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A systematic review of resilience and mental health outcomes of conflict-driven adult forced migrants
Abstract
Abstract
Background: The rising global burden of forced migration due to armed conflict is increasingly recognised as an
important issue in global health. Forced migrants are at a greater risk of developing mental disorders. However,
resilience, defined as the ability of a person to successfully adapt to or recover from stressful and traumatic experiences,
has been highlighted as a key potential protective factor. This study aimed to review systematically the global literature
on the impact of resilience on the mental health of adult conflict-driven forced migrants.
Methodology: Both quantitative and qualitative studies that reported resilience and mental health outcomes among
forcibly displaced persons (aged 18+) by way of exploring associations, links, pathways and causative mechanisms were
included. Fourteen bibliographic databases and seven humanitarian study databases/websites were searched and a four
stage screening process was followed.
Results: Twenty three studies were included in the final review. Ten qualitative studies identified highlighted family and
community cohesion, family and community support, individual personal qualities, collective identity, supportive primary
relationships and religion. Thirteen quantitative studies were identified, but only two attempted to link resilience with
mental disorders, and three used a specific resilience measure. Over-reliance on cross-sectional designs was noted.
Resilience was generally shown to be associated with better mental health in displaced populations, but the evidence
on this and underlying mechanisms was limited.
Discussion: The review highlights the need for more epidemiological and qualitative evidence on resilience in forcibly
displaced persons as a potential avenue for intervention development, particularly in resource-poor settings.
Keywords: Mental health, Forced migration, Adult resilience
... Participants in several studies conducted on refugee populations reported feeling a sense of acceptance, security, belonging, and being able to avoid isolation due to social connections (Walther et al., 2021;Siriwardhana et al., 2014). ...
... Also, the presence of family members in the host country can be a major emotional resource. Social support is a major theme in most studies on refugee resilience (Siriwardhana et al., 2014) and social networks provide emotional and informational support and promote a sense of belonging (Chung, Hong & Newbold, 2013). ...
... p < .05), confirming hypothesis H3b), is consistent with previous studies on refugee populations that identified social support as an important element in alleviating the effects of post-migration stress (Siriwardhana et al., 2014). ...
This study explores the connection between Post-migration Stress and Psychological Well-Being among Ukrainian refugees in Romania, with a focus on the moderating roles of Resilience and Social Support. Using scales for stress, well-being, resilience, and social support, data was collected from Ukrainian refugees (N = 84), mostly women aged 18 to 68. The analysis, conducted before significant changes in government support, revealed a negative correlation between post-migration stress and psychological well-being. Both resilience and social support showed moderating effects in the relationship between post-migration stress and environmental mastery (a facet of psychological well-being construct). The study also examined demographic variations within the refugee community in relation to stress, well-being, social support, and resilience, highlighting potential impacts of subsequent changes in refugees’ circumstances on research outcomes.
... The often-negative impact of migration on mental health is well-known (Siriwardhana & Stewart, 2014;Virupaksha, Kumar & Nirmala, 2014) when trauma was experienced before or during migration (Siriwardhana & Stewart, 2014;Siriwardhana, Ali, Roberts, & Stewart, 2014). ...
... The often-negative impact of migration on mental health is well-known (Siriwardhana & Stewart, 2014;Virupaksha, Kumar & Nirmala, 2014) when trauma was experienced before or during migration (Siriwardhana & Stewart, 2014;Siriwardhana, Ali, Roberts, & Stewart, 2014). ...
... The often-negative impact of migration on mental health is well-known (Siriwardhana & Stewart, 2014;Virupaksha, Kumar & Nirmala, 2014) when trauma was experienced before or during migration (Siriwardhana & Stewart, 2014;Siriwardhana, Ali, Roberts, & Stewart, 2014). ...
