Social Determinants of Mental "Ill Health": Addressing the Needs of Refugee Families During Covid19
A Refugee Crisis before Covid-19
Refugee populations are often displaced due to political violence and/or because of conflict between government forces and opposition armed groups (Somo, 2020). Thus, many refugees have experienced extreme physical and psychological violence leading to several health and mental health challenges (Ballette et al., 2017). COVID-19 exacerbated the health challenges that refugee families already faced (see the Human Right Watch Report, 2021).
However, prior to Covid-19 and before the year 2019, one percent of the world’s population had been forced to flee from their homes (UNHCR, 2021). The United Nations High Council for Refugees (2021) reports the following realities for refugee families:
The year 2019 alone recorded 5.6 million newly displaced refugees and asylum-seekers and 2.1. million will need resettlement in the year 2021.
Most of these families (85%) fled to least developed countries. High income nations host 15% of displaced peoples with Turkey and Germany in the top 5 of hosting countries globally.
Syria, Venezuela, Afghanistan, South Sudan, and Myanmar account for 68% of the world’s refugees.
Refugee crisis during COVID-19
COVID-19 worsened the lives of refugee families in several ways, including disrupting supported migration processes, cutting help from international agencies, exclusion from health and economic assistance. These factors increased mental health challenges amongst families. They also include:
Refugee relocation interruptions. From March 2020 international resettlement departures were significantly stalled and, in some cases, completely halted. This was due to travel restrictions, limited capacity of states and NGOs to provide appropriate reception and support to refugees in resettlement countries, and public health measures stemming from the pandemic. In 2019 the UNHCR relocated about 44,527 refugees and in 2020 only 22,770 were relocated to host countries (UNHCR, 2021). Restricting human mobility had a devasting impact on the ability of displaced families to escape hardships and seek refuge.
Continued violence and displacement. Travel bans also prevented some refugees from getting asylum in neighbouring countries and were forced to remain or return to their home country. For example, since the 2014 about 5.4. million refugees fled Venezuela due to political oppression, executions, poverty and medical crisis. During 2020 approximately 130,000 asylum seekers had to return Venezuela because of the COVID-19 restrictions (UNHCR, 2021). These refugees were then subjected to inhumane conditions upon arrival including overcrowded quarantine centres without medical aid and COVID safety protocols (Human Rights Watch Report, 2021). Refugees from countries such as Syria, the Democratic Republic of the Congo, and Myanmar faced similar fates.
Mental health outcomes. COVID-19 has added to the already existing stressors of forced migration (Rees & Fisher, 2020). For example, finding employment is a challenge for refugees during non-pandemic times and refugees tend to be under employed in minimal wage industries. Jobs in these industries were the first to be terminated following the pandemic and many refugees faced unemployment. Unlike citizens of a country, refugee families are not afforded a relief program and many families were exposed to poverty. It is because of situations like these that refugees report increased anxiety, worry and despair following COVID-19. Many families also experience despair death and feel that the COVID-19 pandemic has diminished their opportunities of better futures in host countries (Rees and Fisher, 2020). The UNHCR field reports have pointed to a rise in suicide attempts in refugee settlements in Kenya and Uganda. Adding to mental health challenges is the limited access health care services. Health care systems in every nation are struggling to respond to local needs, let alone trying to accommodate the needs of refugee families. Mental health care for refugees has also decreased due to services moving to telemental health. Refugee families often live in poverty and cannot afford the resources needed for online therapy (Smith et al., 2021). Family and relational therapists can play an important role in addressing the needs of refugee families during the pandemic and ensuring the mental wellbeing of these families.
How can we proactively address refugee mental health needs during COVID-19?
Recognize cumulative stress and trauma exposure. It is important to consider that refugee populations experience several stress factors from multiple sources and in quick sequence. Pre-migration violence, migration hardships and resettlement stressors can result into vulnerability to co-morbid mental health difficulties. This can cause complex trauma due to the exposure to multiple traumatic events for an extended period (van Nieuwenhove & Meganck, 2017). For manageable care therapists should consider a triage approach, where each stressor or mental health difficulty has equal importance but attention depends on circumstances. Some literature suggest that resettlement stressors may be more pressing than addressing pre-migration and migration traumatic stressors (Miller & Rasmussen, 2010). It is suggested here that therapists use their clinical insights to triage health needs for refugee clients.
