School of Nursing
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Trauma Screening in Female Refugees: Finding a more appropriate alternative

Louise O’Connell

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louiseoconnell@southerndhb.govt.nz

Introduction

Experiences of physical and emotional trauma follow refugees to their new environment making re-settlement difficult (Kulwicki & Ballout, 2015).  This is a great challenge as not only are these refugees in a heightened state of anxiety from their history but they now must contend with a foreign culture, language barriers, social isolation and living in an unfamiliar home without their usual comforts and family support (Bokore, 2013; Vervliet, Lammertyn, Broekaert & Derluyn, 2013).  I have chosen this area to research as the numbers of refugees arriving in Dunedin are increasing, and there is a lack of local information regarding their re-settlement issues.  Because information on New Zealand experiences is scant, we must look to international research to increase understanding and inform our nursing practice.

The Refugee Healthcare Handbook defines a refugee as any person oppressed and unable or unwilling to seek the protection of their own country, for reasons of religion, nationality, political views, race, or being a member of a particular political or social faction (Ministry of Health, 2016).  People escaping these conditions have been through atrocities such as physical violence, torture, rape, witnessing traumatic events, combat situations, no access to medical care, no food or water and a lack of shelter (Schweitzer, Brough, Vromans, & Asic-Kobe, 2011).  Unlike migrants, refugees have no choice but to flee their homeland, leaving behind possessions and loved ones, are unprepared, and often have no documentation, only bringing with them their traumatic experiences and a pervading sense of guilt and worry about those left behind (Kroo & Nagy, 2011; Ministry of Health, 2016).  These experiences lead to Post Traumatic Stress Disorder (PTSD), and the symptoms arising from this are showing up in Primary Health Care.

According to Registered Nurses in community health clinics, however, most times refugees do not come to clinic complaining of PTSD, but rather they have sleep pattern issues, and problems with regulating their emotions (Carrigan, 2014).  In fact, for most refugees, presenting problems are usually headaches, abdominal complaints, sleep difficulties and general body aches and pains (Shannon, O’Dougherty, & Mehta, 2012).  Medical research shows that when a person is in an ongoing stressful situation which they perceive as a threat, a part of the brain (amygdala) is stimulated, and will send their pituitary gland a signal to secrete the hormone adrenocorticotropic hormone (ACTH) into the body and this results in prolonged release of stress hormones which can cause many of the symptoms seen in refugees, for example, headache, fatigue, pain and inflammatory processes (Matheson, Jorden & Anisman, 2007; Shin & Lee, 2013).  Even three-year follow up studies have reported no PTSD improvement. Rather, symptoms of PTSD and depression became worse, described as chronic and debilitating (Cho, Jeun, Yu, & Um, 2005; Vojvoda,  Weine,  McGlashan, Becker, & Southwick, 2008). 

Effects of Trauma on Women

Many studies show that the effects of PTSD are greater on the female population (Shin & Lee, 2012).  Women from countries experiencing a humanitarian crisis - famine, epidemics, armed conflict - rank among the lowest in measures of well-being (Bell, Lori, Redman, & Seng, 2015).  Vojvoda et al., (2008), reported that higher ratings in PTSD scores are due to the differences in the types of traumatic events experienced by women.  Rape, sexual abuse, abuse of children, discrimination, and death of a child are some of the main differences (Kulwicki & Ballout, 2015).  Instead of feeling safe on reaching refugee camps, for some women it is the lowest point in their lives, with lack of food and adequate care, fear and experiences of rape and beatings - both night and day - and a lack of sleep as they fight to protect themselves and their children from human brutality (Bokore, 2013; Finkelstein & Solomon, 2009).  Another issue for women is the social stigma attached to them in some countries, as they become sole parents, having lost their husbands (Shin & Lee, 2013).  Shin and Lee also note that in order to survive in this situation, many women will have to marry a second time, reluctantly, in the resettlement country, and still some will end up as prostitutes in order to make a living for themselves and their children.  

