Health Concerns for Displaced Persons: Difference between revisions

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== Introduction ==
== Introduction ==
The physical, psychological and social experiences of a refugee as one flees conflict and persecution and seeks safety are referred to as refugee experiences 1. According to 1951 Refugee Convention, a refugee is one who is unable or unwilling to return to ones country of origin owing to a well-founded fear of being persecuted for reasons of race, religion, nationality and membership of a particular social group or political opinion.
[[File:Refugee Camp (John Owens-VOA).jpeg|right|frameless|532x532px]]
 
Around 83.9 million people worldwide are currently displaced, with 30.7 million of them crossing international boundaries in search of protection. Migrants and refugees are likely to have good general health initially. However, they can be at risk of falling sick in transition or whilst staying in receiving countries due to poor living conditions or adjustments in their lifestyle.<ref name=":2">WHO [https://www.who.int/news-room/feature-stories/detail/10-things-to-know-about-the-health-of-refugees-and-migrants 10 things to know about the health of refugees and migrants] Available:https://www.who.int/news-room/feature-stories/detail/10-things-to-know-about-the-health-of-refugees-and-migrants Accessed 2.9.2021</ref>
There is an increased risk of health problems among individuals with refugee experience as they are faced with both mental and physical stress in their home countries and also during the migration process 2, 3 .
== Impact of Migration on Health ==
<div align="justify">
What do we need to know about the health impact of migration on refugees? In order to recognise the need for the inclusiveness of this topic and to incorporate whole societies (that includes that of refugees and migrants), it is necessary to vocalise the importance of how migration can and/or has been affecting the refugee population. Addressing communicable disease control and immunisation programs holds importance on its own and needs to be made aware of amongst this population. This comes to light as in many cases, over the world, when addressing of such matters to subpopulations such as migrants has been written over. Saying that Steel et al. (1) noted that the number of non-communicable diseases (NCDs) such as tuberculosis (TB), Hepatitis B and C are recorded to be on the higher end in migrant populations. These vaccine-preventable diseases have vaccines that lie in abundance, however, are not widely known and sought for in the migrant population and their companies (1).


We seek to understand this proposition to fully maximise including the migrant population within the health sector and its denominators, i.e. health services and health whereabouts before their health becomes an unsolvable factor for the country (1). Another aspect that comes into role play is what is termed as Health Vulnerability. Stewart et al. (2) define this as the extent to which the individual (in this case, a migrant) can live with anticipation, to cope with, resist and even recover from the impact of post disease/pandemics. One of the factors that lead to health vulnerability is socioeconomic status. When it comes to migrants, there lies the fear/occurrence of isolation, insecurity, post-traumatic Stress disorder (PTSD) and even the journey of travelling so far per se (2).
The physical, psychological and social experiences of a person fleeing conflict and persecution and seeking safety are referred to as displaced person experiences.<ref>Ministry of Health. Refugee Health Care: A handbook for health professionals. Wellington: Ministry of Health. 2012</ref> There is an increased risk of health problems among individuals who have been displaced as they are faced with mental and physical stress both in their home countries and during the migration process.<ref>Palic S, Elklit A. An explorative outcome study of CBT-based multidisciplinary treatment in a diverse group of refugees from a Danish treatment centre for rehabilitation of traumatized refugees. Torture.2009. 19; 3:248-270.
=== Refugee and Migrant Expectations toward Health Services ===
</ref><ref>Razavi MF, Falk L, Björn Å, Wilhelmsson S. Experiences of the Swedish healthcare system: an interview study with refugees in need of long-term health care. Scandinavian Journal of Public Health. 2011. 39; 3:319-325.</ref>
<div align="justify">
A term contrary to health vulnerability is Health resilience. It accounts for all the access to resources and services that are available to the migrants; whether this is in the form of material or intangible (3). Bhugra (3) mentions that from a migrant’s point of view this would be their general expectation, to have access to necessary commodities and not be vulnerable to diseases that hold vaccines and can be easily preventable. However, some migrants are in better health conditions from their previous country as opposed to their new country of migration.


