A qualitative research on mental health and psychosocial issues impacting Syrian refugee women in Turkey

doi:10.21203/rs.3.rs-2233366/v1

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A qualitative research on mental health and psychosocial issues impacting Syrian refugee women in Turkey

https://doi.org/10.21203/rs.3.rs-2233366/v1

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Background: Due to the civil war since 2011, around 4 million Syrian refugees have migrated to Turkey from their home countries. It is well known that being a refugee, especially a female refugee, is considered to be one of the highest risk group in conflict areas. The psychological adaption challenges and extreme feelings of homesickness have resulted in mental health issues that are more prevalent among refugee women. This study aims to understand how context-specific factors influence Syrian refugee women’ psychosocial wellbeing and mental health through focus group discussions.

Methods: A total of 9 focus groups were conducted with Syrian women (4), Syrian men (3) and stakeholders (2). Qualitative assessment was used to examine the experiences related to the psychological health difficulties of Syrian women living in Turkey with temporary protection status. Thematic analysis was run to analyze the data by coding and identifying themes or patterns. In this study, their psychosocial problems, intention to seek professional help, access to existing services, challenges in access to, and expectations regarding these services were evaluated.

Results: Refugee women experience psychological and social difficulties just because they are women. Also, refugee women seem to be more vulnerable to psychological problems than men due to the effect of patriarchal ideology and the problems experienced before the forced migration.

Conclusions:Psychosocial well-being of Syrian refugee women is affected by the social, economic and political atmosphere, and it is important to develop policies that address the needs of these women.

Syrian refugees

women

mental health

qualitative method

The forced migration caused by the civil war in Syria, which started in 2011 and continues to date, has been described as the 'biggest migration event' by the United Nations High Commissioner for Refugees [1]. Turkey is directly influenced economically, socially, culturally, and politically by this forced migration. From a demographic perspective, the current population of Turkey rose with the Syrian migration (total estimated number of Syrians: 3,644,342) such that now 4 out of every 100 people in Turkey are Syrians. This figure makes Turkey the country that hosts the world's largest refugee population [2].

It is well known fact that refugees often face more than one threat as loss of family, sexual and physical abuse and lack of shelter or food during war [3]. Moreover, refugees face physical exclusion, social isolation, a lack of access to their fundamental rights, linguistic hurdles, racism, cultural marginalization, daily stressors, and discrimination at post-displacement [4, 5]. Taken all these together, it is not surprising that the refugees prone to develop a variety of psychological disorders [6, 7].

A quantitative study of 27000 Syrian refugees resettled in refugee camps found that 19% of them have high levels of anxiety, and 9% have high levels of depression [8]. Furthermore, according to a study that looked at the prevalence of post-traumatic stress disorder (PTSD) among Syrian refugees, it was discovered that roughly one-third (33.5 percent) of Syrians had symptoms that met the criteria for PTSD [9]. Furthermore, when Syrian refugees in Turkey are compared to refugees from Southeast Asia, the former Yugoslavia, and Central America in Western countries (e.g., the United States, Australia, or Canada), they have higher rates of mental disorders [9, 10]. Refugees' mental health issues are likely to persist even years after initial settlement [11].

It is known that half of Syrians have migrated to Turkey are women and girls of reproductive age and Syrians in Turkey have a much younger population. Being both a woman and a refugee means additional suffering that can affect women’s health at multiple levels, mainly due to trauma, accommodation problems, language, education, and income, as well as prevailing sociocultural and traditional norms and values regarding women [12]. Syrian society is a patriarchal society and Syrian women are primarily responsible for housework and childcare in the division of labor, while men are responsible for providing for the household. In case the women work outside the home, they are monitored by the male relatives. These cultural practices, which are already difficult, become more complex for Syrian women refugees. Refugee women are at greater risk for mental health problems such as depression and anxiety due to lack of social support, violence, poverty, adverse health conditions and discrimination [13]. The uncertain living conditions in the refugee country, concerns about the safety of family and friends, uncertainty about the future and lack of control cause refugee women to experience fear, anxiety and hopelessness for the future [14, 15, 16]. In addition, due to their mother or wife roles, women feel obligated to carry extra burdens during the migration process to support family members' adjustment to a new way of life, and they often take on the role of preserving and maintaining family values, culture and beliefs. In the process of struggling with all these difficulties, they show social interaction and wasting enjoyable time outside as the most important coping strategies [14]. However, especially in Turkey, language barriers keep women away from accessing to education, employment opportunities, health services, social networking, and many other psychosocial and economic factors that can facilitate adjustment and adjustment in Turkey more often than men. The most important determinants to facilitate adjustment to refugee country are women's access to education, employment opportunities, health services and creating a social network. According to the results of a systematic review on the health outcomes of Syrian women in Turkey [17], free health services are provided regarding women's reproductive health, sexual health, gender-based violence, and psychosocial support; however, especially in Turkey, women seem to be more hindered than men in accessing these opportunities due to the language barrier [18].

