Burma and resettled in the United States participated in a cross-sectional, explanatory mixed methods study. Maternal mental health distress was found to mediate the relationship betweenmaternal torture experiences and youth adjustment, R² = .357. Physical health problems was found to moderate the degree to which mental health distress mediated the relationship between torture and war trauma experiences and youth adjustment, R² = .409. The current study is significant in that it enhances our mechanistic understanding of factors relevant to the intergenerational effects of trauma within families where maternal caregivers experienced trauma from torture and/or war.

Narratives as Borders: Using an Adapted Narrative Approach to Understand the Retelling of the Physical Narratives of Trauma by Karen Women With Refugee Status Resettled in the United States

The refugee narrative spans time, geography, and generations, enfolding the complexity of constructing identities through displacement and migration. Through adapted narrative analysis, we examined the physical narratives of war trauma which a sample of Karen refugee women constructed, as they claimed their experiences of war trauma and torture in interview discussions. We employed an adapted narrative method relevant to the analysis of field texts to interpret the remembering and retelling of trauma narratives. This method helped to elicit positional identities and physical/sensory memories that were prominent in women's experiences and to contextualized concurrently collected quantitative data. Accounts revealed key constructs relevant to the narrative function and orientation of the narratives: remembering childhood, being a mother, embodiment of trauma.

A qualitative study of experiences of asylum-seeker women of living in detention centres: confinement versus safety

BACKGROUND

Iranian asylum seekers are amongst the highest number of boat arrivals to Australia who have been subject to compulsory detention. Women face more health-threatening problems rather than men in detention, yet, remain understudied in health research. This study aimed to inform healthcare providers about the experiences of living in immigration detentions, which might affect asylum seekers' mental health.

METHOD

A qualitative study using semi-structured interviews and thematic analysis.

RESULTS

17 participants shared their experiences: Living in a prison-like environment was a punishment for their boat arrival and violated their privacy and dignity. In contrast, a sense of security, free access to healthcare services, and building social networks were positive aspects of short-term detention.

CONCLUSION

To prevent further trauma, living conditions in detention must be conducive to promoting coping and adjustment. The length of detention should be minimised and limited to preparing asylum seekers for facing a new socio-cultural environment.

Health determinants among refugees in Austria and Germany: A propensity-matched comparative study for Syrian, Afghan, and Iraqi refugees

In recent years, Germany and Austria have been among the leading European receiving countries for asylum seekers and refugees (AS&R). The two countries have cultural and economic similarities, but differ, for example, in their health care systems, with AS&R having unrestricted access to health services upon arrival in Austria, but not in Germany. This study investigates the determinants of health among refugees in Austria and Germany, and how these determinants differ between the two countries. We analyze comparable and harmonized survey data from both countries for Syrian, Afghan, and Iraqi nationals aged 18 to 59 years who had immigrated between 2013 and 2016 (Germany: n = 2,854; Austria: n = 374). The study adopts a cross-sectional design, and uses propensity score matching to examine comparable AS&R in the two receiving countries. The results reveal that the AS&R in Germany (72%) were significantly less likely to report being in (very) good health than their peers in Austria (89%). Age and education had large impacts on health, whereas the effects of length of stay and length of asylum process were smaller. Compositional differences in terms of age, sex, nationality, education, and partnership situation explained the country differences only in part. After applying propensity score matching to adjust for structural differences and to assess non-confounded country effects, the probability of reporting (very) good health was still 12 percentage points lower in Germany than in Austria. We conclude that many of the determinants of health among AS&R correspond to those in the non-migrant population, and thus call for the implementation of similar health policies. The health disadvantage found among the AS&R in Germany suggests that removing their initially restricted access to health care may improve their health.

Exploring how Syrian women manage their health after migration to Germany: results of a qualitative study

BACKGROUND

In the recent years, the number of Syrians living in Germany increased drastically due to the massive displacement caused by the Syrian conflict. Syrian migrant women in Germany are challenged by both the migration process and the changing of social roles. Seeking out healthcare may be hampered by linguistic and cultural barriers, but the new context may offer opportunities for health and well-being (free access to health care, civil/human rights). Little is known about how Syrian women manage their health after their resettlement in Germany.