... Studies address adaptations to socioeconomic adversity (Wong & Song, 2008), demands of migration including discrimination, language difficulties (Aroian & Norris, 2000), and homelessness (Eggerman & Panter-Brick, 2010). Individual, community and societal resources are important to the resilience in these groups (Siriwardhana, Ali, Roberts & Stewart, 2014). In young domestic workers, an active attitude at the early stages of migration provides a key attribute for fulfilling goals, alleviating stress and promoting wellbeing (van der Ham, Ujano-Batangan, Ignacio & Wolffers, 2014). ...
... Earlier evidence underscore the roles of social support (Kok et al., 2018), intergenerational family relationships (Siriwardhana et al., 2014) and (transnational) belonging (Klok et al., 2017) in resilience, loneliness and well-being. However, other studies show that children sometimes play a contradictory role since for various reasons they do not always provide care (Yerden, 2013). ...
Objectives:
Older immigrants are affected by an accumulation of adversities related to migration and aging. This study investigates resilience in older immigrants by examining the resources they use to deal with these adversities in the course of their lives.
Methods:
Data from 23 life-story interviews with Turkish and Moroccan immigrants aged 60 to 69 living in the Netherlands.
Results:
The circumstances under which individuals foster resilience coincide with four post-migration life stages: settling into the host society, maintaining settlement, restructuring life post-retirement, and increasing dependency. Resources that promote resilience include education in the country of origin, dealing with language barriers, having two incomes, making life meaningful, strong social and community networks, and the ability to sustain a transnational lifestyle traveling back and forth to the country of origin. More resilient individuals invest in actively improving their life conditions and are good at accepting conditions that cannot be changed.
Discussion:
The study illustrates a link between conditions across life stages, migration and resilience. Resilient immigrants are better able to accumulate financial and social and other resources across life stages, whereas less resilient immigrants lose access to resources in different life stages.
... Studies address adaptations to socioeconomic adversity (Wong & Song, 2008), demands of migration including discrimination, language difficulties (Aroian & Norris, 2000), and homelessness (Eggerman & Panter-Brick, 2010). Individual, community, and societal resources are important to the resilience in these groups (Siriwardhana, Ali, Roberts, & Stewart, 2014). In young domestic workers, an active attitude at the early stages of migration provides a key attribute for fulfilling goals, alleviating stress, and promoting well-being (van der Ham, Ujano-Batangan, Ignacio, & Wolffers, 2014). ...
... Earlier evidence underscores the roles of social support (Kok et al., 2018), intergenerational family relationships (Siriwardhana et al., 2014), and (transnational) belonging (Klok et al., 2017) in resilience, loneliness, and well-being. However, other studies show that children sometimes play a contradictory role since for various reasons they do not always provide care (Yerden, 2013). ...
The structure of immigrants’ life is considered discontinuous with less predictable key biographical events. Labour immigrants in Western Europe are affected by adversities from migration affecting their wellbeing. Based on 23 life story interviews with Turkish and Moroccan immigrants living in the Netherlands aged 60 and older, resilience is investigated. Resilience is the process by which individuals cope effectively with adversity using resources. The study illustrates a link between ageing conditions, migration and resilience. Circumstances in which individuals foster resilience collide with four live stages: settling in the host society, negotiating their stay, third age, and fourth age. When investments in resources made in one stage, more resources are transferred into the next stage. Resources include having had an education in the country of origin, early investment in language skills, having two incomes, acceptance through meaning of migration and religion, strong family networks, and ability to sustain a circular lifestyle.
... This meta-analysis revealed a moderate correlation between mental health and resilience. This finding is compatible with that of Siriwardhana et al. (2014) and Hartley (2011) (44,45). Resilience is the capacity of an individual to demonstrate psychological health in a situation in which society views it as aversive (46). ...
... This meta-analysis revealed a moderate correlation between mental health and resilience. This finding is compatible with that of Siriwardhana et al. (2014) and Hartley (2011) (44,45). Resilience is the capacity of an individual to demonstrate psychological health in a situation in which society views it as aversive (46). ...