Finally, it should be emphasized that the Syrian refugee population in Turkey is a diverse one; however, one main limitation of the literature is that it homogenizes this diversity, neglecting how differences based on gender, class, ethnicity, place of origin, religion, and legal status contribute to shaping the everyday practices of Syrian refugees [19]. Of the studies conducted in the last five years and the main findings presented, very few have focused on women and adolescent girls. Adolescent girls and young women's unique needs, opportunities, access to services, and relationships with the host community remain less studied. Consequently, the overarching goal of this study aims is to describe and highlight adolescent girls and young women’s needs with specific focus on their mental health issues as well as psychological service needs based, using the qualitative research methodology.

Participants & Procedure

This qualitative study conducted in Ankara, was part of a multicenter research project aimed to develop and evaluate a psychosocial- SRH integrated intervention package for adolescent girls and young refugee women. The qualitative component aimed to inform the development of this intervention. A total of nine focus groups with Syrian women (4), men (3), and relevant stakeholders (2) were carried out in Ankara. The group was formed based on maximum variation sampling. In determining the participants, assistance was obtained from key people known to Syrians living in Ankara. Participants’ rights were protected throughout the study conduction. They were informed that they could withdraw from the study at any time without explanation and can refuse to answer any question without affecting their care. To protect their confidentiality, their names were kept in a secured computer and replaced with numbers for the following credibility. Participants were informed that they would be contacted later for the credibility of the result and they signed for that. The demographic information was listed in Table 1.

Focus groups with Syrian women and men were held in Arabic and with the stakeholders in Turkish. All focus group discussions (FGDs) were led and moderated by a facilitator and assisted by a transcriber who ensured that the notes were being captured. Informed consent was obtained from the participants. The study was approved by Ankara University Ethics Committee (ref: 01.03.2018–04/12) as well as WHO Ethical Review Committee (ERC) approval (ref: A659340043300).

Table 1

The sociodemographic variables of participants in FGDs
Syrian Women (4 groups; total n = 32)
Age (mean)	23.81
Education Status	illiterate (9.4% ); middle school (62.5%); high school (3.1%); university (25%)
Marital Status	married (81.2%); single (6.3%); divorced (6.3%); widow (3.1%); engaged (3.1%)
Number of Children	1.87 (ranged between 0 to 5)
Syrian Men (3 groups; total n = 21)
Age (mean)	32.19
Marital Status	married (66.6%); single (33.3%)
Number of Children	1.61 (ranged between 0 to 6)
Stakeholders (2 groups; total n = 21)
Gender	Female (85.7%); male (14.3%)
Education Status	100% bachelor degree at least
Duty/profession	doctor (38.1%); psychologist (14.3%); health trainer (14.3%); expert (14.3%); nurse (9.5%); social worker (4.8%); engineer (4.8%)

Study Design

The overall study design was guided by the ecological framework and the health belief model. Thematic analysis was used to examine and analyze the data. This approach involved a systematic classification process of coding and identifying themes or patterns that emphasize the reliability and replicability of observations and subsequent interpretations. Focus group meetings mainly concentrated on two subjects: (i) psychological and mental health and (ii) suggestions about solving the problems. The former topic was queried with the following question as “What types of psychosocial issues/problems could Syrian refugees, adolescent girls, and young women face in your community?”. The other topic was questioned with the question of “Do you think women seek help in order to solve any psychological problems they could be facing?”

According to the observed results, many factors impacted Syrian women’s psychological health and well-being, as expressed by women, men, service providers, and stakeholders. Psychological health was assessed by taking into account five main attributes: i) Family and community-related issues, ii) Working conditions, iii) Service-related issues, iv) Economic issues, and v) Political climate in the region and Turkey (Table 2).

