We have described the key findings based on the theoretical framework described above.
Contextual factors, susceptibility and internal coping mechanisms (Factor A)
We classified several factors related to respondents’ family situation, their experiences of violence before and during their migration to Belgium, as well as , the structure of the asylum centre, including service provision and health system factors, as contextual factors.
Background of research participants
Twenty-seven respondents were interviewed during the research projects, All respondents were above the age of 18 and were able to give informed consent. Some of the refugees were survivors of gender-based violence and torture (4 respondents). The service providers were mostly Belgian, apart from 1, and consisted of social workers, education workers (focused on life skills and supervising daily activities in the centre), medical doctors, nurses and psychologists. The refugees were from East and West Africa and West Asia. A third of the refugees had at least a bachelor’s level of education and cited political unrest and economic reasons as some of their reasons for migration. Specific details about the countries they come from have been excluded to protect their anonymity and prevent stigmatization that might arise from conclusions of the study. During the interviews, issues around integration were identified as important by all the respondents but more by the social workers. This was defined as being more than just understanding the local language but also behaving in what was considered a ‘culturally acceptable manner’. The term ‘culturally acceptable’ was described in terms of adhering to an acceptable dressing style, manner of speaking, ‘ways of conducting oneself’ and hygiene. However, one could argue that these integration issues were not cultural per se, but more related to ideas around propriety in Belgium and conflicts with different behavioural attitudes and diversity.
‘…social network with local people. It is not an easy task. Lots of cultural differences, first they have a cultural shock, a lot of differences, …, you need too much time to integrate.’ (Medical translator and doctor, Refugee)
‘…you walk on the street and you see, a lot of people say. we see these people (refugees) and we are afraid…that’s a small thing, I think the way you dress is less important than the way you conduct yourself.’ (Social worker)
The social worker discussed the underlying tension or fear among the local population, as what could be referred to as ’the fear of difference’, specific issues raised were the ‘loud manner’ of some migrants, which were perceived as aggressive, or the unruly behaviour of migrant children from specific backgrounds.
The service providers which consisted of medical doctors, social workers and nurses, all had prior experience with working with refugees/ and undocumented migrants but few had experiences of migrating and living in another country, which may have implications for how they experience or perceive the needs and appropriate services required for refugees and undocumented migrants.
The duration of stay in Belgium varied from 3 months to 7 years among the research participants, who were refugees. However, there was no reported association between length of stay in Belgium and perceived level of integration. It is important to point out the complexities of integration in Belgium, which are heavily influenced by linguistic and regional politics and can be ether broadly defined as assimilationist or multi-culturist. The multi-culturist-interventionist type of policy and approach, which is more common in the Flemish region is characterized by compulsory civic and language classes, and a focus on migrants adhering to the Flemish identity. The assimilationist colour blind approach is more common in the Walloon region and has a policy that allows room for diversity , hence the lack of compulsory language classes. These differences may add layers of complexity to the definition of cultural integration in Belgium (Adam & Jacobs, 2014).
The asylum process arose from most of the interviews as a crucial component and an indicator of the well-being of refugees. Most of the respondents (refugees and service providers) spoke of the difficulties of being ‘in transition’ being moved from one centre to another, while awaiting the decision on their asylum. This was a factor that had a significant effect on their psychological well-being. These changes and frequent movement among people still within the asylum process, might make it difficult for sexual violence survivors to access needed care, as well as needed follow up, psychosocial counselling and medico-legal procedures.
‘there’s a huge difference, in terms of the challenges, the uncertainty, you often see it in the chain from the asylum procedure, to obtain a status, that makes a huge difference both in the positive and the negative sense, it impacts your mind…positive is what gives security and safety, the feeling that I can now start my life, Negative(asylum status) is that you begin to lose many support structures in terms of the asylum centre and that feeling of stability…’(Service provider, psychologist, female).
Harrell-Bond and Voutira (1992) described this feeling using the term ‘liminality’, an in-between situation that applies not to only economic and social security, but also to legal and psychological situations. This uncertainty makes the lived experiences of many refugees precarious, for as long as they are within the asylum process, they can be moved from one part of the country to the other, disrupting the existing social networks they might have formed as well as a feeling of security they might have developed.
‘the situation here is so hard, the people here are placed and replaced and they have to change from centre to centre and schools it is so inhuman….’(Service provider, doctor, male)
Most of the refugees and health workers interviewed for this study were reflective while describing their experiences providing or accessing healthcare at the centres. Most of the refugees expressed an appreciation for the services they were provided at the different centres, while also expressing dissatisfaction at barriers, which are described later in this paper. The service providers also seemed to understand the budgetary and human resource challenges encountered in their provision of services and described different strategies for dealing with this.