Abstract
Context: Resilience can be seen as an adaption to stress, such as that caused by health problems or disease, that attenuates the
negative effects of stress. The present research performed a systematic review and meta-analysis to study resilience scores among
adults diagnosed with chronic physical diseases.
Evidence Acquisition: Electronic databases, including Persian language (scientific information database [SID], IranMedex, Magiran, IranDoc, and Medlib) and English language (Google Scholar, Science Direct, PubMed, Pre-Quest, and Scopus), were searched.
Fifteen articles were found using the keywords disease or chronic disease, resilience or resiliency, and illness, either alone or in combination, both in Persian and English languages. Data analysis was carried out through meta-analysis (random-effects model), and
heterogeneity was investigated by subgroup and meta-regression analyses. The data were analyzed in STAT software (12.0).
Results: The mean resilience score of the chronic disease patients (n = 3369) was 74.6 (95% CI: 51.8 - 97.4). In terms of diseases, the
mean resilience score of cancer patients was 79.6 (95% CI: 48.3 - 111.1), whereas it was 79.6 for cardiovascular disease patients (95% CI:
45.8 - 113.3) and 64.6 for patients with other diseases (95% CI: 6.6 - 122.7). There was no relationship between the resilience of chronic
disease patients and the year of the study (P = 0.711) and the sample size in the studies (P = 0.351).
Conclusions: The mean resilience score of the patients was less than that of healthy individuals. As resilience can be acquired at
any stage of life, irrespective of age and disease status, there is a need for training to improve resilience among patients through
educational programs.
Keywords: Resilience, Chronic Disease, Meta-Analysis
... death of a partner, chronic diseases) and decreasing resources (e.g. a declining social network), through which their possibilities to use primary control strategies decrease, and secondary control processes become more promising (De Witte & Van Regenmortel, 2019a). Last, it is important to take the specific context into account when studying loneliness because resilience processes always take place in a given social, cultural and economic context (Fuller-Iglesias et al., 2008;Siriwardhana et al., 2014;Wilson et al., 2021). Indeed, certain populations (e.g. ...
... For example, in a qualitative study, Alessi [48] found that "staying hopeful and positive", utilizing community and legal services, receiving support from significant others and friends, "doing whatever it takes", and "giving back" contributed to resilience among gender minority forced migrants. A systematic review conducted by Siriwardhana et al. [49] showed that social and family support are associated with increased resilience. They also describe other factors that may affect resilience, such as daily stressors and prolonged displacement. ...
Introduction
Migrants and refugees often face potentially traumatic events and post-migratory stressors. Upon arrival in the host country, they can be referred to mental health services to assess the impact of their previous experiences. These cross-cultural clinical encounters may raise questions, particularly regarding the assessment of mental health using models based on Western conceptions of psychopathology.
Objectives and method
The objective of the present non-systematic review of the literature is to discuss the psychological evaluation of post-traumatic reactions in migrants and refugees. More specifically, we present current research on psychopathology, resilience and post-traumatic development (PTG) among the migrant and refugee population. We also examine the cross-cultural validity of concepts such as Post-Traumatic Stress Disorder, resilience and PTG. Finally, we describe the most frequently used tools in cross-cultural psychological assessment and briefly reflect on the question of cultural sensitivity of mental health professionals. A bibliographic search was carried out using the databases: PILOTS, Pubmed, APA PsycNET, and Google Scholar using the following keywords: “migrants”, “refugees”, “posttraumatic stress disorder”, “mental health”, “Psychopathology”, “risk factors”, “protection factors”, “posttraumatic growth” and “resilience”. We have also reviewed the reference lists of articles encountered from database searches.