== Major Health Concerns ==
Some key points:
Each country has its management of communicable diseases, health structure and programs that support the non-communicable diseases, mental health, and women health. In addition to the health policies that cover the occupational accident, when it comes to refugees or displaced people there is no track of health support for these communicable diseases and thereby elevated conflicts in the home country (REF) 2


Example of health conditions that affect majority of the refugee populations:
* Immigrant populations are large and heterogeneous, resulting in a wide variety of health situations.
* Communicable Diseases (Tuberculosis, Infectious hepatitis, Hepatitis B, Sexually transmitted infections)
* Migration itself is not considered a risk factor for illness, and migrants have in general fewer health problems than the population both in their home country and in their new country. However, forced migration is a completely different situation, and it is very important to acknowledge this difference. 
* Parasitic Infections (Malaria, Giardiasis, Leishmaniasis)
* People with experience of displacement are at risk of complex physical, mental and social problems, which can contribute to poor health outcomes and impede successful social integration. 
* Mental Health
* Forced migration has a massive impact on the lives of displaced persons causing issues such as [[depression]], anxiety, [[Post-traumatic Stress Disorder|post-traumatic stress disorder]], [[Sleep Deprivation and Sleep Disorders|sleeping problems]], [[Respiratory Disorders|respiratory]] and digestive [[Infectious Disease|infections]], among others.
* Women Health
* Individuals who have experienced displacement can struggle to find a sense of belonging or social recognition. They may also have difficulty developing trust and confidence and maintaining motivation when trying to adapt to their new circumstances. Similarly, they may experience financial and social disadvantages, communication difficulties due to cultural and language differences, instability and constant fear of being deported. All of these factors can have an impact on health. 
* Occupational Health, Job Status or Unemployment.REF
* A significant proportion of displaced persons have been subjects to severe physical and/or psychological torture. This exposure may have long-term physical and psychological consequences.


Moreover, cultural issues might lead to developing health conditions, thereby investing more time in understanding the cultural diversity of the refugees would help understand their health condition and the origin of symptoms such as pain. REF
== Problems and Stressors Facing Displaced Persons ==
Displaced persons often face various problems and stressors which can take place at various stages of the migration process:


According to World Health Organization, a burn is an injury to the skin or other organic tissue primarily caused by heat (hot liquids, hot solids and flames) or due to radiation, radioactivity,electricity, friction or contact with chemicals. This is one of the most common health condition seen in refugees 4 . It becomes life threatening especially in the very young and very old individuals. Due to pain and discomfort, the individuals tend to keep their body in the position of comfort, thus encouraging joint contractures and pressure sore formation. Hence, the physiotherapist plays a role of joint mobilization and turning the individual every 2 hourly during the first few days after a burn injury 5 .
# '''Pre-migration:'''
#* Lack of livelihoods and opportunities for education and development, exposure to armed conflict, violence, poverty and/or persecution.
# '''Migration travel and transit:'''
#* Exposure to challenging and life-threatening conditions including violence and detention and lack of access to services to cover their basic needs.
# '''Post-migration:'''
#* Barriers to accessing health care and other services to meet their basic needs as well as poor living conditions, separation from family members and support networks, possible uncertainty regarding work permits and legal status (asylum application), and in some cases immigration detention.
# '''Integration and settlement:'''
#* Poor living or working conditions, unemployment, assimilation difficulties, challenges to cultural, religious, and gender identities, challenges with obtaining entitlements, changing policies in host countries, racism and exclusion, tension between host population and migrants and refugees, social isolation and possible deportation.


Refugees encounter frequent falls during migration process, there by exposing them to ankle sprain. Thus, Ankle sprain is an injury to the lateral ligament complex of the ankle joint and graded on the basis of severity 6-10 . It is associated with significant socioeconomic cost as well as pain, swelling and impaired function 11-14 . The long term prognosis of acute ankle sprain is low and usually results in persistent residual symptoms and injury recurrence as reported by high proportion of individuals 15, 16 . The physiotherapist aims at reducing swelling and pain, restoring the stability of the ankle joint and regaining full functional status 17 . Strong evidence supports the use of exercise therapy and bracing in prevention of Ankle Sprain recurrence while early mobilization is best used for the treatment of acute ankle sprain 18 .
== Impact of Migration on Health ==
[[File:Health Service for refugees.jpeg|right|frameless]]
Migration can and does have a significant impact on displaced persons. Significant issues include:


Fracture is one of the most prevalent injuries caused by trauma in refugees 19 . The Physiotherapist handles fracture at various stages/ phases;
* Exposure to communicable diseases
* Declining vaccination rates for communicable diseases and issues such as coverage, reliable records etc.<ref>Mipatrini D, Stefanelli P, Severoni S, Rezza G. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5375618/ Vaccinations in migrants and refugees: a challenge for European health systems. A systematic review of current scientific evidence]. Pathog Glob Health. 2017 Mar;111(2):59-68.</ref>
* Health vulnerability i.e. the extent to which the individual (in this case, a migrant) can live with the anticipation of, cope with, resist and recover from the impact of disease, in particular [[Endemics, Epidemics and Pandemics|pandemics]].<ref name=":1">Stewart M, Makwarimba E, Beiser M, Neufeld A, Simich L, Spitzer D. Social support and health: immigrants’ and refugees’ perspectives. Diversity in Health and Care. 2010;7(2):91-103.</ref>
** Socioeconomic status impacts health vulnerability
* The fear / experience of isolation, insecurity, long journeys<ref name=":1" />


Active phase: This phase is characterized with pain and edema. Hence, the physiotherapist employs the use of cold packs and splinting. While the former controls pain and edema, the later prevents movement at the fracture site. After bone reduction and the healing process sets in: The affected limb is engaged in partial weight bearing, grade 1 and 2 mobilization of joints, active and active assisted exercises. The aim is to prevent muscle wasting.
== Challenges in Accessing Health Care ==
Because of factors such as a migrant's legal status, language barriers and discrimination, some national health strategies may not make any reference to the health of displaced persons or the accessibility of health care for them. The World Health Organization calls on every country to implement policies that provide health care services to all migrants and displaced persons, irrespective of their legal status.<ref name=":2" />


After fracture healing: The aim is to build up muscle strength by involving the affected limb in resistive exercises, grade 3 and 4 joint mobilization 20 .
== Major Health Concerns ==
 
[[File:Refugee.jpeg|right|frameless]]Displaced persons can experience many different health and psychosocial issues:<ref>Ackerman LK. Health problems of refugees. [https://pubmed.ncbi.nlm.nih.gov/9297659/ The Journal of the American Board of Family Practic]e. 1997 Sep 1;10(5):337-48.Available : https://pubmed.ncbi.nlm.nih.gov/9297659/ (accessed 2.9.2021)</ref>
Spinal cord injury is one of the major types of war injuries experienced by refugees 21 . Most times, spinal cord injuries do not include severing of the spinal cord 22, 23 . According to the American Spinal Injury Association (ASIS) classification system, spinal cord injury is classified as either complete or incomplete 24 . There is low probability of neurological recovery in individuals with complete lesion while motor recovery following incomplete lesion is highly common 25, 26 . Spinal cord injuries are usually accompanied with associated impairments such as vertebral damage and instability, deep venous thrombosis, spasticity, postural hypotension, osteoporosis and pressure ulcers. The role of the physiotherapist is to conservatively manage these complications. Vertebral damage and instability result from a structural damage and instability of the vertebral column. This is managed conservatively by immobilizing the spine for 6-12 weeks either with an extensive bracing or skeletal traction/pillow wedge 27 . This prolonged bed rest can cause respiratory complications, disuse weakness and contractures.
*[[Non-Communicable Diseases|Non-Communicable Diseases (NCD)]]
 
** Also termed [[Chronic Disease|chronic diseases]]. They are collectively responsible for 71% of all deaths worldwide.<ref>Noncommunicable diseases, WHO, 1 June 2018 [http://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases<nowiki>]</nowiki></ref> Almost 75% of all deaths caused by NCD occur in low- and middle-income countries.<ref name="WHO">WHO. Noncommunicable diseases and their risk factors http://www.who.int/ncds/en/ accessed 15 July 2016</ref>
Venous blood stasis results from lack of movement and paralysis and is aggravated by bed rest 28, 29 .The role of the physiotherapist is to prevent deep vein thrombosis from setting in by the use of electrical stimulation 28 and external pneumatic compression device after the individual has been routinely placed on anticoagulant 30-33 . The use of passive movement is now disputed 30 .  
** NCDs also account for 48% of the healthy life years lost&nbsp;worldwide versus 40% for communicable diseases, maternal and perinatal conditions and nutritional deficiencies, and&nbsp;1% for injuries<ref name="GBD">Bloom, D.E., Cafiero, E.T., Jané-Llopis, E., Abrahams-Gessel, S., Bloom, L.R., Fathima, S., Feigl, A.B., Gaziano, T., Mowafi, M., Pandya, A., Prettner, K., Rosenberg, L., Seligman, B., Stein, A.Z., &amp; Weinstein, C. (2011). The Global Economic Burden of Noncommunicable Diseases. Geneva: World Economic Forum</ref>
 