Experiences of trauma and psychological distress
Physical violence was the most reported type of violence among the respondents. There were different examples of physical violence reported including female genital mutilation, physical assault between refugees, violence from smugglers and intimate partner violence. Most of the respondents discussed this situation with the social workers. One of the most common barriers discussed was the cultural expectation or shame linked with domestic violence (physical or sexual). Responses to reports of physical violence were varied, from ‘no action taken’ to provision of psychological counselling.
Physical mostly, physical violence is often [reported by] men and women, but sexual violence either people are not disclosing, (or there are) rare cases,…, I have seen myself. I think this exists but might be because of shame, taboo or cultural differences they are not going to disclose it. (Research assistant, Male)
Experiences of torture: Some of the service providers reported instances of torture among the male refugees. They also discussed the difficulties with getting these men to share their experiences of trauma. While all the service providers recognized the importance of providing counselling and psychological care to the refugees, most centres had no in-house psychologists present. External referrals were required, however, not all psychologists were willing to work with refugees and undocumented migrants. A commonly cited reason for this was the language barrier. Most of the service providers had to develop a network of psychologists who had experience working with refugees and were willing to conduct therapy sessions with a translator.
Yes, of course I would never say, this one has been tortured, but I could say to the reception or to the nurses, don’t disturb us now, because it is a heavy conversation. So that would create like a kind of bubble…Especially because we had men who had been raped, they would never talk about this in their interview, because of the shame and trauma, it was too big. And in this way, a psychologist …we had a conversation about torture, and I would never stop it at that, because then the story is out, but the evil spirit is also out. So, we need to provide counselling and afterwards…There were some very good psychologists, (with) whom I would make sure that the people would go there for follow up and for treatment. (Medical doctor, Female)
From the interviews, it seemed there was a gender bias in reporting behaviour among men and women. Women were more likely to share their experiences of torture or sexual and gender based violence than men. A reason for this, could be the absence of targeted interventions for men who experience SGBV or adequate screening procedures for them. We would like to advocate for a gender lens to be applied to screening exercises done in the reception centres, with an understanding that men and women of different ages, gender identities and sexual orientation might report experiences of sexual violence and torture differently.
Sexual violence: Though there were instances of sexual violence, disclosure was difficult and often dependent on the attitude of the health professional. Health care professionals who probed deeper for sexual violence risk, were more likely to have patients disclose their experiences.
…I see a lot, and I think not all are… I try to ask, it is not easy to ask directly, for women it’s not easy to answer… I am clear that lot of people (have experienced) sexual violence…not only women, we have a lot of young men from Afghanistan (have experienced) sexual violence too. So, I try to ask whenever it’s possible. But I see a lot, more than normal with my consultations... (Medical doctor 1, Female)
The medical doctor quoted above repeatedly stressed on the sensitive nature of screening for SGBV, a strategy she used, was to ask a lot of general questions before discussing sexual violence. Another medical doctor affirmed:
… A lot. Oh, they were very open about it. But never, almost never from the beginning, of course. That's why I think this intake was ok, because we wanted to give them the feeling that there was an opportunity to talk about it. And for many times we opened, we were very active in starting a conversation about this (Medical doctor2, Female).
This comment reaffirms the importance of screening for experiences of violence, as this provides an ‘opening’ for refugees to discuss their experiences.
Common health problems: psychosomatic symptoms
Some of the most common health problems, the respondents presented with at the health clinic were psychosomatic, it was rare for them to present at the clinic and directly report their experiences of SGBV or torture. They only agreed to share their experiences of violence after several discussions. Psychosomatic symptoms were often related to experiences of trauma, during their migration journey or in their home country.
…it is mostly combination of anxiety related problems including sometimes Post Traumatic Stress Disorder, and sometimes more severe problems like psychosis. Sometimes stomach pain, breast pain, and anxiety related problems like flashbacks, and depression of course. Often related to a combination of traumatic experiences and losses, born in uncertain situations, difficult events...(Psychologist, female)
…long time, long time. But support here (in Belgium) because sometimes I couldn’t sleep, I would dream about it but they gave me some tablets to help me sleep. I used to take them but after some time I stopped because I wanted to sleep in a natural way. I am afraid, still have them with me. Sometimes it happens, I can spend one week without sleep, morning, evening I don’t sleep, and I am strong. But that is not life... (Refugee, female)
These findings show that service providers need to spend sufficient time discussing with their patients/ clients and probing for experiences of violence, as discussed above. It also requires that most medical centres ensure that they have the right referral pathways, so they can ensure survivors of violence identified have the right access to psychosocial support.