Results
Responses to a potentially traumatic situation are multiple. Regarding the migrant and refugee population, the reviewed articles studied different post-traumatic reactions such as resilience, post-traumatic development, and psychopathologies. The most studied psychopathological responses were depression, anxiety and Post-traumatic Stress Disorder. After reviewing these studies, we asked the following question: considering the complexity of the migration process, what are the factors associated with the development of these different post-traumatic responses? Indeed, several individual and social factors before, during and after migration influence the mental health of individuals in a migration situation. Among the most cited risk factors identified were: to be a victim of or witness to violence in the country of origin and, after migration, to face post-migration difficulties such as asylum denial, to be in a precarious situation with regard to housing and work, as well as the difficulties linked to adaptation to the new culture. We have also described protective factors for the mental health of this population, such as: social support, psychological support, and a good quality of life in the host country. The reviewed articles also describe an important influence of cultural aspects on mental health, such as the perception of an event as traumatic. Although the authors of the reviewed articles accept this influence of culture on post-traumatic responses, most of the tools used to assess the mental health of migrants and refugees were created in a Western context. Studies show a growing concern with these cultural aspects, and certain tools that allow a more culturally sensitive evaluation, such as the “Cultural Formulation Interview”, are being developed.
Discussion and conclusion
Even if the concern with the sensitivity of the tools used in cross-cultural assessment seems to be more present in the international literature, researchers seem to encounter difficulties in better understanding the effects of culture on the mental health of individuals. With increasingly diverse societies, new research should not be based on participants’ geographic or ethnic origins, but rather try to “unpack” culture with, for example, the exploration of the relationships between certain values or orientations and the different expressions of psychological distress. Finally, given the still lacking development in the field of cross-cultural research, certain practices, such as the participation of interpreters, the supervision of cultural mediators or the use of culturally sensitive tools, can help the clinician to maintain good practices with patients from different cultures in the diagnostic and psychotherapeutical processes.
... O acesso às instituições e aos serviços sociais do país de recepção, bem como a forma com que estas mesmas instituições são preparadas para receber imigrantes, também parece influenciar na qualidade de vida e oportunidades pessoais e profissionais dos imigrantes (Flick, Hans, Hirseland, Rasche & Röhnsch, 2017). O desenvolvimento da resiliência, definida como a habilidade de se recuperar de situações estressantes ou traumáticas, é um processo multidimencional dinâmico não--linear (Siriwardhana, Ali, Roberts & Stewart, 2014;Pearce, McMurray, Walsh, & Malek, 2017), pois é potencializada por toda a rede de relações de uma pessoa vivendo no país receptor a partir de intervenções de distintas intensidades e processos protetivos que promovam mudanças (Ungar, 2012). Em situações de adversidade, a promoção de resiliência se dá conforme o ambiente social e institucional, que facilita o acesso a recursos psicológicos, sociais, culturais e físicos que sustentem o bem-estar e propiciem oportunidades individuais e coletivas para a navegação das pessoas por esses recursos, no âmbito das famílias, comunidades e governos, promovendo a negociação de formas culturalmente significativas (Ungar, 2012). ...
Resumo Este artigo tem por objetivo analisar a produção de significados em dinâmicas de interpretação de si, a partir da experiência de vida de uma migrante venezuelana. O Brasil passa por uma emergência humanitária recebendo imigrantes venezuelanos que chegam ao país. Em deslocamentos geográficos, o senso de continuidade de si se reorienta e é desafiado por rupturas e transições em que os processos de convencionalização atuam promo-vendo dinâmicas reflexivas nas inter-historicidades. Realizou-se entrevista semiestruturada e mediada por objeto, mediadas por objeto que foi submetida à análise dialógico-temática. Os resultados indicaram que o jogo polifônico ocorre no embate entre o presente, que interpreta o passado e se regula por possibilidades de um futuro, em que conhecimentos anteriores são utilizados para a obtenção exitosa de novas formas de conhecer e estar, no novo país. Os significados regula-dores estão relacionados à possibilidade de ficar no país escolhido e aos sacrifícios que podem ser vencidos com as próprias atuações, em escolhas e buscas por soluções, e pela mediação da família, de instituições que trabalham com migrantes e pela religiosidade. Palavras-chave: imigração, transições, convencionalização, significados, posicionamentos.