***[[:Category:Oncology|Cancer:]] Aside from cervical cancer, displaced persons have a lower risk for all forms of cancer. "However, cancer is more likely to be diagnosed at an advanced stage in persons who are displaced, which can lead to considerably worse health outcomes compared with the host population"<ref name=":2" />
Spasticity is only seen in individuals with intact lower motor neurons and is usually troublesome with incomplete lesions 34 . Due to neural sprouting or changes in the sensitivity of neural receptors, spasticity tends to increase over the first year of injury 35 . Spasticity predisposes individuals to pain, contractures and pressure ulcers as movement is restricted 35-37 . The physiotherapist provides a transients relief not a long lasting reductions in spasticity with the use of passive movements, hydrotherapy, stretch, heat, TENS, cold, electrical stimulation, therapeutic exercises and vibration. 38, 39
***[[Cardiovascular Disease|Cardiovascular disease]]
 
***[[:Category:Chronic Respiratory Disease|Chronic respiratory disease]]
Postural hypotension is the loss of supraspinal control of the sympathetic nervous system, resulting to the inability to regulate blood pressure. This is typically seen in individuals with lesions above T6 and is exacerbated by poor venous return secondary to lower limb paralysis and loss of lower limb muscle pump 40-43 . The physiotherapist employs the use of slowly implemented mobilization by sitting out in bed with the legs elevated at different angles. This aims at increasing the individual’s tolerance of lightheadedness with lower blood pressure 44-47 .A common long term complication of spinal cord injuries is Osteoporosis, which predispose individuals to fractures 48-50 . Individuals experience 25-50% reduction in bone mineral contents of the lower limb over a lifetime, although most of the mineral contents are lost in the first year following spinal cord injury 48-57 . Assumptions have been made that the loss of the bone mineral content is due to lack of weight bearing and axial loading 58, 59 . The use of early standing and electrical stimulation therapy has been advocated for Physiotherapy treatment 60-64 .
***[[Diabetes|Diabetes:]] Displaced persons have a higher incidence, prevalence and mortality rate for diabetes than their host population<ref name=":2" />
 
*[[Communicable Diseases|Communicable diseases]]
When blood supply is compromised by the compression of small arteries and capillaries between internal bony prominences and external hard surface, soft tissue necrosis occurs. Hence, Pressure ulcers result from the necrosis of soft tissues 65 . The most vulnerable tissues are those underlying the heel, head of fibular, greater trochanter of femur, ischial tuberosity, sacrum, inferior tip of scapular, olecranon and back of the head 66 . The first sign of excessive pressure is redness that does not blanch with localized pressure 67 . This indicates the damage of the underlying tissue as it is the first to be damaged and the last to repair. Skin breakdown is a later stage of pressure ulcer and indicates more destruction to the underlying tissue 68 . The key to pressure ulcer management is prevention. This involves the prescription of pressure relieving equipments such as bed mattresses (either air or water based), wheelchair cushions and wheelchair 68
**[[Tuberculosis]]
 
**[[Hepatitis A, B, C|Hepatitis]]
Potential profile for physiotherapist services:
**[[Human Immunodeficiency Virus (HIV)]]
 
**[[Parasitic Infections|Parasitic infections]]:  
Refugee populations are likely to present with a series of complex and complicated health and wellness, including impairments, activity limitations, and participation restrictions. Landry et al. (REF) describe the following:
***[[Malaria]]
 
*** Giardiasis
(a) Pre-existing disability/physical limitation
*** Leishmaniasis
 
*[[Mental Health and Forced Displacement|Mental health]]
Due to the onset of migration/ displacement, they were either receiving the required careful attention or did
**[[Post-traumatic Stress Disorder|Post-traumatic stress disorder (PTSD)]] appears to be more common among displaced persons than their host population<ref name=":2" />
 