Co-factor A: Contextual Factors
Contextual factors such as cultural norms and health system factors were also reported by most interviewees as influential in their decision making to access healthcare services.
Cultural norms around IPV:
Family network members, key players and reporting of gender-based violence: Family members of a survivor of violence could influence their coping strategies and attitudes towards reporting their experience of violence. In a case of a female survivor of domestic violence, her mother’s support was highly valued as it gave her the psychological support required. Her mother told her to cope with the experience of domestic violence, as it was a cultural norm for husbands to sometimes beat their wives. This example outlines the complexity of family relationships and reporting patterns. Family members might be able to provide functional support to survivors of violence and aid them in coping with stress and psychological effects, and still discourage them from reporting. In some cases, the family member might be the main aggressor, and more interested in preventing the reporting of violence. Hence, network interventions that focus on key players (very influential network members) would have to take into account the complexities that exist in social networks with family members.
Health system and health worker responses
In general, health service providers, social workers, nurses and doctors who provided services to intimate partner violence survivors, referred the survivors to psychologists, with their consent. The responses from these service providers ranged from supportive to ambivalent.
Opening hours: There was a reported disconnect between refugees and service providers’ expectations about availability and opening hours. The working hours of the centres were sometimes perceived as a barrier for access to healthcare for most of the refugees, however, for the service providers it was very important for them to have that structure to enable them function effectively. When the opening times were not respected, this was often viewed as ‘crossing boundaries’ or ‘being disrespectful’.
… But I always give the signal that it is possible to come, if they want something, and I keep reminding them. But they also have to follow the rules, because it is not because you are a loner and one time you make a decision you come and ask for help, if you do it in the break, it is break time, you are not getting special treatment… (Social worker, female)
…yeah, yeah, it’s been easy (to access healthcare). The problem is that they just open for two hours. But the service is good when they try to do everything, and when they can’t they transfer you to the big hospital. If you don’t have an appointment, they can’t. But they do their best’ (Refugee, female)
. It is important to note that the concept of availability is not the same for service providers and for refugees (service users), and this could influence how survivors of violence perceive the availability of support for them. It is important that service providers take into account that specific vulnerable groups, for example, survivors of violence might require access to support services that extend beyond daily working hours. Creating alternative services, like chat lines or emergency support could make a difference in access to healthcare for these groups and mitigate harmful consequences. Also, from the human resource perspective, understanding the need for extra hours and more staff, referral pathways and adequate compensation for staff, can prevent burn out and motivate service providers.
Limited human resources: Some of the respondents reported difficulties in accessing services due to the lack of sufficient human resource. This problem also limited the ability of service providers to provide sufficient assistance and support to the survivors of violence
…I know a lot of people came once or twice to the nurses and then say I don’t want to come back because it not good. Lots of people think that medical services (are) not good because it’s difficult to access the doctors because there are lot of people, we don’t have sufficient spaces and workers…(Medical doctor, female)
Lack of trust and ambivalence from service providers: Trust arose as an important factor, that could also be enabling and encourage disclosure of experiences of violence. It was also a barrier when there is a lack of trust present.
… Many are willing to discuss but there are parts that are hard to express. And it largely depends on the situation they were in. if they are at peace to talk in a quiet stable situation. For some it’s hard to talk about because it reveals lots of emotions. Sometimes they feel like avoiding those emotions because they are too tough to feel. It depends. I feel there is lot of distrust preventing them to talk about it. Protecting themselves. It depends… (Psychologist, female)
In some cases, when the survivors of violence reported their experience of violence, they were met with ambivalence from the service providers which discouraged reporting of violence.
… [breathes] last time I was passing by the block F, I had come to see my assistant, I heard in one office one lady telling that one guy was abusing her. But sometimes these things happen. [And even if they talk to the assistant they do nothing]. I don’t know… they just give them advices … like I heard even before I came to PC [centre] one lady was telling that one guy was abusing her, the assistant was laughing, did nothing [reports of abuse taken very lightly, no redress l[sic]…but I heard that later they changed her room. (Refugee, Male)
Medical centres that provide care to refugees or undocumented migrants, often have a huge demand with limited resources, making it difficult for many refugees and undocumented migrants to develop relationships of trust with their service providers. However, it is possible for these relationships to be built over time. For example, most refugees interviewed developed good relationships with their social workers because of sustained interactions over time. In centres, where refugees saw a particular health provider over a long period of time, there was also more trust between the provider and refugee.