Resumen Este artículo tiene por objetivo analizar la producción de significados en dinámicas de interpretación del sí, a partir de la experiencia de vida de una migrante venezolana. Brasil pasa por una emergencia humanitaria recibiendo inmigrantes venezolanos que llegan al país. En desplazamientos geográficos, el sentido de continuidad del sí se reorienta y es desafiado por rupturas.
... O acesso às instituições e aos serviços sociais do país de recepção, bem como a forma com que estas mesmas instituições são preparadas para receber imigrantes, também parece influenciar na qualidade de vida e oportunidades pessoais e profissionais dos imigrantes (Flick, Hans, Hirseland, Rasche & Röhnsch, 2017). O desenvolvimento da resiliência, definida como a habilidade de se recuperar de situações estressantes ou traumáticas, é um processo multidimencional dinâmico não--linear (Siriwardhana, Ali, Roberts & Stewart, 2014;Pearce, McMurray, Walsh, & Malek, 2017), pois é potencializada por toda a rede de relações de uma pessoa vivendo no país receptor a partir de intervenções de distintas intensidades e processos protetivos que promovam mudanças (Ungar, 2012). Em situações de adversidade, a promoção de resiliência se dá conforme o ambiente social e institucional, que facilita o acesso a recursos psicológicos, sociais, culturais e físicos que sustentem o bem-estar e propiciem oportunidades individuais e coletivas para a navegação das pessoas por esses recursos, no âmbito das famílias, comunidades e governos, promovendo a negociação de formas culturalmente significativas (Ungar, 2012). ...
This article aims to analyze the production of meanings
in a case study of a migrant woman self-interpretation dynamics from a migrant’s life experience. Brazil is undergoing a humanitarian emergency receiving Venezuelans
arriving in the country. In geographical displacements, the
sense of continuity of oneself is reoriented and challenged
by ruptures in transitions. Conventionalization promotes
reflexive dynamics in inter-historicities. The participant
took part in a semi-structured and an objects mediated
interview. Data were submitted to a dialogic-thematic
analysis. Results indicated that the polyphonic games
occur in the tensions between the present that interprets
the past and is regulated by possibilities of a future in
which previous knowledge is used to successfully obtain
new ways of knowing and being in the new country.
Regulatory meanings relate to the possibility of staying
in the chosen country and to the sacrifices surmountable
through one’s actions, choices, and searches for solutions
and through the mediation of the family and institutions
that work with migrants and religiosity.
Keywords:Immigration, transitions, conventionalization,
meanings, positions.
... Displacement can lead to disruptions of traditional family and community structures that support mental health[3]. Although successful adaptation to adverse circumstances occurs for most people (e.g. through employing positive coping strategies to target stressors or their psychological consequences), others may develop mental health disorders and preexisting mental illness may go untreated[4,5]. Mental disorders in conflict-affected populations have been shown to be associated with significant impairment in functioning and productivity[6][7][8]. Addressing the mental health and well-being of populations exposed to armed conflict should therefore be treated as a priority. ...
Background:
Since December 2013, an armed conflict in South Sudan has resulted in the displacement of over 2.2 million people, more than 270,000 of whom are presently in refugee settlements located throughout Uganda. Existing literature suggests that refugees are at increased risk for a range of mental health and psychosocial problems. There is international consensus on the importance of needs and resource assessments to inform potential mental health and psychosocial support (MHPSS) interventions.