**[[Depression]] is a common illness worldwide, with more than 264 million people affected. It is commonly reported in displaced persons, particularly in those who have lengthy asylum-seeking processes and who live in poor socioeconomic conditions (e.g. unemployment or isolation).<ref name=":2" />
not have access to them yet because there was a lack of those services in their system.
**[[Generalized Anxiety Disorder|Generalised anxiety disorder]] is one of the most common mental health disorders affecting up to 20% of the adult population worldwide. It produces fear, worries, and a constant feeling of being overwhelmed. Generalised anxiety disorder is often characterised by persistent, excessive, and unrealistic worry about everyday things. It is commonly reported/linked to lengthy asylum-seeking processes and poor socioeconomic conditions, such as unemployment or isolation.<ref name=":2" />
 
* Pelvic pain and dysfunction
(b) Underlying health condition/elderly people
* Musculoskeletal injury
 
** Displaced persons encounter frequent falls during the migration process. Fractures are one of the most prevalent injuries caused by trauma in displaced persons.<ref>Yigit Duzkoylu, Salim Ilksen Basceken and Emrullah Cem Kesilmez. Physical Trauma among Refugees: Comparison between Refugees and Local Population Who Were Admitted to Emergency Department—Experience of a State Hospital in Syrian Border District. Journal of environmental and Public Health. 2017. https://doi.org/10.1155/2017/8626275
The developed chronic disease and disorder accompanied with the activities limitation is more likely to result with a series of short- and long-term disabilities.
</ref>
 
*[[Burns Overview|Burns]]
(c) Post-migration/displacement health condition
** According to the World Health Organization, a [[Burns Overview|burn]] is an injury to the skin or other organic tissue primarily caused by heat (hot liquids, hot solids and flames) or due to radiation, radioactivity, electricity, friction or contact with chemicals. This is one of the most common health conditions seen in displaced persons. It becomes life-threatening, especially in very young and very old individuals. Due to pain and discomfort, the individuals tend to keep their body in a position of comfort, thus encouraging joint contractures and [[Pressure Ulcers|pressure sore]] formation.<ref>Van Hasselt, EJ. BURNS MANUAL.A manual for health workers.2018 2nd edition. pg 51.</ref>
 
*[[Spinal Cord Injury]]
This arises due to the migrant’s journey itself or change of occupation. Majority of the refugees will opt to find jobs in sectors such as construction, seasonal jobs, service industries and domestic industries as a reason for not having to provide health insurance.
**Significant life-changing injury seen in war, conflict or disaster injuries experienced by displaced.<ref>Hermansson AC, Thyberg M, Timpka T. War-wounded refugees: the types of injury and influence of disability on well-being and social integration. Med Confl Surviv. 1996; 12(4):284-302. doi:10.1080/13623699608409299
 
</ref> For war-injured displaced persons, spinal cord injury (SCI) is a leading cause of catastrophic neurologic injury, with evidence focused on the care of this vulnerable population. There are multiple challenges in caring for displaced persons with SCI in low and middle-income countries where most displaced persons are based. An interdisciplinary SCI rehabilitation approach can provide comprehensive care for this vulnerable population.<ref>Jones MW, Crane DA. [https://pubmed.ncbi.nlm.nih.gov/32345983/ Interdisciplinary care for spinal cord injured refugees.] Spinal cord series and cases. 2020 Apr 28;6(1):1-3.Available: https://pubmed.ncbi.nlm.nih.gov/32345983/ (accessed 2.9.2021)</ref>
The physiotherapist plays its role when these health problems causes pain, limits function and restrict movement of refugees either at ones country or during the migration process. Hence, the Canadian Physiotherapy Association describes physiotherapy as a primary care, autonomous, client-focused health profession dedicated to improving quality of life by:
* Unaccompanied Children or Orphaned Children
* Promoting optimal mobility, physical activity and overall health and wellness;
** Children without parents or a guardian are especially vulnerable and at risk for both health and social problems. They risk for "abduction and trafficking for sale and exploitation can be exacerbated if border controls are weak, violations of children’s rights already exist and there is easy access to the child. Children are also vulnerable to sexual exploitation and experience higher rates of depression and symptoms of post-traumatic stress disorder."<ref name=":2" />
* Preventing disease, injury, and disability;
* Occupational health, job status or unemployment.
* Managing acute and chronic conditions, activity limitations, and participation restrictions;
* Improving and maintaining optimal functional independence and physical performance;
* Rehabilitating injury and the effects of disease or disability with therapeutic exercise programs and other interventions; and
* Educating and planning maintenance and support programs to prevent re-occurrence, re-injury or functional decline.