Table 2

Sub-themes and codes addressed in the assessment of psychological and mental health
Sub-themes	Codes
Family and Community	Home-bound living Social isolation Not knowing Turkish No habit of being seen by a doctor for psychological problems Male child preference of the husband and the family Changing gender roles Failing to engage in harmonious relations within the community and exclusion Broken families
Working Conditions	Housing Limited work rights Discrimination Difficult working conditions
Service-related Issues	Language barriers Privacy
Economic Issues	Poverty Unemployment Economic dependency
Political Climate	Uncertainties about today and tomorrow Feeling fragile Low level of trust in others

Gender dynamics

Syrian women reported in the FGDs that they were under pressure from their husbands and other family members about appearing in public. The home-bound status of Syrian women was cited to be negatively impacting their psychological health in particular:

"In general, women are under more pressure than males; it may be because of family or husband. For example, she cannot go out of the home even when she wants to. And there is this language problem again. She cannot speak and understand the language spoken around her and is not given training in the language; she finds it difficult to be outside of the home." (Man)

Stigma In Seeking Psychological Services

Seeking support and services for psychosocial problems is often perceived as weak and tends to be stigmatized. In many circumstances, it is difficult to decide to seek out psychological support, and they tend to conceal it due to the fear of being stigmatized as "having gone insane":

"Nobody goes since people who go to a psychologist are regarded as nuts in Syria. We know this is not the case, but this is how it goes." (Woman)

Difficult Living Conditions

Another issue was attributed to the nature of their men's working life. Trying to adapt to working under harsh conditions (e.g. long and intense working hours) that are often perceived as unfair can present psychological challenges. The fact that their husbands work so as to help maintain the family order, looking for a job, working hard, and earning little, pushes women to be "understanding":

"In Syria, we used to have our own house, and we did not pay rent. It is not the case here, and we have to pay. We try to speak silently and understandably mitigate the responsibility of the male." (Woman)

Group Solidarity Among Syrian Women

Service providers expressed how Syrian families tend to live close to each other, building strong community networks and enhancing solidarity among women. The internet is another medium of communication in this regard. All the women indicated that they have smartphones, participate in Facebook groups, and communicate with other Syrians through virtual channels:

" I see there is strong solidarity among women. Women come in as a group. A man is leading them, but he waits outside without intervening. A single woman rarely comes by herself. They act as a group, and group members support each other. If you can find somebody in the group that you can act in rapport with, she can easily lead others." (Gynecologist, female)

Political Climate

It has been observed that Syrian women are directly affected by the discourse and policies concerning refugees. This further aggravates their psychosocial problems:

The authorities have recently grown quite suspicious about and strict toward us. What would I do if they suddenly decided to send us back? No home, no means, no safety?" (Woman)

Some discriminatory attitudes, failure to engage in harmonious relationships with the host community, and exclusion were stressed upon as often causing profound psychological impacts, making the women feel alone:

" For example, we cannot mesh with the local community here. For example, when we try to rent a house, they tell us no house for Syrians, saying they don't like Syrians. We Syrians can adapt to the local conditions/ people if they are open to us, but actually, they are afraid of us. They behave like we are a weird, strange community." (Woman)

Coping Mechanisms: Formal And Non-formal Strategies

It is observed that trying to solve the problem within the family and through personal individual efforts to cope without telling anybody else were the main methods they used. Crying alone and letting no one learn about their problems was regarded as an indicator of psychological strength.

"I lost two brothers in the war. My mother died of cancer a month ago, and it was because of chemical weapons used in the war. My son and my cousin were taken to intensive care after having been wounded in an airstrike. All these events passed before my eyes. However, I still cannot accept seeing a psychologist. It seems as if that is a place where only insane people should go. It gives you bad thoughts, and I keep crying all the time." (Woman)

Perceived Barriers: The Trust Issue

An essential reason behind women’s reluctance to seek psychosocial help was the "trust" issue. The women need to discuss their problems among trusted others in a safe place. When these opportunities are perceived as available, the women do seek out help and find it helpful:

"It is a matter of trust. Some Syrian women came in and were silent. They asked these women if they needed psychological support. They were hesitant at the beginning, but some of them said yes. The women who received psychological support visited their psychologist after two months and thanked her. So they want to speak out, and they want to speak with someone they feel they can trust." (Doctor)

Language

One of the most commonly reported difficulties in seeking access to psychosocial services was noted to be language:

" Language is a problem in psychological support sessions. Although translators are often used, psychological support requires much longer and better quality communication than other healthcare services. Transferring emotions is interrupted when a third party interferes. Psychological support must be a process involving only two parties, and this barrier is one of the important problems." (Turkish Female Expert, Women's Services, Ministry of Family and Social Policies)

However, others noted the quality of services is also problematic, highlighting that private healthcare provides better care, better treatment, and shorter periods of waiting, but many cannot afford this.