Apply social ecological considerations. It is important for therapists to acknowledge and address the social complexities that impact refugee mental health. Therapists should consider how COVID-19 have impacted refugees in the following areas: (1) access to health care (2) economic status (3) perceptions of refugee status (4) access to resettlement help (5) ability to travel to home countries. While therapists cannot meet all the needs of refugee families, they can play an important role in referrals so that needs are met appropriately elsewhere. It is essential for therapists to establish a strong network of collaborations with other professionals in the community such medical professionals and specialists, social workers, school district personnel and, legal and immigration professionals. For example, it is essential for therapists to be knowledgeable about the refugee access for the COVID-19 vaccine within their own context, as some countries will only prioritize nationals and exclude refugees in the inoculation. Knowledge of social factors that impact refugee clients will help therapists provide holistic care towards family wellbeing. To improve holistic care therapists should also consider a culturally responsive approach.
Perform culturally responsive therapy. Culturally responsive approaches privilege indigenous ways of knowing of refugees including how they understand mental health and what treatments they use to address family well-being. Responsive approaches validate cultural coping mechanisms and seek to support families implement cultural healing practices within the context of the host country. To incorporate clients’ cultural understanding of well-being into therapy it is recommended that therapist collaborate with members of the refugee community through cultural consultants, cultural advisors and customary healers. In this way, families can use innate skills and strengths to address migration stressors and resettlement stressors including the adverse effects of COVID-19 pandemic.
References
Ballette, F., Nosé, M., Ostuzzi, G., & Barbui, C. (2017). Common mental disorders in asylum seekers and refugees: Umbrella review of prevalence and intervention studies. International Journal of Mental Health Systems, 11 (51), 1-14. https://doi.org/10.1186/s13033-017-0156-0
Human Rights Watch. (2021). World report 2019: Events of 2018. Retrieved from: https://www.hrw.org/world-report/2019
Miller, K. E., & Rasmussen, A. (2010). War exposure, daily stressors, and mental health in conflict and post‐conflict settings: Bridging the divide between trauma‐focused and psychosocial frameworks. Social Science & Medicine, 70, 7–16. https://doi.org/10.1016/j.socscimed.2009.09.029
Rees, S., & Fisher, J. (2020). COVID-19 and the mental health of people from refugee backgrounds. International Journal of Health Services, 50(4), 415–417. https://doi.org/10.1177/0020731420942475
Somo, C. M. (2020). Trauma-informed family therapy: Considerations for the systemic treatment of trauma in refugee communities. ProQuest Dissertations & Theses.
Smith, J.A., de Dieu Basabose, J., Brockett, M., Browne, D.T., Shamon, S., & Stephenson. M. (2021). Family medicine with refugee newcomers during the COVID-19 pandemic. The Journal of the American Board of Family Medicine 34 (Supple) S210-S216. https://doi.org/10.3122/jabfm.2021.S1.200115
United Nations High Council for Refugees: UNHCR. (2021). Global appeal 2021 update. https://www.unhcr.org/globalappeal2021/
Van Nieuwenhove, K., & Meganck, R. (2019). Interpersonal features in complex trauma etiology, consequences, and treatment: A literature review. Journal of Aggression, Maltreatment & Trauma, 8, 903. https://doi-org.proxy-remote.galib.uga.edu/10.1080/10926771.2017.1405316
Dr Charity Somo is an Educational Psychologist in South Africa. She earned her doctorate degree in Human Development and Family Science with an emphasis in Marriage and Family Therapy, from the University of Georgia (U.S.), in May 2020. For more about her and her work, please visit our Meet our Panelist page, or catch the video of her guest panelist appearance for this project under the Panels section of our website.