Methods:
We conducted a MHPSS needs and resource assessment in Rhino Camp refugee settlement in northern Uganda, between June and August 2014. We followed World Health Organization (WHO) and United Nations High Commissioner for Refugees (UNHCR) guidelines for MHPSS needs assessments in humanitarian settings. The assessment used a range of methodologies including: 1) a desk (literature) review to understand the context for mental health service provision; 2) an analysis of data from existing health information systems (HIS); 3) an assessment of the current infrastructure for service provision using a shortened version of a Who does What Where until When (4Ws); and 4) semi-structured individual and group interviews (total n = 86) with key informants (n = 13) and general community members (individual interviews n = 28, four focus groups with n = 45).
Results:
Data from the HIS indicated that visits to health centers in refugee settlements attributable to psychotic disorders, severe emotional disorders, and other psychological complaints increased following the refugee influx between 2013 and 2014, but overall help-seeking from health centers was low compared to estimates from epidemiological studies. In semi-structured interviews the three highest ranked mental health and psychosocial problems included "overthinking", ethnic conflict, and child abuse. Other concerns included family separation, drug abuse, poverty, and unaccompanied minors. The 4Ws assessment revealed that there were very limited MHPSS services available in Rhino Camp.
Conclusions:
The types of MHPSS problems among South Sudanese refugees in northern Uganda are diverse and the burden appears to be considerable, yet there are currently few available services. The assessment indicates the need for a range of services addressing social concerns as well as varied types of mental conditions. The idiom of "overthinking" may form a useful starting point for intervention development and mental health communication.
In light of the 2021 United States military withdrawal from Afghanistan, as well as the humanitarian crises of mass displacement and subsequent health system strain that have ensued, practitioners worldwide will need to develop a more nuanced understanding of the adverse life experiences that women from Afghanistan frequently endorse. As they bear a disproportionate impact of constraints within Afghan society, and as patriarchal systems affect most of their life domains, women from Afghanistan may present with high levels of baseline trauma upon resettlement, and health systems may seek to attenuate this distress; However, the nature of these traumatogenic events may shape women's receptivity to psychosocial interventions, particularly those which are at least partially rooted in Western modalities. In the absence of sufficient literature on evidence-based interventions for this population, a diversity of ethnographic and clinical literature is synthesized, including literature on interventions alleged to be compatible with Afghan norms. As it will be essential to support Afghan women's mental health following social reorganization on a massive scale, considerations arising from the interdisciplinary literature are offered so that they may inform the development of structured, trauma-focused interventions and so that the health systems with which they interface may be better prepared to serve them.
Objective
This study explored the protective mechanisms of resilience and positive emotion regulation against psychological trauma among Wuhan’s high school students during the COVID-19 outbreak.
Method
We obtained 286 valid samples from four high schools in Wuhan, China. To construct a measurement model and a structural model, structural equation models using four measurement scales with valid items were adopted, including a scale of psychological trauma, a scale of resilience, a scale of positive emotional regulation, and a scale of mental health. Participants reported their answers to items on a 5-point Likert-like scale.
Results
The results revealed that psychological trauma was a negative predictor of mental health, and resilience and positive emotion regulation mediated the relationship between psychological trauma and mental health.
Conclusions
Accordingly, we concluded that resilience and positive emotion regulation interrupted the direct impact of psychological trauma on mental health, thereby greatly protecting the mental health of Wuhan’s high school students during the COVID-19 outbreak.
Background
With conflict driving millions of refugees away from their homes worldwide, there has been an increase in interest in the field of refugee trauma. However, while trauma and bereavement interlink, prior studies have focused on trauma and its related disorders (PTSD) and predictive factors. This paper reviewed up-to-date literature on the prevalence rates of prolonged grief disorder (PGD), its comorbidities, and associated risk factors among adult refugees.
Method
We systematically reviewed the literature using five databases (PsycINFO, PsycARTICLES, Psychology and Behavioral Sciences Collection, Academic Search Elite, and PubMed). The process of study selection was designed according to PRISMA guidelines.
