Abstract
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.
Introduction
The most recent statistics from the United Nations High Commissioner for Refugees (UNHCR) estimate that currently about 69 million people live in a situation of displacement worldwide. 1 These people are classified as asylum seekers, if they apply for refugee status in a country other than the one of their origin, and refugees if they have been granted the status. In addition, individuals can move within their country of origin as internally displaced people or move to other countries as migrants, that is, without applying for asylum. 2
Conflict-related displacement has affected Africa and the Middle East for several decades, while Europe, Northern America, and Australia have limited the influx of refugees into their territories. In the years 2015/2016, Europe has experienced the largest mass migrations since World War II and was dramatically unprepared in meeting the needs of these populations. Given the instability of the geopolitical situation in many regions of the world and the growing impact of climate change, flight, migration, and displacement within countries are expected to increase. 3 Accepting nations will be called to provide adequate supporting services, such as health care and social support, and ensure the fundamental right to health to facilitate long-term integration for the incoming.
Health-care represents an essential need of the refugee population 4,5 in the acute postarrival phase as well as in the long-term integration phase. Upon the assessment of needs and necessary interventions, subgroups are rarely taken into account. Women represent a particularly exposed group among refugees due to their gender roles, care duties, and physical vulnerability. Many of the fleeing women have had limited access to education in their home countries, making them logistically, economically, and physically dependent on their partners. 6 They frequently bare the sole responsibility of care for children and elderly limiting their mobility and social participation beyond their immediate family. Finally, women are at higher risk for all forms of violence, domestic, physical, and sexual, compared to male refugees. 7 -9
While the Geneva Refugee Convention in 1951 did not specifically mention gender as a source of vulnerability, in more recent years, the UNHCR identified the higher protection needs of women as a policy priority and explicitly mentioned gender as a relevant criterion in the asylum application process. 10,11 Nevertheless, research into the specific needs of women and the development of tailored offers are lagging behind. This review will assemble the current knowledge about the health-related needs of female refugees to aid the development of future gender-sensitive programs and interventions. We will only focus on studies that address female refugees’ health needs from their own perspective, not from the perspective of health-care providers. Any methodology that serves this purpose will be taken into consideration and descriptive as well as interventional studies will be considered.
Methods
Research Question and Eligibility Criteria
We designed the following review to highlight the specific health needs of female refugees, asylum seekers, and displaced individuals.
Articles were included if (1) they addressed health needs of female refugees, asylum seekers, or displaced individuals, (2) the included population was mostly female (ie, more than 50% of the participants identified as women), (3) described the experience from the perspective of the affected population and not of their health providers, and (4) were original publications.
“Health care” was conceptualized as any intervention contributing to health and well-being and directed toward the reduction of disease/illness. Thus, next to medical interventions, preventative efforts, such as health promotion programs and community-based interventions were also included.
Search Strategy
We developed the applied search strategy in consultation with a health librarian at our institution. We searched PubMed, Medline, EMBASE, Cochrane Library, and Scopus using the terms and keywords ([refuge* OR asylum* OR newcomer* OR displaced*] AND [femal* OR woman OR women] AND health AND need) and identified all relevant publications published between January 1, 2008 and June 30, 2018 in English language. The initial search was conducted on February 27, 2018, a follow-up search on July 4, 2018. In addition, we searched the reference lists of the included articles for potential other relevant publications. Article titles and abstracts were reviewed by 2 researchers (Z.W. and S.O.P.). If they disagreed on meeting of the inclusion criteria, the agreement was reached by discussion and feedback from a third reviewer (J.J.).
Data Analysis
We collected, analyzed, and reported data according to the Preferred Reporting Items for Systematic Reviews guidelines, 12 however, the identified literature consists mostly of small qualitative studies, which limit the application of some of its criteria. Research about sensitive issues conducted with vulnerable populations under logistic constraints limits the opportunity to produce large, “high-quality” studies. Since our objective was collecting data from a user-centered perspective, the methodologies applied within the studies differ from the ones typically employed in well-controlled clinical settings. All identified articles are reported (Table 1). The included qualitative papers were read in detail by 1 reviewer (S.O.P.) to define a model. This was compared to an independent classification by another reviewer (J.J.) to ensure consistency of the identified themes. The derived themes were applied to all selected publications and data extracted. We collected information on settings, countries surveyed, sex distribution of the included population, origin of the researchers, size of the studied population, methodology, and primary health-related issues identified. Bias was not specifically assessed given the nature of the included studies, yet the limitations derived by methodology will be addressed in the discussion.
