Syrian refugee women are more likely to experience mental illness due to various obstacles and barriers. Some of these barriers are from past physical and mental trauma, feelings of isolation from lost family support, language and culture difficulties, and the social stigma associated with mental illness.
Imagine you’re a pregnant, female Syrian refugee, being forced to relocate from the war-torn country in which you were born and raised. Leaving all your family and friends behind or experiencing the horrific death of a loved one. According to Dench (2012), “Refugees often arrive to Canada with serious health problems as a consequence of the persecution they have suffered such as the physical and psychological effects of torture or rape” (p. 44). Experiences like this can increase a female refugee’s risk for various mental health issues that have long lasting effects. Some refugee women come from refugee camps before relocating to Canada where they can experience various forms of sexual and physical violence, trauma and the death of loved ones (Ahmed, Bowen & Xin Feng, 2017). Female refugees can also arrive to their new country pregnant as a result of being raped, or having been the victim of human trafficking, forced prostitution or slavery (McCarthy & Haith, 2013). Exposures to violence can also put them at risk for post-traumatic stress disorder (PTSD). Refugees from unstable homelands are prone to suffering higher levels of PTSD than returning combat veterans and are 10 times more likely to experience PTSD as compared to the general population (Heavey, 2014). Experiencing PTSD while being pregnant could negatively affect the bonding between mother and baby and increase the risk of postpartum depression. Despite witnessing all of the trauma, violence, murders or bomb explosions just to name a few, the refugee is usually not receptive to receiving psychological help. Instead, they would rather just forget about it (Garakasha, 2014).
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Being torn away and forced to relocate from your country can result in feelings of isolation. There can be a loss of family support especially during the postpartum period which makes the female refugee feel socially isolated, lonely and bring up feelings of uncertainty which can lead to a decline in the refugee woman’s physical and mental health (McCarthy & Haith, 2013). Language difficulties can also prevent the female refugee from participating in social activities which brings about further isolation. Additionally, the common roles of the female refugee change drastically in their new country. Consequently, they feel powerless because of the loss of their social support network, leaving them more dependent on their significant other thus increasing the risk of abuse (Ahmed et al., 2017).
A majority of Syrian refugees are of the Muslim faith, and for many of them, there is a deep stigma associated with mental illness (Ahmed et al., 2017). It is believed that healing should come from religious faith. Mental illness can be seen as a lack of faith or a shift from the right path as well as a personal flaw, which can bring shame upon family and friends (Ahmed et al., 2017). This stigma can be a huge barrier for seeking mental health care. Being shamed for mental illness can be very embarrassing, putting the female refugee at risk for sexual violence, harassment and depression.
Furthermore, there are many cultural and ethnical barriers in caring for a female Syrian woman. Researchers found that, “Given their experiences, refugee women may distrust care providers, be resistant to North American healthcare practices and procedures and face communication barriers with their providers” (Winn, Hetherington & Tough, 2018 p. 2). In turn, the pregnant refugee will be less likely to seek the help they need. Not participating in prenatal or postpartum care could negatively affect the mother and babies’ physical and mental health. The communication barrier these women face can make even the simplest tasks in life seem overwhelming. Imagine trying to find a job, transportation, navigating the healthcare and dealing with legal responsibilities without knowing the language. This can wreak havoc on a female refugee’s overall mental wellbeing. Discrimination against the Arabic ethnicity can also play a negative factor due to the false belief that most Muslims are terrorists. Being treated poorly because of one’s ethnicity may cause a major amount of stress and could result in an individual becoming more isolated as well as developing a greater risk for maternal depression. Another cultural barrier a female refugee may face is acculturation or the fear of losing one’s culture and traditions which can cause the refugee much stress and hinder them from obtaining healthcare services (Garakasha, 2014).
There are many barriers to obtaining local, state and national healthcare services that a pregnant or postpartum refugee may encounter. Language issues are a deterrent in whether they choose to seek healthcare. In a recent study of health service utilization by Syrian refugee women, it was found they were not consistently provided interpretation services nor were qualified interpreters even available (Guruge et al., 2018). In a 2018 interview with various health care providers discussing barriers to healthcare for pregnant refugee women, researchers found inadequate resources available for pregnant refugee women in Calgary (Winn, et al., 2018). The participants in this study also reveal how complicated the healthcare system can be for these patients to figure out, especially if they have lack of a support group as well as language difficulties (Winn et al., 2018). A further barrier to healthcare for pregnant refugees is the specific category in which the refugee is admitted into Canada. “Those who come as claimants have a lot more barriers I think in Canada, than you know, private and government sponsored refugees” (Winn et al., 2018, p. 7).
Some strategies for successfully communicating with a Syrian, female, refugee patient is making them feel comfortable and not overwhelmed because they may likely have had a very difficult experience relocating from their home country. Being non-judgmental is also important because it makes the nurse more approachable. If English is their second language, the nurse should try to have an interpreter in the room with the female refugee (Heavey, 2019). This will help facilitate communication back and forth between the patient, doctor and nurses which can help decrease the patient’s anxiety and frustration. Having an interpreter present will also help develop the doctor to patient relationship, and the patient will be more willing to attend prenatal and postpartum appointments, as well as, participate in patient teaching regarding maternal depression signs and symptoms. A possible strategy to help with the language difficulties and understanding would be to have the patient repeat back the information that the doctor has given them, draw maps or use visual aids (Winn, et. al., 2018).