Results
The initial search generated 126 articles, of which 12 met the inclusion criteria. The pooled prevalence of PGD was 33.2% (95% CI: 15.2–54.2%). Being an older refugee, traumatic and multiple losses implying the death of first-degree relatives appeared to be consistent risk factors for PGD, combined PTSD/PGD, depression, idioms of distress, and functional impairment. PGD, PTSD, and PTSD/PGD intersect on PTSD-intrusions and painful memories.
Limitations
All included studies adopted a cross-sectional design, thus limiting the understanding of causal pathways.
Conclusions
Our findings showed that the high prevalence of PGD and related comorbidities were influenced by the load of traumatic circumstances surrounding the death(s). The findings shed light on the current proposed grief-related diagnostic criteria . Psychopathological and transcultural aspects are discussed, and we provide concrete recommendations for improvements to future research in this field.
Background: Conflict and violent crises have resulted in over 40 million of internally displaced persons (IDPs). Most affected regions lack access to basic health resources and generally rely on humanitarian support. The objective of this review was to appraise primary health service interventions among conflict-induced internally displaced populations in low and middle income countries between 2000 and 2019. Methods: A systematic review of literature in the following databases: Embase, MEDLINE, PsyArticles, PsycINFO, Scopus, Web of Science, LILAC and CAB Articles, was performed to identify interventions implemented in conflict IDP settings. Results: Initial searches yielded 4578 papers and 30 studies met the inclusion criteria. Descriptivesynthesis analysis was used, and the final selections were assessed using a customized CriticalAppraisal Skills Programme (CASP) checklist. Included papers were from Sub-Saharan Africa, South Asia and the Middle East regions. Most studies were on prevention interventions, especially water treatment and maternal health. Treatment interventions mostly focused on onmalaria and mental health. Only one food and nutrition study with outcome data was identified, indicating limitations in IDP health-related intervention publications. Reported interventions were conducted between one week to five years, and the study qualities were moderate. The most effective interventions were integrated programmes and common challenges were weakstudy methodology and data reporting. Conclusion: Regardless of the intervention types and durations, the services offered were beneficial to the IDPs. More intervention evidence are, however required as shown in gaps around food and nutrition, health education and disease surveillance.
This three-paper dissertation aims to explore how contextual factors (e.g., social and
cultural norms, policies, and economic conditions) in two locations, Buffalo, NY and Istanbul,
Turkey, influence the mental health, resilience, and gender roles of Syrian refugees. The study is
a convergent parallel mixed-methods design in which data analysis consists of merging
quantitative (QUAN) and qualitative (QUAL) data and comparing the results from both data sets
and locations. The QUAN data drew upon a sample of adult Syrian refugees in Buffalo, NY
(N=82) and Istanbul, Turkey (N=103). The QUAL data consists of four group interviews
(N=25). As a theoretical framework, this dissertation uses a triangulation approach, where
resilience, empowerment, and forced migration concepts are thoroughly integrated into all three
papers. The first paper identifies living difficulties and resources in each location and examines
their associations with the mental health and psychosocial wellbeing of Syrian refugees. The
second paper explores Syrian refugees’ sources of resilience from a socio-cultural perspective
and their conceptualizations of mental health. Finally, the third paper seeks to understand
changes in gender roles and dynamics among Syrian refugees after their displacement through
the application of the theories of resilience, empowerment, and forced migration. Overall,
findings suggest that the local and structural circumstances, socio-cultural factors, and everyday
experiences of Syrian refugees must be recognized to develop culturally congruent and gendersensitive
interventions for Syrian refugees in post-resettlement contexts. Additionally, there is an
immediate need to find solutions for the legal status issues of Syrian refugees in Turkey and to
change the discriminative rhetoric against refugees at the policy level in the United States, in
order to provide a supportive and psychologically safe environment for this population.