The PECOT Model – Finding the Question

To better understand the effect traumatic experiences have on re-settlement, I needed to explore whether or not a screening tool (trauma questionnaire or interview) to fast-track a refugee to mental health treatment, is a good idea in the first instance of healthcare in New Zealand, or if there is a better way to help refugees to navigate our health system and thrive in their new country. In order to narrow down this question, the PECOT/PICOT table (below) was used. A good PECOT question also helps to sift through the many research papers to identify what will have useful and relevant information (Whitehead, 2013). 

Table 1.  PECOT (Whitehead, 2013).

The PECOT table has enabled me to narrow down my literature search for articles that are relevant to the question: “Is there a more appropriate alternative to routine trauma screening for female refugees?”

Argument for Trauma Screening

Options for initial contact with incoming refugees range from compulsory trauma screening to more comprehensive plans which help the individual to move forward, whilst keeping alert for any symptoms related to PTSD.  The rationale for trauma screening is supported by many authors.  In their article on barriers to health care access, Asgary and Segar (2011) attempted to highlight the level of access that asylum seekers have to health care.  They recommended further studies to help eliminate barriers experienced by refugees, including screening for histories of trauma and abuse.  In their own study, however, it was found that the sensitive nature of the participant histories and their fragile mental health made screening and data collection prohibitive.  Focus groups and interviews had to be changed to individual interviews due to the difficulties experienced, and they found that perhaps language was the greatest barrier to access.

Al-Obaidi, West, Fox and Savin (2015), also argue that better outcomes for refugee mental health is likely with use of a mental health screening tool.  Again, however, communication was a major issue due to a lack of a common language between refugees and providers.  Their future recommendations were to help refugees increase their own advocacy skills, yet without a common language, this seems unlikely to work in the short term.  They also noted that their new 15 item screening instrument should only be conducted where there are further mental health resources available, and this is not going to be the case in many situations, particularly in the community settings.

PTSD symptoms 3 ½ years after resettlement were expected to be lower in Bosnian refugees entering America.  Vojvoda et al., (2008), found that 25% of refugees were actually worse.   Like the previous authors, they highlighted the importance of early mental health screening in order to seek treatment for symptoms of trauma, however they did not offer any suggestions on how to go about this. They noted that a limitation in their assessments was the language difference and retrospective recall of events which could be inaccurate.  A plus for screening is that as the trauma can be quantified by a score, it can then be re-checked later on to see if there is any improvement.  In this case there were no improvements, and women and older adults fared even worse after 3 ½ years than when first screened, with the authors stating that women are more vulnerable to the ongoing aftermath of trauma.  They also found that general functioning of an individual improved as their proficiency with English language increased.

In their study of a brief screening tool for women’s mental health Bell et al., (2015), discuss a self-reported questionnaire, designed to detect presence or absence of mental disorders which is currently used by the World Health Organisation.  The goal of this study was to find a highly predictive, sensitive and specific questionnaire to identify PTSD and other mental health disorders in order to predict future health and suicidal risk of refugee women.  This new tool would be used in primary health care settings for women, either in refugee camps or in women’s health clinics.  The authors concluded that more study is needed to make this tool highly efficient to identify these high risk populations.  An important finding was that no screening tool should be used if there was no treatment available, as this creates an increased vulnerability.

Finding an Alternative to Trauma Screening

The case against trauma screening begins with more communication difficulties. When Shannon et al., (2012), asked refugees their opinions on barriers to communication, they heard that refugees often find it difficult to engage with doctors in a primary health setting.  Refugees find that their cultural norms prevent them from initiating discussions of trauma history.  They also lack the health literacy required to understand how their trauma is affecting their ongoing physical and mental health.  Barriers were communication and culture. A lack of knowledge that their distress affected ongoing health was also a major barrier, as well as the idea that the patient must defer to the authority of the doctor.  This combination meant that important discussions never took place.  Often both parties did not want to bring up the past. 