== Resources  ==
== Role of Rehabilitation Services ==
[[File:Refugees welcome.jpeg|right|frameless]]Refugee populations are likely to present with a series of complex and complicated health and wellness issues, including impairments, activity limitations, and participation restrictions. Landry et al.<ref>Landry MD, van Wijchen J, Jalovcic D, Boström C, Pettersson A, Alme MN. Refugees and Rehabilitation: Our Fight Against the “Globalization of Indifference”. Archives of physical medicine and rehabilitation. 2020 Jan 1;101(1):168-70.</ref> describe the following:


== References ==
# Pre-existing disability and physical limitation
# Underlying health conditions in the older adult
# Post-migration and displacement health conditions
<br>The rehabilitation professional plays a role when health problems cause pain, or limit the function of displaced persons either in their country of origin or during the migration process and are involved in:
* Promoting optimal mobility, [[Physical Activity|physical activity]] and overall health and wellness
* Preventing disease, injury, and disability
* Managing acute and chronic conditions, activity limitations, and participation restrictions
* Improving and maintaining optimal functional independence and physical performance
* Rehabilitating injury and the effects of disease or disability with [[Therapeutic Exercise|therapeutic exercise]] programmes and other interventions
* Educating and planning maintenance and support programmes to prevent re-occurrence, re-injury or functional decline
== References ==
<references />
<references />


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Latest revision as of 07:30, 30 April 2023

Original Editor - Nimisha Gorasia, Ayman Baroudi, Chidera Lilian as part of the PREP Content Development Project

Top Contributors - Naomi O'Reilly, Lucinda hampton, Kim Jackson, Jess Bell, Ewa Jaraczewska, Aminat Abolade and Carin Hunter  

Introduction[edit | edit source]

Refugee Camp (John Owens-VOA).jpeg

Around 83.9 million people worldwide are currently displaced, with 30.7 million of them crossing international boundaries in search of protection. Migrants and refugees are likely to have good general health initially. However, they can be at risk of falling sick in transition or whilst staying in receiving countries due to poor living conditions or adjustments in their lifestyle.[1]

The physical, psychological and social experiences of a person fleeing conflict and persecution and seeking safety are referred to as displaced person experiences.[2] There is an increased risk of health problems among individuals who have been displaced as they are faced with mental and physical stress both in their home countries and during the migration process.[3][4]

Some key points:

  • Immigrant populations are large and heterogeneous, resulting in a wide variety of health situations.
  • Migration itself is not considered a risk factor for illness, and migrants have in general fewer health problems than the population both in their home country and in their new country. However, forced migration is a completely different situation, and it is very important to acknowledge this difference. 
  • People with experience of displacement are at risk of complex physical, mental and social problems, which can contribute to poor health outcomes and impede successful social integration. 
  • Forced migration has a massive impact on the lives of displaced persons causing issues such as depression, anxiety, post-traumatic stress disorder, sleeping problems, respiratory and digestive infections, among others.
  • Individuals who have experienced displacement can struggle to find a sense of belonging or social recognition. They may also have difficulty developing trust and confidence and maintaining motivation when trying to adapt to their new circumstances. Similarly, they may experience financial and social disadvantages, communication difficulties due to cultural and language differences, instability and constant fear of being deported. All of these factors can have an impact on health. 
  • A significant proportion of displaced persons have been subjects to severe physical and/or psychological torture. This exposure may have long-term physical and psychological consequences.

Problems and Stressors Facing Displaced Persons[edit | edit source]

Displaced persons often face various problems and stressors which can take place at various stages of the migration process:

  1. Pre-migration:
    • Lack of livelihoods and opportunities for education and development, exposure to armed conflict, violence, poverty and/or persecution.
  2. Migration travel and transit:
    • Exposure to challenging and life-threatening conditions including violence and detention and lack of access to services to cover their basic needs.
  3. Post-migration:
    • Barriers to accessing health care and other services to meet their basic needs as well as poor living conditions, separation from family members and support networks, possible uncertainty regarding work permits and legal status (asylum application), and in some cases immigration detention.
  4. Integration and settlement:
    • Poor living or working conditions, unemployment, assimilation difficulties, challenges to cultural, religious, and gender identities, challenges with obtaining entitlements, changing policies in host countries, racism and exclusion, tension between host population and migrants and refugees, social isolation and possible deportation.