Children Have Too Many Problems

It was indicated that Syrian women tend to prioritize seeking health services for their children’s problems over solutions for their own psychological and psychosocial issues.

"Given our population, most families coming in for counseling services do so for their children. Their complaints include bedwetting, including its form as 'post-traumatic stress disorder,' peer bullying at school, insomnia, and nightmares. These suggest that families are concerned about their children and do rush around for help." (Social worker, female, Migrant Health Centre)

Sexual And Reproductive Health

The women agreed that issues related to sexual reproductive health and psychosocial problems are interrelated. Traditions support early child marriage and having numerous children. All these are too tiring for women, and feeling psychologically tired and unwell badly affects sexual life as well:

" For example, when I feel psychologically tired, I don't want to have sex. Maybe I recalled something from the past, or a story has come to my mind … My husband has no respect for such situations. He does not care about my psychology; all he cares about is what he wants at that moment. It makes me feel bad, and I want to stay away." (Woman)

Two important findings can be highlighted based our assessment. First, refugee women have significant difficulties associated with being a woman. Women continue to face important challenges related to their psychosocial well-being. This was perceived to be predominantly attributed to the patriarchal ideology and the problems experienced before the forced migration. These patriarchal norms continue to exist in Turkey, often closely linked with the prevailing social norms and the status of women in Syrian society. The second finding pertained to being, specifically, a refugee woman. Refugee experiences, generally, often make women more vulnerable than men. Being a woman and a refugee means additional suffering that can affect women’s health at multiple levels, mainly due to trauma, language, education, income, and sociocultural and traditional norms and values about women.

Syrian refugees face a slew of challenges that could jeopardize their physical and mental health in their daily lives. Various public studies have revealed that Syrian refugees face social marginalization and frequently feel compelled to return to their home countries. Syrians are burdened by these feelings, which cause trauma and psychological suffering, stigmatize them, and prevent them from assimilating into the society they live [20, 21]. Syrians are psychologically distressed and considering suicide as a result of challenges in both their own country and the nations to which they travel. However, they cannot communicate their views due to cultural and religious restrictions and the risk of stigma and exclusion [22]. Similarly, in this study, it was emphasized that inability to enter into harmonious relations with the host community and exclusion cause deep psychological effects.

Current studies on Syrian adolescent girls and young women appear to be limited. Results show that young women face significant challenges, including access to general reproductive healthcare services, antenatal coverage, obstetric and gynecological care, psychological and mental health services, access to modern contraceptives, access to STIs and HIV prevention efforts, and support against domestic and intimate partner violence [23]. Cost, language, cultural understanding, limited availability and quality of services, poor quality of services, insufficient knowledge of mental disorder symptoms, lack of awareness of mental health and psychosocial support and stigma have all been identified as significant barriers in studies with other conflict-affected populations. The experience of forced migration and life experiences in Turkey negatively affect their psychological well-being. Language difficulties also further aggravate this situation, as language proficiency is a significant issue when accessing services and care.

The Turkish government and non-governmental organizations have worked hard to meet the refugees' basic needs, such as food and shelter. Nevertheless, Syrian men and women participating in this study talk about difficult working conditions and that men have to work longer hours in order to live in better conditions. It has been stated that these difficult conditions affect the mental health of women and may cause psychological difficulties. Furthermore, while efforts are being made to meet the mental health and social service needs of those who have been forcibly displaced, counseling services remain insufficient [24].

According to a study [25], investigating the prevalence of mental illness among Syrians living in Istanbul and their ability to access mental health services, findings showed that post-traumatic stress disorder, anxiety, and depression symptoms were prevalent among Syrian refugees. However, only a tiny part of the population in need asked for psychosocial support. According to the authors, giving access to the national health system is not enough to overcome the mental health-related problems of refugees. Improving access to the needed care in this area calls for addressing shame, fear of social stigmatization and reprisals, and concern about lack of confidentiality. For example, sexual and gender based violence survivors are often reluctant to report instances of sexual violence or harassment or seek treatment [26].