METHODS

In depth interviews in Arabic were conducted with 9 Syrian women who were recruited through purposive sampling (18-55 years, migrated in 2011-2017, different education levels), focusing on capabilities to control one's health and to navigate the German healthcare system, and social/environmental barriers and facilitators to effectively manage their health. Interview transcripts were analysed using qualitative content analysis.

RESULTS

The women reported their health to be impaired by post-migration stressors, such as perceived discrimination, loss of social status and worrying about the future. Many interviewees felt disempowered and incompetent to successfully and actively navigate the German healthcare system, lacking information and not understanding their rights and options under the health insurance plan. The language barrier added to feeling vulnerable. Many women experienced doctors declining to treat them for capacity reasons; when treated, they often did not feel taken seriously or were dissatisfied with the emotional/cultural aspects of care. If possible, Arabic doctors were sought out. Some women, however, described improved resources for health, and appreciated better women's rights as a source of power.

CONCLUSIONS

The lack of information about the structure and offers of the German healthcare system, language and culture specific barriers as well as socio-cultural challenges are undermining the ability of Syrian women to manage their health effectively after their resettlement in Germany. Providing tailored information on the German healthcare system, creating a health-literacy supportive environment, and improving cultural sensitivity in healthcare provision could help Syrian women better utilize medical care offered in Germany.

Rides for Refugees: A Transportation Assistance Pilot for Women's Health

Transportation barriers can limit access to healthcare for refugee and asylum seeking women. This study assesses the efficacy of a healthcare-directed rideshare application for overcoming these barriers at an urban health clinic. A pilot study was conducted at Boston Medical Center's Refugee Women's Health Clinic from June 2018 to February 2019. Women with gynecologic visits reporting transportation difficulties were offered rides. The primary outcome was no-show rates. Secondary outcomes included cost, and patient/provider experiences. Of 102 eligible visits, 31 reported transportation insecurity and received rides. Those women had a 6% no-show rate, compared to 30% in women denying transportation barriers, and 50% amongst unreachable women (p < 0.0001). The intervention cost $2033 and generated $30,337 in charges. Minimal adverse experiences were reported. Healthcare-directed rideshare applications are an effective and cost-efficient strategy for refugee and asylum seeking women to access essential health services.

Exploring the State of Gender-Centered Health Research in the Context of Refugee Resettlement in Canada: A Scoping Review

Interdisciplinary health research that investigates gender as a relational process is necessary to facilitate a safe and healthy resettlement process for refugees in Canada. This scoping review explores the range, nature, and extent of published research examining gender in relation to refugee health during resettlement in Canada. An initial search of six databases yielded 7325 articles published before June 2019. A total of 34 articles published between 1988 and 2019 were included for in-depth review. Articles meeting inclusion criteria primarily focused on refugee women. Categories of focus included maternal health, social and emotional health, health impacts of sexual and gender-based violence and torture, access to health and social services, decision-making and health-seeking behavior, mental health, and sexual and reproductive health. Our thematic analysis identified connections between gender roles, expectations, ideals, and health through interactions and lived experiences within the family, community, and healthcare system. Review findings suggest that many refugee women are influenced by pervasive gender roles and expectations as well as exposed to gendered health systems and practices that may pose risks to health, particularly mental health and access to services. Further efforts should be made to understand processes and experiences of resilience and community building in countering negative impacts of gendered beliefs and practices on health during resettlement.

Migrants Are Underrepresented in Mental Health and Rehabilitation Services-Survey and Register-Based Findings of Russian, Somali, and Kurdish Origin Adults in Finland

Mounting evidence suggests that migration background increases the risk of mental ill health, but that problems exist in accessing healthcare services in people of migrant origin. The present study uses a combination of register- and survey-based data to examine mental health-related health service use in three migrant origin populations as well as the correspondence between the need and use of services. The data are from the Finnish Migrant Health and Wellbeing Study (Maamu), a comprehensive cross-sectional interview and a health examination survey. A random sample consisted of 5909 working-aged adults of Russian, Somali, and Kurdish origin of which 3000 were invited to participate in the survey and the rest were drawn for a register-based approach. Some of the mental health services, based on registers, were more prevalent in the Kurdish origin group in comparison with the general population and less prevalent in the Russian and Somali origin groups. All the migrant origin groups were underrepresented in rehabilitation services. When affective symptoms were taken into account, all the migrant origin groups were underrepresented in all of the services. This calls for actions to promote mental health, diminish the barriers to access services, and improve the service paths for migrants.