Summary information about the included articles.
Abbreviations: DRC, Democratic Republic of Congo; HC, health care; IDP, internally displaced person.
Results
General Results and Methodological Considerations
Work with displaced populations is characterized by a degree of complexity that exceeds many other forms of human-centered research. The population investigated is frequently on the move and living in precarious situations, 3 which might shift their choices and priorities compared to a stable living situation. Organizing research with a highly mobile and vulnerable population under economic constraint is a logistic challenge as well as an ethical one. 13,14 Language and culture might be very diverse in a single sample, mandating adaptation of research methodology and requiring a substantial degree of flexibility and empathy. Furthermore, the investigation of the needs of specific subgroups, in our case women, is not a priority and this reflects on the funding opportunities. 15 All these factors can impact methodological choices, sample size, timing, and incentives.
Our initial search identified 3191 articles. After screening, removal of duplicates, and application of inclusion criteria, 13 articles remained (Figure 1) from 13 different research groups. Researcher originated primarily from Australia. The represented refugee populations were very diverse, including women from the Middle-East, Central and Eastern Africa, and South-East Asia. Women represented between 60% and 100% of the study population and participant numbers ranged from 6 to 1383 individuals. Twelve of the 13 included articles employed qualitative methodology, only 1 was a large quantitative survey. Most research was exploratory and frequently based on techniques that would bridge cultural and linguistic barriers, such as ethnographies, 16 the use of pictures and index cards, 17 and photovoice. 16 The challenges of conducting a randomized controlled trial with refugees have been reported elsewhere. 13
Selection flow of inclusion.
Our thematic analysis identified 5 health-related domains: direct health-care needs and barriers, communication needs and barriers, cultural/spiritual needs and barriers, social/family needs and barriers, and economical needs and barriers.
Direct Health-Care Needs and Barriers
The fulfillment of health-care needs hinges on access to services, which in most Western countries is associated with the availability of health-care insurance. Insurance for asylum seekers and refugees is subject to different regulations in different countries but frequently limited in its extension. Furthermore, some countries extend insurance for families, placing women in a dependent position toward the head of the household. 18 Access to services is limited by two factors: national rules for the provision of services, that is, certain services are covered according to the insurance plan accessible to refugees and others are for-payment only, 16,19 and understanding of the functioning of the health-care provision. 17,20 -22 This can be limited due to language barriers or to the difficulties associated with navigating an unknown system. 20
Next to the structural limitations in access, barriers also emerge when contact with health-care providers is established. These might be due, for example, to the request of a gender congruent service based on cultural or religious precepts. Many of the issues addressed by women are related to the obstetric and gynecological domain and associated with culture-specific taboos. 23 Women frequently report that sexuality cannot be explicitly addressed, neither with family members nor with health-care professionals. 19 Taboos around sexuality include themes ranging from menstruation to intercourse to contraception to sex work. 23 -25 Female genital mutilation is also common and might represent a clinical challenge for inexperienced physicians.
Presence of these taboos associates with misinformation and unconscious risk behavior. 23 Misconceptions about menstruation, its function and management, safe intercourse, and contraception are frequently reported. For example, girls confound menarche with injury or bleeding, young women are not informed about the relationship between intercourse and pregnancy 23,25 and might not know that condoms cannot be used more than once. 24 Lack of knowledge limits female agency making women vulnerable to disease, but also abuse and violence. Violence in general and specifically domestic violence are common in the female refugee population, yet often go underreported due to patriarchal concepts of consent. 19,23 Women comply with culturally set and socially acceptable marital duties without questioning their acceptability and the opportunity to refuse to adhere to them.
Integration into the host societies frequently reduces these taboos and offers women the opportunity to obtain information and a degree of emancipation. 23 This emancipation, however, challenges formerly accepted gender roles and might be a source of conflict within the family.
