Salutogenic Approach to Health for Displaced Persons

Original Editor - Thalia Zamora Gómez as part of the PREP Content Development Project

Top Contributors - Naomi O'Reilly, Jess Bell, Kim Jackson, Admin and Carin Hunter  

Introduction[edit | edit source]

Even in the 21st century, armed conflicts, poverty and political or religious persecution are constant and widespread around the world, causing large populations to flee from their places of origin in the quest for safety, freedom and an income to be able to live. Adding together adult individuals, families, and unaccompanied minors, the numbers of asylum seekers and refugees have increased steadily in the past years. According to the United Nations High Commissioner for Refugees (UNHCR), at the end of 2021 83.9 million people were displaced from their places of origin; around half of the population of forced migrants were women and girls.[1] 8 million people, more than half of them under 18 years old, have left their countries as a result of the wars in Syria, Afghanistan and Iraq between 2011 and 2016.[2] This has been described as the biggest migration crisis in Europe’s history since World War II.[3][4] After facing dangers, crossing rivers, and/or walking hundreds of kilometres over different terrains, one-fifth of the asylum seekers arrive at high-income European countries, while the remaining four-fifths stay in neighbouring countries such as Lebanon, Jordan, Turkey, Cyprus, Kurdistan and Greece, where they are crowded in mass refugee camps.[5]

As is expected, forced migration has a massive impact on the lives of displaced persons including depression, anxiety, post-traumatic stress disorder, sleeping problems, respiratory and digestive infections, among others.[2][6][7] Furthermore, individuals have struggled with finding a sense of belonging or social recognition, with developing trust and confidence ,[8] with maintaining motivation to try to adapt to their new circumstances,[7] with financial and social disadvantages [5], communication difficulties due to cultural and language differences, instability and a constant fear of being deported.[7] However, the salutogenic approach offers ways to give displaced persons the tools and opportunities to overcome a difficult past and have a better present and future. In fact, the strategies may take advantage of the point that “under certain circumstances, adversity may have the potential for positive outcomes, such as increased resilience and thriving”.[9][10] It is a task that requires commitment on two sides: the displaced person on one; and the governments and the population of the territories that offer sanctuary on the other.

Salutogenic Approach[edit | edit source]

A Finnish study[11] found that the integration of migrants in social affairs relied mainly on migrants themselves, and underlined the importance of society to put effort in building relationships with migrants to make the process reciprocal and successful. Similarly in their research on the mediational role of schools in supporting psychosocial transitions among unaccompanied young refugees, Pastoor[7] points out that “it is not only displaced students who have to adapt to the educational and socio cultural requirements of (Norwegian) schools, but these, including the local and national education authorities, need to actively support resettling displaced students' adaptation to life in a new society.” Some of the proposals are for schools to promote an easier transitional process and coping strategies for young refugees, including a salutogenic arena for:[7]

  1. Socialisation
    • So they can acquire knowledge, skills and understand the norms needed for participation and inclusion in their new society.[7]
  2. Integration
    • So they can receive support, a sense of someone caring about them and their future, and motivation to achieve their goals, either from a mentor, a teacher or classmates.[7]
  3. Rehabilitation
    • To promote the process of mental recovery and restoration of meaning after their traumatic experiences.[7]

In addition, teachers may need to be willing to step a bit outside of their role and be a significant person in their student's lives, to guide them by “means of advice and authority, praise for achievement, understanding their experience before and after flight, help in conflict resolution, further education and career advice.”[12]

In a similar way, it was found that safety, calm, efficacy, connectedness and hope are essential principles for promoting resilience in any disaster.[13] Based on this background, at the International School of Peace on Lesbos, Greece, connectedness, and hope, are essential principles for promoting resilience in any disaster. The plan to help minors in their transition process to feel and express more hope has included “developing mutual help, giving opportunities for older children to help younger ones, practising conflict resolution by means of dialogue and mediation, and creating social age groups that build joint activities together, which facilitate development of behavioural patterns in the spirit of tolerance and reciprocity.”[2]