In sum, available research on the problems faced by Syrian refugee women is also very limited in Turkey. More research is related to general issues facing Syrian refugees and children than to women-related problems. Living at home, the lack of paid work opportunities, difficult living conditions, economic difficulties, and lack of acceptability to seek and receive professional psychological support predisposes women to compromised physical and mental wellbeing. Embarrassment to seek psychological help, fear of social stigma, and anxiety about privacy hinder the seeking out the needed psychological support services. When language difficulties are further added to the difficulties produced by the leading social structure, the problems become even more significant.

As a conclusion, the young women and adolescent girls in this study are yearning to be proactive and to address their needs and challenges. Safe spaces that women and girls can seek out for their unmet psychological services that privately and confidentially accessible will encourage the Syrian migrant women to seek the needed services and take on a proactive role in managing their day to day problems. Also, it is strongly believed that additional research is needed to help address gender inequality in order to tailor better responsive interventions and programs, grounded by the realistic expectations that patriarchal values are inherit, less amenable to change, and were brought along with the Syrian refugee communities in with migration.

To get the most out of the services available, refugees must first learn about them. The government and humanitarian organizations must adopt terminology that Syrians understand. Organizations should clarify available mental health and counseling services, define counselors, and explain their benefits in brochures, handbooks, reports, and nameplates. Most Turkish counselors who work with Syrians were educated in Turkish counseling programs fashioned after those in the United States and contained Western-based therapy ideas [27]. Because Syrians come from an Eastern culture, this Western-based education and practices may reduce the effectiveness of counseling and pose challenges to counselors. In this regard, a group of Syrian mental health facilitators who have been trained through the NBCC MHF program could help work with this community [28].

Acknowledgements

To all our colleagues at the WHO Turkey country who facilitated access to the desired target population, field, data collection as well as informed the interpretation and the understanding of the assessment findings. To all the research participants who participated in this assessment, whose feedback and point of views were instrumental to this work.

Ethics approval and consent to participate

This study was conducted after obtaining ethical clearance from the Institutional Review Board Ankara University Ethics Committee (ref: 01.03.2018–04/12). In addition, the Research Project Review Panel (RP 2) of the World Health Organization-Department of Sexual and Reproductive Health reviewed and approved this protocol as well as WHO ERC (ref: A659340043300). Additionally, all ethical procedures, including obtaining informed consents, were in line with WHO guidelines for health research and were closely coordinated with the WHO Turkey Country Office and the Department of Sexual and Reproductive Health and Research (SRH) of WHO Geneva Office. The FGDs were carried out after getting oral and written consents from. Participants were provided with detailed information on the study aims, procedures, and any potential risks and benefits due to their participation. To encourage honest and accurate responses, study participants were also assured that they had the full right to participate or withdraw from the study at any point during the FGDs.

Consent for publication

Not applicable

Availability of data and materials

Available upon request

Competing interests

The authors declare that no competing interests exist. The authors alone are responsible for the views expressed in this article and they do not necessarily represent the views, decisions or policies of the funding bodies or institutions with which they are affiliated. The authors also declare that they have no conflicts of interest financial or otherwise.

Funding

This work received funding from the UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), a cosponsored programme executed by the World Health Organization (WHO). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Authors’ Contributions

LK and MÇ conceptualized and designed the study and all authors reviewed the paper and provided critical inputs. MÇ, BAS, KÇ, AUM drafted the initial version of this paper with support from all authors who reviewed and helped critically revise the paper. MÇ, BAS, KC, AUM revised this manuscript after feedback from all other co-authors. All authors approved the submitted version.

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No competing interests reported.

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A qualitative research on mental health and psychosocial issues impacting Syrian refugee women in Turkey

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Abstract

Background

Methods

Participants & Procedure

Study Design

Results

Gender dynamics

Stigma In Seeking Psychological Services

Difficult Living Conditions

Group Solidarity Among Syrian Women

Political Climate

Coping Mechanisms: Formal And Non-formal Strategies

Perceived Barriers: The Trust Issue

Language

Children Have Too Many Problems

Sexual And Reproductive Health

Discussion

Conclusions

Declarations

References

Additional Declarations

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