Communication
Communication, specifically language barriers, is one of the most frequently mentioned hurdles for integration and successful meeting of health-care needs. 16,19,20,22 Women have been identified as frequently lagging behind in language acquisition due to several factors. These are, among others, no access to language courses, unavailability of courses close to their housing, unavailability of childcare during the courses and specific needs not being met, for example, a desire for gender-homogenous groups.
Lack of language skills lead to reduced health literacy and long-term dependency on others for effective communication. Specifically, women will not be able to understand health-care information in any form (oral, written, or communicated through other media) in the language of their host country. 19,20 This leads to a persistent dependency on translation and interpreter services. Interpreter services are not structurally provided in many contexts and even if translators are available, distrust in their abilities, or intentions might be present. 16,20,22 Sometimes, this is due to the translator being from a rival ethnic group in the home country or to simple distrust in the translation process. Women consequently recur to engaging family members and friends as translators 16,20,22 limiting the breadth of subjects that can be openly discussed with the health-care provider. For example, if children take up the role of translators any discussion about reproduction, contraception, or sexuality will not be addressed. If asked about their preferences for health communication materials, pictorial designs and web-based information were favored. 17
Cultural/Spiritual Aspects
The main cultural differences described lie within the conceptualization of health and disease overall in different cultures. Many non-Western cultures conceive health in a holistic manner and refugees struggle with the pragmatic, disease-oriented approach in the countries of arrival. 20,22,26,27 This specifically reflects the perception that health-care professionals in the host countries do not dedicate enough time to understanding the illness presented. 20
Several themes might also constitute taboos in the country of origin and are, hence, never spontaneously addressed during consultation. These are specifically relevant to the areas of mental health, sexuality, and HIV. 22 -24,26,27 Sexual activity, sexually transmitted diseases including HIV, and the performance of sex work, all fall within this range. In addition, cultural differences strongly influence ideas about family setup, gendered roles and behaviors, affecting health-related factors such as, for example, the negotiation of consent. 23
Religion and spirituality also play an important role in the perception of health and, most importantly, in the degree of agency ascribed to the individual in the management of their health. 23,27 Strong religious beliefs can lead to a degree of fatalism and assumption that sickness and health are given and cannot be controlled by human action. Religious competence can, however, be productively employed to promote prevention in accordance with religious precepts. 18
Social Networks/Family
Family separation represents one of the primary sources of distress for refugee women 19,22,27 and has been linked to a deterioration of mental health, ranging from sadness and grieving to depression. 22,28 The presence of social networks, on the other hand, is perceived as a source of support. 16 The main consequence of family separations is an increase in vulnerability for the women affected, psychologically and physically. Women have less support to cope with the stress of the flight and resettlement and lack support for childrearing activities. 22 Severed from the sociocultural context of origin, they have feel fear, insecurity, and question their ability to transmit cultural practices to their children. 27 This increases stress and reduces resilience. Physically, women without a male partner of a family member are more vulnerable to all forms of violence, abuse, and aggression in the context of displacement. 28 However, shifts in gender roles towards more male participation were also experienced due to the new environment. 27 Some female refugees perceived that single female providers obtained more support than families. 26
Economic Aspects
Women are consistently reported as having less access to the job market in their host countries than men. 22,26,28 This is due to several factors, from gender role perceptions to lack of provision of adequate courses. In the present context, we will not review this issue but only refer to the health-related aspects. Lack of job-related social integration leads to less support from peers, less access to health-relevant knowledge, and less integration. 21,22 Women remain dependent on social services or on a male provider, which places them at higher risk for abuse, for example, domestic violence, and limits their ability to leave a violent context with their children. 21 If women are excluded from the job market, they might be driven into sex work, which significantly increases their health risks. 24
Discussion
Female refugees have unique health-related needs. Although all refugees display a similar range of necessities, the underlying priorities and vulnerabilities differ according to gender. Our present data offer a more nuanced description of these vulnerabilities, allowing us to define priorities for gender-sensitive action.