A research study by Bonmatí-Tomas et al.[14] looked at refugee women at risk of social exclusion. Over 6 months, the authors evaluated the effectiveness of salutogenic health promotion programme "designed to empower of these women". It also acknowledged the health inequities that migrants experience based on variables like gender, country of origin or socioeconomic status. The objectives of the interventions in this case were to improve self-knowledge, and to identify family and community roles (comprehensibility and manageability, linking to a sense of coherence) and personal capacities discussing future projects (manageability and meaningfulness). The authors[14] observed increased self-esteem and the physical quality of life, and reduced perceived stress in the migrant women. Thus, they suggest that the salutogenic model of health should be applied in health promotion programmes and included in policies to reduce health inequity among migrant populations.[14]

Other studies have focused on pregnant displaced women in their perinatal period and giving birth in the country where they have been given refuge.[5][8] Many women in these studies felt socially unrecognised and found difficulties in trusting and accessing the same services as local citizens in the health care system. They also felt less able to communicate with professionals. However, according to Varjonen,[11] this seems to be a two-way issue. Varjonen[11] found that building trust and confidence with and from migrants seems to be a challenge for health care providers in Finland. Thus, a key to successfully integrating migrants and making them feel acknowledged and confident in the system requires “conscious efforts from the healthcare providers to facilitate social recognition and reciprocal relationships”. Simple actions like greeting and answering patients’ questions, might help women to overcome difficult experiences related to pregnancy and childbirth.[8] However, it is also important to support healthcare professionals by allowing them access to interpreters or tools to be able to communicate more effectively with users.

Balaam et al.[5] suggest some prompts for health professionals to contemplate while interacting with asylum seeker and refugees, in particular women:

1. Communication[edit | edit source]

  • "[F]eeling safe and trusting the caregiver is vital. Use professional interpreters. Speak slowly. Using ‘safe’ open questions such as: ‘Tell me about yourself?’ and ‘How does this compare to back home?’ Listen if she wants to talk, if she doesn’t, reassure her that this is ok. Explain how confidentiality works within the maternity services."[5]

2. History Taking[edit | edit source]

  • "[C]onsider the woman’s social situation. Has she got the resources to access maternity care? Is she receiving the financial support she is entitled to?"[5]

3. Advocacy[edit | edit source]

  • "[S]upport the woman in challenges she faces such as lobbying to avoid dispersal and to access appropriate housing."[5]

4. Signposting[edit | edit source]

  • "[T]o local displaced persons organisations, support groups, specialist services such as FGM support, peer/ doula support schemes."

5. Cultural Context[edit | edit source]

  • "[E]xplain the organisation of healthcare services. Discuss women's expectations of childbirth and how any cultural requests can be met."

As has been mentioned above, there are many positive outcomes of salutogenic approaches that have been studied in displaced persons, and these include, among others: post-traumatic growth as appreciation of life, changes in priorities concerning what is important in life, personal strength, becoming resilient through struggle, compassion for others, a sense of responsibility and personal strength, self-knowledge, and the ability to make sense of experiences to project brighter futures.[15]

“While every displaced person’s story is different, and their anguish personal, they all share a common thread of uncommon courage, the courage not only to survive, but to persevere and rebuild their shattered lives.” -- Antonio Guterres, UN High Commissioner for Refugees, 2005

Summary[edit | edit source]

Although more research needs to be conducted on the salutogenic model for displaced persons, there is plenty of evidence suggesting that the model is an effective health promotion resource to increase resilience. It also has an affirmative effect on the perceived physical and mental state, quality of life and wellbeing of people, including displaced persons, as individuals and in society. Since it is a valid, reliable, multidimensional, and applicable instrument for measuring health in different situations and cultures,[16] more policies for health promotion through the model should be suggested and implemented at an international level, including migration programmes. The interventions should continue to be focused not on disease but on health.