Factor B: Network members’ reaction to the survivor reporting
We describe below several factors we identified, that might mediate network members’ ability and reaction to experiences of violence.
Inability to speak the language of the service providers was often cited as a barrier to disclosure of experiences of violence and also a limitation on the service providers’ ability to help the refugee. This also limited opportunities for integration into the society. Specifically, for refugees who experienced PTSD or mental health issues, this barrier was significant as it limited opportunities to get psychosocial counselling, as well as isolated the survivors of violence. Hence, limited the efforts of service providers to support survivors of violence or other kinds of trauma.
… They are not used to disclosure, there are many barriers to disclosure. And there are more barriers of disclosure when the woman is in a more vulnerable position. This can be because she is without papers, does not speak the language, because she depends on that guy, he supports her, especially because she does not speak the language. (Gynaecologist, female)
…so we’re supposed to refer the patients, who were having psychological troubles, to psychologists or therapists outside of the centre. But of course, because of the language barriers and because of a shortage of interpretation services and because of attitudes of local therapists and so on, and lack of experience in working with this population. We did most of it ourselves, unless we say that there was really a psychiatric problem, then we would send them to psychologists or psychiatrists or a mix of them, of whom we knew that they had experience and willingness to work with this population… (Medical doctor, female)
Lack of power:
Among some of the respondents interviewed, the inability of members of their social network to influence ‘outcomes’ affected their willingness to discuss their issues with them. In most instances, the inability of the network member to influence the asylum process or ensure access to resources, discouraged them from seeking help from these people.
‘hmmm [pauses] I don’t think because I just said, I specifically know 2 persons that they don’t do politics, they can talk of my problems, if something happened to me, no, they don’t have voice…they are citizens like any simple citizens, so they cannot say anything if something happened to me’ (Refugee, male)
This comment draws attention to the fact that the presence of a large social network for a refugee and survivor of violence, does not necessarily translate to increased access to resources. The network members of the survivor of violence must also be perceived by them, as able to positively impact their circumstance, either through functional or instrumental forms of support.
Co-Factor B: Effort required by the network members’ to support or oppose
From the interviews, efforts required by family members, friends and service providers, did not come up as an issue or factor that influenced the level of support. However, in one interview with a political refugee, she mentioned that it was impossible to get support from her father because contact (via phone) would put him at risk. In this case, the effort and personal cost required by her father to provide emotional or financial support to her, was too high. The same fear of persecution of family members, arose from other conversations with political refugees who had survived SGBV and whose families were still living in their home country. In most of these cases, there was no contact from family members.
From interviews with service providers, the personal cost of working extra hours or providing care during ‘lunch hours’ could serve as a barrier to access. Some of them were unwilling to do this. Hence, our earlier recommendation for training, recognition and compensation of extra working hours for service providers.
Factor C: Costs of effort for the survivor to report or not, degree and centrality measure of network members (constraint and cohesiveness of the network)
Cohesiveness of the network: The closeness of social network members of refugees who are survivors of violence (sexual violence or torture) can encourage or deter them from reporting their experiences of violence during a medical consultant or to their social assistant.
‘Yeah. And also, if the, for example, there is abuse in one family, ehm, and the family is here, there is more pressure from the family members not to tell anything instead of, there is woman, or a man, coming here and has been abused, but here she is alone, maybe there is less pressure from the family’ (Social Assistant, Female)
In many situations, especially if the asylum claim is made by a whole family, and there is an incident of SGBV, where the perpetrator is a family member, it would be very difficult for the survivor to disclose and seek help for the incident because of the implications (the asylum process) for the whole family. In other instances, the dependence many refugees have on family and social networks for emotional and financial assistance, can also negatively influence their ability to disclose incidents of SGBV within the family circle. Understanding these dynamics can be helpful for service providers and researchers, in understanding the barriers to access to healthcare.