Eggertson (2016), a Canadian registered nurse, highlights some of the work being done by nurse practitioners with Syrian refugees in a women’s hospital in Toronto.  Contrary to pro-screening literature, she suggests that questioning patients on trauma could potentially re-traumatise them.  The nurses argued that their job was to keep them moving forward in an attempt to acculturate the refugees.  They suggest that routine screening for trauma should not happen but that there still needs to be an alertness for any impaired social functioning, anxiety or depression related to PTSD and that immediate referral for assessment and follow-up be made.  Nurse practitioners believe that refugees are better served by our being advocates for their needs:  connecting them with specialists, counselling, social workers, writing letters, and helping them navigate the health system with advocacy, empathy and support.

Carrigan, (2014), echoes the above views of Eggerston in her article on refugee health in Australia.  She agrees that addressing trauma straight up can be confronting.  Some people wish to talk, while many others want to look forward and not dwell on the past.  However looking for issues such as poor sleep patterns, difficulty regulating emotions, and anger problems can be a starting point for further discussion about their experiences and resulting trauma.  Their main theme was that an integrated response must be found that addresses the mental health requirements of refugees.  Nursing, allied health and medicine must work together in a collaborative response to this community problem.

Support for future studies of women refugees with PTSD is put forward by Bokore (2013).  Her case study on Somalian women refugees focuses on the obstacles that inhibit Somali mothers from experiencing health and wellness in their new country (Canada).  Experiences of prolonged trauma and its effects on both mother and child was investigated, along with any transference to the child of PTSD.  Most participants were single mothers, having been left widowed by war.  It looks at gender-based violence and how it impacts re-settlement for these women and how this can also be transferred to the next generation via ‘intergenerational trauma’.  Further research suggested holistic frameworks for dealing with the missing links in the lives of these women, particularly around experiences of gender violence such as rape and female genital mutilation. 

Finally, according to Alemi et al., (2014), further study on women and children is the key to finding ways to mitigate distress among refugees and discourage utilisation of secondary health services.  In a secondary-source, mixed method review on psychological distress, the authors point out the importance of the buffering nature of parents in the mental health of future generations of re-settled Afghan refugees. Their findings indicated the high prevalence of depressive behaviours and PTSD in unaccompanied child refugees and the need for continued mental health research.

Recommendations

Gagnon, Tuck and Barkun, (2004), reviewed many studies recommending the design and use of a screening tool for trauma in female refugees, however, I see three major problems: the first is that there is often a lack of specific and targeted mental health resources to refer these patients on to, which makes such a tool irresponsible (Bell et al., 2015). Secondly, there is a risk of re-traumatising the patient by making them re-live their experiences to yet another stranger (Eggertson, 2016).  Last of all, trauma screening must take place in the very early stages of resettlement, and if it does not occur at that stage, then the patient is likely to be overlooked (Carrigan, 2014; Sanchez-Cao, Kramer & Hodes, 2012).  There is somewhat of a ‘honeymoon period’ immediately after arriving, when refugees feel safe and everything seems great in comparison to where they have fled from. However once the realities of isolation, language barriers, culture changes, lack of support systems and finding their way around a new health system start to sink in,

then the mental health issues begin to manifest (Carrigan, 2014; Schweitzer, Melville, Steel & Lacharez, 2006).  This lack of support early on, either from refugee camps or initial assessments in healthcare settings means that a refugee’s essential human right of access to appropriate care is denied (Bell et al., 2015).