Being culturally competent is also very important to the nurse when it comes to communicating with the female refugee. This means being respectful and responsive to their health beliefs and practices, as well as their cultural needs, which will help the nurse interact more effectively with the female refugee. The family dynamic is important to know so the nurse can better communicate with the patient and their family members. Syrian families are very close knit and patriarchal. Consequently, the eldest male has the final decision-making authority and is seen as the family protector (Center for Disease, 2016). Therefore, when asking for a decision regarding a medical issue, it should not be a surprise that the husband makes the final decision regarding his wife’s care.
When applying strategies for incorporating cultural information into the nursing process, the first thing the nurse should do is become culturally informed by researching the Syrian culture so as to know more about their preferences, attitudes, and expectations regarding cultural norms and healthcare in general. According to the website, www.cdc.gov, under Syrian Refugee Health Profile (2016), there are many reasons why Syrian patients, or their families, may become more likely than the general U.S. patient population, to prefer a provider of the same gender or to request a long hospital gown for modesty. The nurse should be sure to make meal requests in accordance with Islamic dietary restrictions during hospital stays or even request family members to bring specific meals. Also, the nurse should be aware that specific medical practices may be refused during certain periods of religious observance such as the month of Ramadan. During the nurse’s assessment and while gathering your data, be sensitive to the fact that the female refugee may not be open to questions regarding issues of sex, or sexually transmitted diseases. Syrians are also more likely to decline consent for organ donation or autopsy (Center for Disease Control, 2016). Implementing these cultural norms regarding care for the female refugee may help to put her at ease, decrease her stress level and feel more respected as an individual. Cultural competency is an integral part of holistic patient care.
A nurse’s role in reducing health disparities in Syrian female refugees at risk for mental health issues starts with being patient, listening, and providing extra time to establish a safe and trusting relationship to help them overcome any fears of seeking healthcare for themselves. Again, being culturally competent and respecting the cultural background and practices of the patient is important and will help put them at ease. The nurse should always have interpreters available if possible, to assist them in navigating through the unknowns which is also part of being a patient advocate. Introducing them to other Syrian refugees that have been through the same circumstances can be beneficial to their mental health, as well as connecting them with a mental health specialist, that speaks their Arabic language.
In conclusion, I admit when I see a person of Arabic descent the first thing that comes to my mind is “terrorist” even though I know deep inside that this isn’t the case. This has been instilled in me since watching the news about terrorists, starting on Sept 11, 2001, which has dominated the television for well over a decade. I don’t want to be the kind of nurse that treats someone differently because of their ethnicity or culture. I don’t want to see all Syrians through the same distrusting lens. It’s always good, as a nurse, to be self-aware which involves not only examining one’s culture but also examining perceptions and assumptions regarding your patients’ culture. Developing self-awareness can bring my own bias into light and shed a light on how this might affect me personally and my work.
Reference
- Ahmed, A., Bowen, A., & Feng, C. X. (2017). Maternal depression in Syrian refugee women recently moved to Canada: A preliminary study. BMC Pregnancy and Childbirth, 17(1). doi:10.1186/s12884-017-1433-2.
- Centers for Disease Control and Prevention. (2016). Syrian Refugee Health Profile. Retrieved from https://www.cdc.gov/immigrantrefugeehealth/pdf/syrian-health-profile.pdf.
- Dench, J. (2012). Recognizing refugees as human beings. Canadian Nurse, 108(8), 44. http://ezproxy.library.skagit.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=c8h&AN=108105093&site=ehost-live. Accessed March 13, 2019.
- Garakasha, N. (2014). Working with refugee young people: a nurse’s perspective. Australian Journal of Advanced Nursing, 32(2):24-31.
- Guruge, S., Sidani, S., Illesinghe, V., Younes, R., Bukhari, H., Altenberg, J., Rashid, M., Fredericks, S. (2018). Healthcare needs and health service utilization by Syrian refugee women in Toronto. Conflict and Health, 12(46), doi:10.1186/s13031-018-0181-x.
- Heavey, E. (2014). Female refugees: sensitive care needed. Nursing 2019, 44(3), 28-34.
- McCarthy, R., & Haith-Cooper, M. (2013). Evaluating the impact of befriending for pregnant asylum-seeking and refugee women. British Journal of Midwifery, 21(6), 404-409. doi:10.12968/bjom.2013.21.6.404.
- Winn, A., Hetherington, E., & Tough, S. (2018). Caring for pregnant refugee women in a turbulent policy landscape: perspectives of health care professionals in Calgary, Alberta. International Journal for Equity in Health. 17(91). Retrieved from https://doi.org/10.1186/s12939-018-0801-5.
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