Co-factor C: Degree and centrality measure of network members
Among refugees interviewed, it was difficult to assess which refugees were ‘central’ to their network and were key players. However, it was clear from some interviews, that certain people had more authority and more contacts with different refugees than others. Also, during collection of pilot data and ethnographic work, it was clear that some family members’ or friends’ opinions were more valued than others in decision making. In some instances, especially when it was about navigating the legal and social system in Belgium, the perspective of the social assistant was more valued, or another refugee with more years of experience of living in Belgium. The implication this has for SGBV survivors, is that if SGBV interventions are directed to individuals, and influential members of their network oppose their decision to access health care, this will make it very difficult for the refugee to receive the necessary emotional and physical support required, and might even result in isolation from other members of their network.
The Bridge: During the interviews, I identified people whom Valente (2012) refers to as people with bridging properties within a network, they were often people who had been in the centres for less than 6 months, had few social network members, were bi-lingual and had friendship networks that were heterophilic. In a microsystem, were most people sought friendships with people they viewed as being similar, bridges were often people who had friendships across ‘cliques’. Though they had close friendships with people from their own country, they were likely to identify people from different countries as being part of their friendship network. They would not be identified as key players/ opinion leaders in a network analysis, but during my interviews and subsequent informal conversations with them, they were the ones who expressed more of an interest in my research project and proffered specific recommendations to address gender-based violence and its effects, that were based on peer-support. I ended up engaging some of these people as volunteers in my research project. I think these are the people with the greatest potential to effect change, especially in complex network structures, like those found in the centres I worked in.
‘No, no [responds to question about having friends from the same country]…. from other places like Rwanda, Congo, Niger, Ivory Coast, Kenya, Morocco, yeah, [the friendships are helpful]...One day, was talking to a staff at PC [centre] regarding as we are coming from different countries, we have different cultures, many things, I was telling them like to do one meeting for all people at PC…for some people who, how to say it, who in their life had difficult times, they want to be consulted [and speak about it].. because talking about it, you will feel well… [Male, refugee]
The refugee I spoke with above supported the idea of getting different refugees and nationalities together and consulting with them to jointly develop solutions to address their past experiences of violence and trauma and develop sustainable solutions.
Type of support groups identified from the research project
Support from family members
Family support was cited often as a source of emotional support, that buffered the psychological distress from the migration process and from the experience of structural violence,
Yeah, I have been in contact (with family members) you can say that they help. Not financial. It is like a psychological support (which helps) – (Male, refugee)
Other forms of family support included instrumental support, but this was not mentioned often. Instrumental support was mostly financial support or connections made through family members that facilitated the migration process. However, after they left their home country, most of the support received from family members was psychological, or in some cases, the respondents were reluctant to let their family know how dire their situation was and preferred to not be in contact with them.
In some cases, family members were seen as possible stressors, or unable to proffer any help. Hence, some of the refugees would rather not disclose their experiences to them.
‘. The other guys (family members) I don’t want them to know where I am. The reason why I am here is the problem I face with (some of my) family members…because my father was in ..a polygamous marriage,.. so I am supposed to be the one to take care of the family… by knowing where I was they try to kill me when I was in Cameroon. So it will be good for me to be apart…(Male, refugee)
The recognition that the presence of family members might not be positive is important while developing social network interventions for survivors of violence, who are refugees and other vulnerable populations. Analysis or probing to understand the quality and type of connections between network members should be a pre-requisite before mapping or developing social network interventions.
Support from friends:
Among many respondents, peer support was often the most common source of support sought and received, and the level of support was mostly classified as good or fair. ‘Good’ referring to support that was perceived by the refugee as making an impact on their daily lives, and ‘fair’ as irregular assistance. Peers were cited as sources of functional and instrumental support, and sometimes helped to buffer stressful factors, by listening, providing information and facilitating social connections required by the refugees. In many of the centres, there was a mix of different nationalities and languages, many refugees sought people of the same nationality, who spoke the same language as friends. In a few cases, especially for refugees with children, they sought people in the same ‘situation’, specifically refugees with children whom they could communicate with. The reasons for doing this differed, for some the fact the people they met spoke the same language and had the same culture, was reassuring for them. Especially in a context that was different and filled with a lot of uncertainties regarding their future and opportunities. For others, through these networks, it was easier to get functional support, specifically information and resources that helped them improve their socioeconomic status. Seeking and receiving peer support was associated with seeking social support from other sources, like social assistants and family members. Among the survivors of violence, survivors who sought help from friends, were also likely to have other sources of support from their network, like social assistants and it helped with coping with psychosocial distress.