Impact of Migration on Health[edit | edit source]

Health Service for refugees.jpeg

Migration can and does have a significant impact on displaced persons. Significant issues include:

  • Exposure to communicable diseases
  • Declining vaccination rates for communicable diseases and issues such as coverage, reliable records etc.[5]
  • Health vulnerability i.e. the extent to which the individual (in this case, a migrant) can live with the anticipation of, cope with, resist and recover from the impact of disease, in particular pandemics.[6]
    • Socioeconomic status impacts health vulnerability
  • The fear / experience of isolation, insecurity, long journeys[6]

Challenges in Accessing Health Care[edit | edit source]

Because of factors such as a migrant's legal status, language barriers and discrimination, some national health strategies may not make any reference to the health of displaced persons or the accessibility of health care for them. The World Health Organization calls on every country to implement policies that provide health care services to all migrants and displaced persons, irrespective of their legal status.[1]

Major Health Concerns[edit | edit source]

Refugee.jpeg

Displaced persons can experience many different health and psychosocial issues:[7]

  • Non-Communicable Diseases (NCD)
    • Also termed chronic diseases. They are collectively responsible for 71% of all deaths worldwide.[8] Almost 75% of all deaths caused by NCD occur in low- and middle-income countries.[9]
    • NCDs also account for 48% of the healthy life years lost worldwide versus 40% for communicable diseases, maternal and perinatal conditions and nutritional deficiencies, and 1% for injuries[10]
      • Cancer: Aside from cervical cancer, displaced persons have a lower risk for all forms of cancer. "However, cancer is more likely to be diagnosed at an advanced stage in persons who are displaced, which can lead to considerably worse health outcomes compared with the host population"[1]
      • Cardiovascular disease
      • Chronic respiratory disease
      • Diabetes: Displaced persons have a higher incidence, prevalence and mortality rate for diabetes than their host population[1]
  • Communicable diseases
  • Mental health
    • Post-traumatic stress disorder (PTSD) appears to be more common among displaced persons than their host population[1]
    • Depression is a common illness worldwide, with more than 264 million people affected. It is commonly reported in displaced persons, particularly in those who have lengthy asylum-seeking processes and who live in poor socioeconomic conditions (e.g. unemployment or isolation).[1]
    • Generalised anxiety disorder is one of the most common mental health disorders affecting up to 20% of the adult population worldwide. It produces fear, worries, and a constant feeling of being overwhelmed. Generalised anxiety disorder is often characterised by persistent, excessive, and unrealistic worry about everyday things. It is commonly reported/linked to lengthy asylum-seeking processes and poor socioeconomic conditions, such as unemployment or isolation.[1]
  • Pelvic pain and dysfunction
  • Musculoskeletal injury
    • Displaced persons encounter frequent falls during the migration process. Fractures are one of the most prevalent injuries caused by trauma in displaced persons.[11]
  • Burns
    • According to the World Health Organization, a burn is an injury to the skin or other organic tissue primarily caused by heat (hot liquids, hot solids and flames) or due to radiation, radioactivity, electricity, friction or contact with chemicals. This is one of the most common health conditions seen in displaced persons. It becomes life-threatening, especially in very young and very old individuals. Due to pain and discomfort, the individuals tend to keep their body in a position of comfort, thus encouraging joint contractures and pressure sore formation.[12]
  • Spinal Cord Injury
    • Significant life-changing injury seen in war, conflict or disaster injuries experienced by displaced.[13] For war-injured displaced persons, spinal cord injury (SCI) is a leading cause of catastrophic neurologic injury, with evidence focused on the care of this vulnerable population. There are multiple challenges in caring for displaced persons with SCI in low and middle-income countries where most displaced persons are based. An interdisciplinary SCI rehabilitation approach can provide comprehensive care for this vulnerable population.[14]
  • Unaccompanied Children or Orphaned Children
    • Children without parents or a guardian are especially vulnerable and at risk for both health and social problems. They risk for "abduction and trafficking for sale and exploitation can be exacerbated if border controls are weak, violations of children’s rights already exist and there is easy access to the child. Children are also vulnerable to sexual exploitation and experience higher rates of depression and symptoms of post-traumatic stress disorder."[1]
  • Occupational health, job status or unemployment.