References[edit | edit source]

  1. UNHCR. (2015). Women, particular risks and challenges.
  2. 2.0 2.1 2.2 Asher, SB., Sagy, S., Srour, A., Walden, T., Huss, E., Shahar, E., Alsraiha, K. (2020)
  3. Price, M., Gohdes, A., Ball, P. (2014) Updated Statistical Analysis Of Documentation Of Killings In The Syrian Arab Republic. Geneva: Human Rights Data Analysis Group..
  4. UNHCR (2016) Mid-year Trends 2016. trends-June-2016.html
  5. 5.0 5.1 5.2 5.3 5.4 5.5 5.6 Balaam, M. C., Haith-Cooper, M., Korfker, D., Savona-Ventura, C. (2017) Asylum Seekers and Refugees; A Cross European Perspective. In: Thompson, G. and Schmied, V. (Eds) Psychosocial Resilience and Risk in the Perinatal Period: Implications and Guidance for Professionals. Routledge, 3, 28-43.
  6. Borwick, S., Schweitzer, R., Brough, M., Vromans, L. & Shakespeare-Finch, J. (2013). Well-being of refugees from Burma: A salutogenic perspective. International Migration, 51(5), 91 105.
  7. 7.0 7.1 7.2 7.3 7.4 7.5 7.6 7.7 Pastoor, L.D.W. (2015) The mediational role of schools in supporting psychosocial transitions among unaccompanied young refugees upon resettlement in Norway, International Journal of Educational Development, 41, 245-254.
  8. 8.0 8.1 8.2 Lillrank, A. (2015). Trust, Vacillation ad Neglect: Refugee women’s experiences regarding pregnancy and birth giving in Finland. Nordic Journal of Migration Research, 5(2), 83–90. 0009
  9. Carver, C. S. (1998). Resilience and thriving: Issues, models, and linkages. Journal of Social Issues, 54, 245– 266.
  10. Rutter, M. (1987). Psychosocial resilience and protective mechanisms. The American Journal of Orthopsychiatry, 57, 316–331.
  11. 11.0 11.1 11.2 Varjonen, S 2013, Ulkopuolinen vai osallistuja? Identiteetit, ryhmäsuhteet ja integraatio maahanmuuttajien elämäntarinoissa, University of Helsinki Press, 157–159.
  12. Rutter, J. (2003) Supporting Refugee Children in 21st Century Britain: A Compendium of Essential Information, New Revised Edition. Trentham Books, Stoke on Trent, 167.
  13. Hobfoll, S. E., Watson, P., Bell, C. C., Bryant, R. A., Brymer, M. J., Friedman, M. J., Friedman, M., Gersons, B. P., de Jong, J. T., Layne, C. M., Maguen, S., Neria, Y., Norwood, A. E., Pynoos, R. S., Reissman, D., Ruzek, J. I., Shalev, A. Y., Solomon, Z., Steinberg, A. M., & Ursano, R. J. (2007). Five essential elements of immediate and mid-term mass trauma intervention: empirical evidence. Psychiatry, 70(4), 283–369.
  14. 14.0 14.1 14.2 Bonmatí-Tomas A, Malagón-Aguilera MC, Gelabert-Vilella S, Bosch-Farré C, Vaandrager L, García-Gil MD, Juvinyà-Canal D. Salutogenic health promotion program for migrant women at risk of social exclusion. International journal for equity in health. 2019 Dec 1;18(1):139.
  15. Shakespeare-Finch, J., Schweitzer, R. D., King, J. & Brough, M. (2014) Distress, Coping, and Posttraumatic Growth in Refugees From Burma, Journal of Immigrant & Refugee Studies, 12:3, 311-330.
  16. Eriksson, M., & Lindström, B. (2006). Antonovsky's sense of coherence scale and the relation with health: A Systematic Review. Journal of Epidemiology and Community Health, 60(5), 376–381.