‘…yeah. So it was leaving everything to me, cleaning the house... And when I used to come back I was really sad, so one day he tried to beat me [the husband]…it was first time, so the (social) assistant is trying to help. It happened. You can’t deny it didn’t happen . I talked to my friend living here. Last time I talked to her. And assistant of course,… yeah it helps…’(Female, refugee)
…No, I do not have family here…But actually I know some of the Guineans and Cameroonian guys with whom I am sharing, but apart from that I don’t have any family or friends here…I cannot say if they are friends but because I am in some country where I don’t know anyone, I wanted to have somebody I can talk to, I can… I don’t know… They are naturals (refers to same nationality)…. Made them my friends (Male, refugee)
Respondents reported peer support to have a buffering quality from a lot of stressors present in their daily lives. These friends provided emotional support, or information regarding opportunities. For a refugee who was a single mother and a survivor of violence, having friends that could look after her daughter while she ran errands or looked for jobs, buffered some of the psychosocial effects of the experience of violence, as well as what she perceived to be the difficulties living in the centre. For another survivor of violence, being able to speak sometimes with friends she trusted, alleviated some of her psychological stress, as she was unable to speak to a lot of people, because of fear that, that would affect her asylum status.
Support from social workers:
In centres where the medical service were provided within the centre, an ‘intake’ procedure was in place for new refugees who are sent to the centre by the commiserate. In many cases, the social workers were responsible for giving an introduction or orientation to the centre, afterwards a medical intake was done by the nurses, which also involved a screening exercise for tuberculosis and other infectious diseases. Other illnesses or ailments reported were addressed by the nurse if they were perceived to be not ‘serious’ or not requiring prescription medication. For many survivors of violence and torture, this meant they sometimes shared their experiences of violence with the social worker and might never share their experience with the doctor, unless the doctor probed and screened for experiences of violence specifically.
‘ I think when they arrived in the centre there is a social intake with a social worker and she explains how the roles are and also explains there is a nurse here you can see her you can come to her if you have questions and this is the first pad which be done by the social workers and they come to see us but if they do not come to see us we do not search for them normally there is a flow of info about a person, then Fedasil calls us if there is a special medical issue then we know it before, but normally people one day they will come to see us, but the social worker has to say you have to take your medical profile to your nurse and the most of the people do this’ (Nurse, female).
‘I first… I didn’t know it was important to come to a doctor. Just went to the assistant. She is the one who took me here’ (Refugee, female)
Most of the respondents identified social assistants as sources of instrumental support, people they sought help from when they required tangible things, and not emotional support. For survivors of violence, who were willing to discuss their experiences, they were more likely to discuss their situation with the social assistant than with any other service provider. There was an associated perception that discussing issues with the social worker would provide tangible solutions. The dependence on social assistants is usually more in the ‘beginning’, when a lot of refugees are not aware of the existing social structures, but as time passes and they become aware of the existing infrastructures, they rely on the social workers less. Probably, because they have also built external networks and are more clear on how to navigate the social systems.
The time dependent nature of sources of support should be taken into account when developing relevant interventions; as SGBV survivors who are refugees will build their own network after some time, and there might be a need to combine service provider based and more peer based support interventions for refugees who have spent some time in their host countries.
Threshold and Resilience
In our conceptual model we postulated that for survivors of violence to access health care, they would need to achieve a threshold, a minimal level of support that was beneficial enough to compensate for any potential conflict with network members or socioeconomic losses, reporting might result in. Through our interviews, and discussions and observations we found that the quantity of connections did not influence access to health care services or help seeking behaviour. The quality of the connections was more important and this was different for every refugee interviewed. Though this observation is not new, its relevance should be noted in developing peer based interventions, a focus on quality of interactions and perceived value of relationships is important. In relation to this is the concept of resilience and the effect this has on the threshold effect. Valente (2012) discusses the importance of ‘low threshold’ individuals and their roles in disseminating evidence. These individuals required less persuasion and support and were quick to take up new ideas and technologies. If we link this concept to resilience, we believe that individuals who are able to cope better with stress, require less support to take the initiative to access care and health. Pulvirenti and Mason discuss how high levels of resilience among female refugees, translated into lower prevalence of long term mental health difficulties, after experiencing violence compared to the general population . Understanding this concept and incorporating it into research and interventions targeted at refugees could improve outcomes (Pulvirenti & Mason, 2011). Resilience might explain low rates of screening of violence, as refugees who are survivors of violence might perceive their experiences of violence as part of their ‘new norm’ given their prior experiences of violence during migration. Also, incorporating this concept into designing intervention requires consultation with refugees and discussing priorities and interventions that are more useful to them, which might be very different, from interventions developed when the ‘victim’ rhetoric is used.