Association of Neighborhood Disadvantage With Cardiovascular Risk Factors and Events Among Refugees in Denmark

IMPORTANCE

Refugees are among the most disadvantaged individuals in society, and they often have elevated risks of cardiovascular risk factors and events. Evidence is limited regarding factors that may worsen cardiovascular health among this vulnerable group.

OBJECTIVE

To test the hypothesis that refugee placement in socioeconomically disadvantaged neighborhoods is associated with increased cardiovascular risk.

DESIGN, SETTING, AND PARTICIPANTS

The study population of this quasi-experimental, registry-based cohort study included 49 305 adults 18 years and older who came to Denmark as refugees from other countries during the years of Denmark's refugee dispersal policy from 1986 to 1998. Refugees were dispersed to neighborhoods with varying degrees of socioeconomic disadvantage in an arbitrary manner conditional on observed characteristics. The association of neighborhood disadvantage on arrival with several cardiovascular outcomes in subsequent decades was evaluated using regression models that adjusted for individual, family, and municipal characteristics. Health outcomes were abstracted from the inpatient register, outpatient specialty clinic register, and prescription drug register through 2016. Data analysis was conducted from May 2018 to July 2019.

EXPOSURES

A composite index of neighborhood disadvantage was constructed using 8 neighborhood-level socioeconomic characteristics derived from Danish population register data.

MAIN OUTCOMES AND MEASURES

Primary study outcomes included hypertension, hyperlipidemia, type 2 diabetes, myocardial infarction, and stroke. Before data analysis commenced, it was hypothesized that higher levels of neighborhood disadvantage were associated with an increased risk of cardiovascular risk factors and events.

RESULTS

A total of 49 305 participants were included (median [interquartile range] age, 30.5 [24.9-39.8] years; 43.3% women). Participant region of origin included 6318 from Africa (12.8%), 7253 from Asia (14.7%), 3446 from Eastern Europe (7.0%), 5416 from Iraq (11.0%), 6206 from Iran (12.6%), 5558 from Palestine (via Lebanon, Israel, Occupied Palestinian Territories; 11.3%), and 15 108 from Yugoslavia (30.6%). Adjusted models revealed an association between placement in disadvantaged neighborhoods and increased risk of hypertension (0.71 [95% CI, 0.30-1.13] percentage points per unit of disadvantage index; P < .01), hyperlipidemia (0.44 [95% CI, 0.06-0.83] percentage points; P = .01), diabetes (0.45 [95% CI, 0.09-0.81] percentage points; P = .01), and myocardial infarction (0.14 [95% CI, 0.03-0.25] percentage points; P = .01). No association was found for stroke. Individuals who arrived in Denmark before age 35 years had an increased risk of hyperlipidemia (1.16 [95% CI, 0.41-1.92] percentage points; P < .01), and there were no differences by sex.

CONCLUSIONS AND RELEVANCE

In this quasi-experimental cohort study, neighborhood disadvantage was associated with increased cardiovascular risk in a relatively young population of refugees. Neighborhood characteristics may be an important consideration when refugees are placed by resettlement agencies and host countries. Future work should examine additional health outcomes as well as potential mediating pathways to target future interventions (eg, neighborhood ease of walking, employment opportunities).

Migrant Women-experiences from the Mediterranean Region

Introduction:

The phenomenon of migration is characterized and influenced by a number of different variables; and the different stages of journey are related to different levels and types of psychological distress. Women, in particular, are exposed to further specific risks during migration.

Aim:

To determine the factors that affect the psychological health of migrant women during the different stages of the migration journey.

Methods:

We provide a narrative review of the literature around the experiences of women during migration process, with a geographical focus on women migrating to the Mediterranean area.