From a medical perspective, the following areas will need to be prioritized through the provision of adequate knowledge and specific services: reproductive health, mental health, and infectious diseases. Most of the displaced women are of reproductive age, 1 thus, adequate care represents an essential priority for this population. 29 However, the identified literature emphasizes how female and reproductive health topics are commonly associated with various degrees of taboo and stigma. This needs to be taken into account when designing targeted offers. Women will only engage in preventative measures, contraceptive, and maternal care, if they are allowed to address cultural perceptions in a safe space. The identified literature highlights how a lack of knowledge of basic reproductive functions frequently impairs the ability to even recognize, for example, contraceptive and menstrual health needs. 23,25 Since female health needs and health risks potentially increase in a situation of displacement, solutions that systematically combine information and service provision should be prioritized. As one of the cited studies demonstrated, the training of health operators within a refugee camp can represent an opportunity to provide knowledge, expose misconceptions, and empower women. 24
To bridge cultural and knowledge barriers, reliable and culturally competent translation services are needed while concurrently ensuring maximum confidentiality. Bodily functions or complaints are not directly addressed in many cultures where illness is described through idioms of distress instead. 30 The interpreter needs to collect this hidden information and make it available to the health-care provider in order to aid the understanding and building of rapport. This is of particular importance for taboo themes, like sexuality, domestic violence, or infectious diseases. Furthermore, absolute confidentiality needs to be guaranteed as stigma could compromise the safety of the client in her social circle.
Most importantly, the examined literature demonstrates how the specific vulnerability of women is rooted in interrelated forms of lack of access. Women lack access to education, which limits their access and ability to process health information. Their lack of access to education also limits their opportunities in the workforce, which reduces their economic means, which in turn correlates with health itself and access to services. These inequalities are established in the societies of origin of many of the women, but the flight and displacement process exacerbates their consequences in the form of poor physical, mental, and reproductive health. 31,32 Furthermore, host countries generally provide services to refugees under the assumption that their permanence will be limited in time. Yet statistics demonstrate how currently refugees can be expected to remain in the host country for a decade or longer. 33 Services should be designed with this reality in mind.
The described lack of access is rooted in stereotypical gender roles, which restrict women’s opportunities, both within the country of origin and potentially in the host country. Addressing these gender roles and their consequences for health is imperative, yet, challenging these roles also represents a potential source of conflict. Depending on the gender norms in the host country, women might question their traditional roles and engage in a more emancipated lifestyle. 34 Some of their partners might encourage this transition and increasingly engage, for example, in care duty 27 themselves, but others might feel challenged in their self-worth and authority. This might lead to conflict within the partnership and in some cases, even trigger domestic violence. 7,35
To our knowledge, the current review is the first of its kind and several methodological challenges have to be pointed out. Research with refugees is complicated by potential linguistic, logistic, ethical, and economic hurdles, which reflect on the size and the methodology applied. Furthermore, many studies address the perspectives of health-care providers or the logistics of health-care access from a systemic perspective, but very few investigate the refugees’ own priorities and needs. Most of the studies included had a limited sample size and an uneven geographical distribution. Samples were frequently convenience-based and methodological choices had to be made to accommodate potential language and culture barriers. Thus, our results cannot be generalized to the same extent as large quantitative studies would have permitted. Nevertheless, the data gathered provide a richness and depth that qualitative studies would have missed.
Conclusions
The presented literature highlights how a concerted action providing information and culturally sensitive care, while supporting language acquisition and economic empowerment, is essential in improving the health status of female refugees. An increase in participation could furthermore empower them and decrease the costs of care during their permanence, as they would be more reliant on their own means rather than solely dependent on the host country. Transformative interventions should recognize these interrelations and concurrently address multiple axes of unequal access for female refugees to increase both participation and overall health.
Footnotes
Authors’ Notes
S.O.P. designed the study, J.J. and Z.W. acquired data, J.J., Z.W., S.O.P. analyzed the data, S.O.P. drafted the manuscript, J.J. and Z.W. reviewed the manuscript for important intellectual content, S.O.P. acquired funding. All authors have read and approved the manuscript. All data generated or analyzed during this study are included in this published article.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The current study was funded by the German Ministry of Research and Education [BMBF-03101638]. The funding organizations had no role in design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