Nurses must therefore find other ways to assess and manage trauma, and the symptoms arising from these experiences, and to provide a progressive style of healthcare that might help refugees to move forward with their new lives, rather than dwelling on past experiences (Robertson et al., 2006).  This does not suggest that PTSD and serious mental illness is not to be treated by conventional and medical means, but rather that nurses can provide an improved level of care through advocacy, empathy, support and kindness, and creating an awareness both in the community and the refugee themselves that when trauma symptoms appear, that everybody is aware of them (Eggertson, 2016).  The following recommendations are suggested:

Co-operative Care - There is good argument for advocating for patients who are not able to make autonomous decisions.  This is very much the situation with refugee health care experiences, when the language barriers and cultural conflict create a divide that makes communication about health decisions very difficult (and potentially dangerous).  As it is more increasingly acknowledged in patient-centred care, the role of advocate by nurses is becoming more accepted, indeed, expected. Co-operative care means that refugees can become empowered to make and manage their own decisions by being taught new skills (Wellard, 2014).

Communication - It has been noted in most articles that communication has suffered due to there being no common language between individuals and providers, with the result being inadequate understanding around the patient’s health care needs (Al-Obaidi et al., 2015; Wagner et al., 2013).  Asgari and Segar (2011) interviewed women about linguistic barrier challenges, and the comments were that if private and medical information was being discussed, they do not like their husbands or children interpreting.  In the absence of well-trained interpreters, nurses can access external help when working with refugees. Culturally and Linguistically Diverse (CALD) is an organisation which runs training courses for interpreters to work with health professionals to increase ways of communication, language skills and cultural competency (Scott, 2016).

Cultural Competency - Knowledge of your own and other cultures is essential in providing care that is tolerant, inclusive and appreciative of others (Reitmanova & Gustafson, 2008).  To that end, health practitioners must strive to upskill their cultural competency.  Improving access to, and availability of, female nurses and other health providers is important for those female refugees who feel uncomfortable with male health providers because of cultural norms and modesty (Asgary & Segar, 2011).  Women’s discussion groups can also play a role in assisting refugees to learn together. Serious issues such as mental health and gender-based violence can be discussed and worked through in a general discussion that does not single out women. Group discussions have been shown to be useful in relieving stress and coping with feelings of isolation, and they can often lead to requests for individual counselling (Bokore, 2013).

Courage - Waiting for a health professional to begin a conversation about traumatic experiences means that refugees may sometimes never get a chance to talk about their PTSD or symptoms arising from it (Shannon et al., 2012).  Going forward, nurses must show courage and initiate the discussion about traumatic refugee experiences and their ongoing effects.  At this point, patients can opt to be referred on to a specialist in mental health, or make their way forward with guidance from the nurse and other allied health professionals.  It is key to remember that refugee women are not just a helpless group, but are keen to help themselves too, for example, as one participant in a Muslim maternity healthcare study put it, “We have to do changes ourselves” (Reitmanova & Gustafson, 2008, P110).

Commitment to Care - Care for refugees is challenging, and the way to tackle this is to be prepared for every situation.  Prepare well for your assessments, allocating sufficient time to plan for the special needs of these patients, and understand common mental health conditions (Ministry of Health, 2016).  Do not assume traumatisation and then refer on to therapies that may escalate the problem, but commit to implementing comprehensive assessments with sensitivity so that psychological distress is reduced (Schweitzer et al., 2010).   Know who to refer on to: it is not always psychiatric help, but usually basic issues such as child health, immunisations, dental care, longstanding chronic illnesses, contraception, nutrition and cancer screening programmes (Eggertson, 2016). 

Conclusion

The answer to the question posed is yes, there is a more appropriate alternative to routine trauma screening for female refugees.  Although there are many articles researching the use of screening tools for trauma in refugees, with arguments both for and against this idea, their arguments fall short of a truly progressive way forward for this population.  In fact, these same articles acknowledge that language and communication barriers are significant, and that there may not be any treatment available post-screening.  What treatment there is, might not be appropriate, acceptable, accessible or affordable.  Given that screening can re-traumatise refugees, and the resettlement period can often cause just as much distress as fleeing from their homes, a better way forward is for nurses to improve their communication skills, show courage in health care discussions, take a co-operative approach to care, be culturally competent, and show a commitment to their refugee clients.  In this way we can aid resettlement, and improve the life satisfaction and functioning of individuals (women) who come into our care.

References

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