Results:

Little data is currently available on the burden of mental health disorders for female migrants. Most studies about the mental health status of migrants were not gender-disaggregated or focused specifically on migrant women’s experiences of violence. Sexual and Gender-Based Violence (SGBV) was found to be a common risk factor faced by all the women who leave their native country to migrate to other countries.

Conclusion:

Despite the importance of the issue and the gender-specific variables related to the experience of migrant women, few studies have looked specifically at psychological variables and mental health status in the female migrant population. It is crucial that future studies are conducted around female migration, violence towards women, and women’s mental health, in order to provide an evidence-base for promoting adequate policies and prevention/treatment programs for women.

Prevalence and determinants of perinatal depression among labour migrant and refugee women on the Thai-Myanmar border: a cohort study

BACKGROUND

Perinatal depression is a significant contributor to maternal morbidity and mortality globally. Migrant women, particularly those living in low- and middle-income settings, represent a particularly vulnerable group due to stressors experienced before, during and after migration. The vast majority of global migration flows occurring within and between low- and middle-income regions, yet existing evidence focuses predominantly on migrants in high-income destinations. This study aimed to redress this significant gap in the evidence by determining the prevalence and determinants of perinatal depression among migrant women on the Thai-Myanmar border.

METHODS

A cohort of labour migrant and refugee women was followed-up from the first trimester of pregnancy to one month post-partum. Depression status was assessed in the first, second and third trimesters of pregnancy and at one month post-partum using the Structured Clinical Interview for the Diagnosis of DSM-IV Disorders. Women diagnosed with depression had immediate access to care. Data on potential demographic, social and clinical associated factors was collected using a questionnaire. Prevalence and incidence of any depressive disorder and moderate-severe depressive disorder was calculated. Univariable and multivariable logistic regression using complete case analysis was used to estimate odds ratios (OR) of association between exposure variables and depression status.

RESULTS

Five hundred sixty-eight women participated. Period prevalence (from first trimester of pregnancy to one month post-partum) of moderate-severe perinatal depression was 18.5% (95% CI 15.4-21.9%). Overall, 15.4% (95% CI 11.8-19.6%) of women developed new-onset moderate-severe depression during the study period. Forty-two participants received treatment for depression. Risk factors were interpersonal violence (OR 4.5; 95% CI 1.9-11.1); history of trauma (OR 2.4; 95% CI 1.4-4.3); self-reported history of depression (OR 2.3; 95% CI 1.2-4.2); labour migrant status (OR 2.1; 95% CI 1.1-4.0); low social support (OR 2.1; 95% CI 1.1-3.7); and maternal age (OR 1.1 per year; 95% CI 1.0-1.1). Limitations of the study include that culturally specific manifestations of depression may have been missed.

CONCLUSIONS

Perinatal depression represents a significant burden among migrant women on the Thai-Myanmar border. Programmes to address the determinants along with early case identification and effective treatment and referral systems are key to addressing perinatal depression in this low-resource setting.

Understanding the healthcare experiences and needs of African immigrants in the United States: a scoping review

BACKGROUND

Africans immigrants in the United States are the least-studied immigrant group, despite the research and policy efforts to address health disparities within immigrant communities. Although their healthcare experiences and needs are unique, they are often included in the "black" category, along with other phenotypically-similar groups. This process makes utilizing research data to make critical healthcare decisions specifically targeting African immigrants, difficult. The purpose of this Scoping Review was to examine extant information about African immigrant health in the U.S., in order to develop lines of inquiry using the identified knowledge-gaps.

METHODS

Literature published in the English language between 1980 and 2016 were reviewed in five stages: (1) identification of the question and (b) relevant studies, (c) screening, (d) data extraction and synthesis, and (e) results. Databases used included EBSCO, ProQuest, PubMed, and Google Scholar (hand-search). The articles were reviewed according to title and abstract, and studies deemed relevant were reviewed as full-text articles. Data was extracted from the selected articles using the inductive approach, which was based on the comprehensive reading and interpretive analysis of the organically emerging themes. Finally, the results from the selected articles were presented in a narrative format.

RESULTS

Culture, religion, and spirituality were identified as intertwined key contributors to the healthcare experiences of African immigrants. In addition, lack of culturally-competent healthcare, distrust, and complexity, of the U.S. health system, and the exorbitant cost of care, were identified as major healthcare access barriers.