Role of Rehabilitation Services[edit | edit source]

Refugees welcome.jpeg

Refugee populations are likely to present with a series of complex and complicated health and wellness issues, including impairments, activity limitations, and participation restrictions. Landry et al.[15] describe the following:

  1. Pre-existing disability and physical limitation
  2. Underlying health conditions in the older adult
  3. Post-migration and displacement health conditions


The rehabilitation professional plays a role when health problems cause pain, or limit the function of displaced persons either in their country of origin or during the migration process and are involved in:

  • Promoting optimal mobility, physical activity and overall health and wellness
  • Preventing disease, injury, and disability
  • Managing acute and chronic conditions, activity limitations, and participation restrictions
  • Improving and maintaining optimal functional independence and physical performance
  • Rehabilitating injury and the effects of disease or disability with therapeutic exercise programmes and other interventions
  • Educating and planning maintenance and support programmes to prevent re-occurrence, re-injury or functional decline

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 WHO 10 things to know about the health of refugees and migrants Available:https://www.who.int/news-room/feature-stories/detail/10-things-to-know-about-the-health-of-refugees-and-migrants Accessed 2.9.2021
  2. ↑ Ministry of Health. Refugee Health Care: A handbook for health professionals. Wellington: Ministry of Health. 2012
  3. ↑ Palic S, Elklit A. An explorative outcome study of CBT-based multidisciplinary treatment in a diverse group of refugees from a Danish treatment centre for rehabilitation of traumatized refugees. Torture.2009. 19; 3:248-270.
  4. ↑ Razavi MF, Falk L, Björn Å, Wilhelmsson S. Experiences of the Swedish healthcare system: an interview study with refugees in need of long-term health care. Scandinavian Journal of Public Health. 2011. 39; 3:319-325.
  5. ↑ Mipatrini D, Stefanelli P, Severoni S, Rezza G. Vaccinations in migrants and refugees: a challenge for European health systems. A systematic review of current scientific evidence. Pathog Glob Health. 2017 Mar;111(2):59-68.
  6. ↑ 6.0 6.1 Stewart M, Makwarimba E, Beiser M, Neufeld A, Simich L, Spitzer D. Social support and health: immigrants’ and refugees’ perspectives. Diversity in Health and Care. 2010;7(2):91-103.
  7. ↑ Ackerman LK. Health problems of refugees. The Journal of the American Board of Family Practice. 1997 Sep 1;10(5):337-48.Available : https://pubmed.ncbi.nlm.nih.gov/9297659/ (accessed 2.9.2021)
  8. ↑ Noncommunicable diseases, WHO, 1 June 2018 [http://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases]
  9. ↑ WHO. Noncommunicable diseases and their risk factors http://www.who.int/ncds/en/ accessed 15 July 2016
  10. ↑ Bloom, D.E., Cafiero, E.T., Jané-Llopis, E., Abrahams-Gessel, S., Bloom, L.R., Fathima, S., Feigl, A.B., Gaziano, T., Mowafi, M., Pandya, A., Prettner, K., Rosenberg, L., Seligman, B., Stein, A.Z., & Weinstein, C. (2011). The Global Economic Burden of Noncommunicable Diseases. Geneva: World Economic Forum
  11. ↑ Yigit Duzkoylu, Salim Ilksen Basceken and Emrullah Cem Kesilmez. Physical Trauma among Refugees: Comparison between Refugees and Local Population Who Were Admitted to Emergency Department—Experience of a State Hospital in Syrian Border District. Journal of environmental and Public Health. 2017. https://doi.org/10.1155/2017/8626275
  12. ↑ Van Hasselt, EJ. BURNS MANUAL.A manual for health workers.2018 2nd edition. pg 51.
  13. ↑ Hermansson AC, Thyberg M, Timpka T. War-wounded refugees: the types of injury and influence of disability on well-being and social integration. Med Confl Surviv. 1996; 12(4):284-302. doi:10.1080/13623699608409299
  14. ↑ Jones MW, Crane DA. Interdisciplinary care for spinal cord injured refugees. Spinal cord series and cases. 2020 Apr 28;6(1):1-3.Available: https://pubmed.ncbi.nlm.nih.gov/32345983/ (accessed 2.9.2021)
  15. ↑ Landry MD, van Wijchen J, Jalovcic D, Boström C, Pettersson A, Alme MN. Refugees and Rehabilitation: Our Fight Against the “Globalization of Indifference”. Archives of physical medicine and rehabilitation. 2020 Jan 1;101(1):168-70.
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