CONCLUSION

Knowledge about African immigrant health in the U.S. is scarce, with available literature mainly focusing on databases, which make it difficult to identify African immigrants. To our knowledge, this is the first Scoping Review pertaining to the healthcare experiences and needs of African immigrants in the U.S.

Health-Related Needs and Barriers for Forcibly Displaced Women: A Systematic Review

The number of forcibly displaced people has been steadily increasing over the last decades. Women represent a large proportion of this population. Due to gender roles, duties of care, educational and economic imbalances, their experiences during flight and relocation differ from those of men and children. The currently available information about their specific health-related needs and barriers to access is scarce. We sought to explore the specific needs of the female refugee population employing a user-centered perspective. Rather than focusing on provider-designed interventions, we aimed at defining what female refugees want and need and which priorities they define themselves.

We searched PubMed, Medline, EMBASE, Cochrane Library, and Scopus to identify publications that explored the unique experiences of female refugees between January 1, 2008 and June 30, 2018. Publications needed to address the health needs of refugees, asylum seekers, or displaced individuals, include at least 50% women in their study and employ a user-centered perspective. A framework of themes was identified and applied to all publications.

We identified 1945 publications of which 13 could be included in the present review. Twelve of these publications employed qualitative and/or innovative methodology. We identified 5 broad categories of health-related needs (immediate health care, communication, cultural/spiritual, social, and economic).

The identified publications described the need for complex, coordinated approaches. Concerted action providing information and culturally sensitive care, while supporting language acquisition and economic empowerment is essential to improve the health status of female refugees. Transformative interventions need to address multiple axes of unequal access for female refugees to improve their overall health.

Refugee women's experience of the resettlement process: a qualitative study

Background

Resettlement can be particularly challenging for women as having a lower socioeconomic status and language barriers, may impede women’s access to education, employment opportunities, health-care services, as well as the cultural, social, material and resilience factors that facilitate adjustment and adaption. Thus, the aim of this study is to further explore the perception of refugee women in Sweden concerning their situation during active participation in the resettlement process in the country.

Methods

Qualitative interview study with 11 recently arrived refugee women who had received their residence permits and were enrolled in the resettlement process. The interviews were conducted in Swedish with the support of an authorized Arabic translator present by telephone.

Results

Refugee women suffered from being separated from their loved ones and felt compelled to achieve something of value in the host country. All experienced both physical and mental anguish.

Conclusions

Stakeholders in societies that receive refugee women should stress the importance of finding opportunities for and fast entrance into employment in the host countries. This would be beneficial for the integration and well-being of refugee women after migration.

"I'm a Mother Who Always Tries to Give My Children Hope"-Refugee Women's Experiences of Their Children's Mental Health

Background: The prevalence of mental health problems is high among refugee children. Childhood mental health problems have long-term negative consequences and costs both for the individual child and society. The present study aimed to explore refugee parents' experiences of their children's mental health. Methodology: A qualitative explorative study was conducted. Data were collected through semistructured interviews with nine refugee mothers who have been in Sweden less than 5 years and with at least one child in the ages 8-14 years. Data were analyzed inductively using thematic network analysis. Results: The global theme that emerged from the analysis was Navigating the moving landscape of forced migration, which described the refugee mothers' experiences of the previous adversity the family went through, the ongoing transition in the new context, and, lastly, the pathways to promote their children's mental health. Two organizing themes described mothers' and children's navigation of the forced migration: Previous adverse events and new suffering and Promoting children's well-being. Mothers described aggression and frequent conflicts, or refusal to play or eat, in their children related to living conditions at asylum centres and social isolation. This improved when children started school and possibilities of social relations increased. Mothers' own mental health and lack of language skills could also have a negative impact on the children. To focus on the present and have hope of the future was helpful to the children. Encouragement and social support from parents, teachers, and friends promoted children's well-being. Conclusion: The role of the host country in the promotion of the mental health of refugee children is emphasized. Interventions aimed to improve peer relations and reduce discrimination are needed, and these point to the school as a potential arena for positive change. Parental support groups were also mentioned as helpful in understanding the children's need for support.

Discourse of nurses and doctors on the use of the emergency service by immigrants

Abstract Objective: To describe the discourse of nurses and physicians on the use of emergency services by immigrants. Method: Descriptive and exploratory study, with qualitative approach, carried out inan emergency public unit located at the north of Paraná. Sixteen health professionals were interviewed through a semi-structured questions. The interviews were audio-taped and their contents, after transcription, submitted to French discourse analysis. Results: It was identified, according to professionals, that immigrants seek emergency services mainly due to work-related problems, because they are unaware on how the Brazilian health system works and because they have difficulties to access other services. In addition, communication, cultural, professional, socioeconomic, and prejudice barriers were highlighted as influencing the care for the immigrant population. Conclusion and implications for practice: Given such findings, it is imperative to develop orientation and preparation activities for the immigrant population on the Brazilian culture and health system and health professionals regarding the cultural and socio-sanitary profile of the immigrant population, thus enhancing the adequate search of the users and the qualified care.

Refugee women's experiences negotiating motherhood and maternity care in a new country: A meta-ethnographic review

OBJECTIVES

The aim of this meta-ethnographic review was to examine refugee women's experiences negotiating motherhood and maternity services in a new country with a view to identifying the specific needs of refugee women accessing maternity care in high income countries.

DESIGN

A meta-ethnographic synthesis of qualitative research.

DATA SOURCES

Five databases were searched for papers published in English between January 2000 and January 2017.

REVIEW METHODS

The synthesis process was guided by the seven steps of meta-ethnography. The quality of included studies was assessed using the COREQ tool.

RESULTS

One overarching theme and three major themes emerged from the synthesis. The overarching theme "Living between two cultures" conveyed women's experience of feeling "in between" cultures and described refugee women's experience of striving to maintain a strong cultural identity from their country of origin while simultaneously adapting to their new context and country. This theme permeated the following three major themes: 1) "Constructing maternal identity across cultures" which discusses the cultural conflict experienced by refugees accessing maternity services in their host country; 2) "Understanding in practice" which describes reciprocal issues in communication between women and health professionals; and 3) "Negotiating care" which illustrates a mix of coping mechanisms which refugee women utilise to navigate health services in the context of high income countries.

CONCLUSION

Liminality is a ubiquitous experience for refugee women seeking maternity care in high income countries. It impacts feelings of belonging and connection to services and society. It is often a challenging experience for many women and a time in which they reformulate their identity as a citizen and a mother. This review found that the experience of liminality could be perpetuated by social factors, and inequality of healthcare provision, where communication and cultural barriers prevented women accessing care that was equal, accessible, and meaningful. Findings revealed both positive and negative experiences with maternity care. Continuity, culturally appropriate care, and healthcare relationships played an important role in the positive experiences of women. The review also revealed the damaging effects of disparities in care experienced by refugee women.

Healthcare needs and health service utilization by Syrian refugee women in Toronto

Objective

Access to healthcare is an important part of the (re)settlement process for Syrian refugees in Canada. There is growing concern about the healthcare needs of the 54,560 Syrian refugees who were admitted to Canada by May 2018, 80% of whom are women and children. We explored the healthcare needs of newcomer Syrian women, their experiences in accessing and using health services, and the factors and conditions that shape whether and how they access and utilize health services in the Greater Toronto Area (GTA).

Method

This community-based qualitative descriptive interpretive study was informed by Yang & Hwang (2016) health service utilization framework. Focus group discussions were held with 58 Syrian newcomer women in the GTA. These discussions were conducted in Arabic, audio-recorded with participants’ consent, translated into English and transcribed, and analyzed using thematic analysis.

Results

Participants’ health concerns included chronic, long-term conditions as well as new and emerging issues. Initial health insurance and coverage were enabling factors to access to services, while language and social disconnection were barriers. Other factors, such as beliefs about naturopathic medicine, settlement in suburban areas with limited public transportation, and lack of linguistically, culturally, and gender-appropriate services negatively affected access to and use of healthcare services.

Conclusion

Responding to the healthcare needs of Syrian newcomer women in a timely and comprehensive manner requires coordinated, multi-sector initiatives that can address the financial, social, and structural barriers to their access and use of services.