Recent studies have emphasized the influence of resettlement factors on the mental health of refugees resettling in developed countries. However, little research has addressed gender differences in the nature and influence of resettlement stressors and sources of resilience. We address this gap in knowledge by investigating how gender moderates and mediates the influence of several sources of distress and resilience among 259 Afghan refugees residing in Northern California (USA). Gender moderated the effects of four factors on levels of distress. Intimate and extended family ties have little correlation with men’s distress levels, but are strongly associated with lower distress for women. English ability is positively associated with lower distress for women, but not men. In terms of gender ideology, traditionally oriented women and egalitarian men have lower levels of distress. And experiencing greater dissonant acculturation increases distress for men, but not women. The influence of gender interaction terms is substantial and patterns may reflect difficulty adapting to a different gender order. Future studies of similar populations should investigate gender differences in sources of distress and resilience, and efforts to assist new arrivals might inform them of changes in gender roles they may experience, and facilitate opportunities to renegotiate gender roles.
Approximately half of the global refugee population are women, yet they remain largely understudied from the perspective of gender. The aim of this review was to investigate the impact of refugee women’s resettlement and socio-cultural experiences on their health. This review also explored factors promoting resilience in refugee women. Eight databases were searched for peer-reviewed manuscripts published from 2005 to 2014. Grey literature was also reviewed. Data were extracted for population, data collection methods, data analysis, and findings. The Resource-Based Model was used as an overarching framework for data synthesis. Following the screening of titles and abstracts, 20 studies met the study inclusion criteria. Cultural factors, social and material factors, personal factors, and resilience factors were identified as main themes influencing the health of refugee women. Promotion of factors that enables resettlement is important in promoting the health and wellbeing of refugee women.
Early research on the mental health of civilians displaced by armed conflict focused primarily on the direct effects of exposure to war-related violence and loss. Largely overlooked in this
war exposure model
were the powerful effects of ongoing stressors related to the experience of displacement itself. An
ecological model
of refugee distress is proposed, drawing on research demonstrating that mental health among refugees and asylum seekers stems not only from prior war exposure, but also from a host of ongoing stressors in their social ecology, or displacement-related stressors. Implications of this model for addressing the mental health and psychosocial needs of refugees and other displaced populations are considered.
A poor use of mental health services has been described in immigrants. We compared the sociodemographic, clinical and treatment features of immigrants and natives attending a Community Mental Health Centre (CMHC). 191 immigrants and 191 randomly selected natives applying to the Borgomanero CMHC between 1 January 2003 and 31 August 2013 were compared. Our sample consisted mainly of the so-called "economic" immigrant. Adjustment disorders and reaction to stress were the most frequent diagnoses; in most cases symptoms onset occurred after migration. Although treatment features overlapped in the two groups (duration, number of contacts), immigrants showed a higher frequency of treatment dropout. While it is necessary to improve access to mental health services for immigrants, for the "economic" immigrant it may be more important to focus on establishing a therapeutic relationship that can be experienced as reliable and trustworthy. The finding of similar pathways to access the CMHC in natives and immigrants is encouraging.
A series of Médecins Sans Frontières projects for irregular migrants over the past decade have consistently documented high rates of 14 physical and sexual trauma, extortion and mental illness amidst severe healthcare, food, and housing limitations. Complex interventions were needed to begin to address illness and barriers to healthcare and to help restore dignity to the most vulnerable women, children and men. Promising interventions included mobile clinics, use of cultural mediators, coordination with migrant-friendly entities and NGOs and integrating advocacy programs and mental health care with medical services. Ongoing interventions, research and coordination are needed to address this neglected humanitarian crisis.
Background
The rising global burden of forced migration due to armed conflict is increasingly recognised as an important issue in global health. Forced migrants are at a greater risk of developing mental disorders. However, resilience, defined as the ability of a person to successfully adapt to or recover from stressful and traumatic experiences, has been highlighted as a key potential protective factor. This study aimed to review systematically the global literature on the impact of resilience on the mental health of adult conflict-driven forced migrants.
Methodology
Both quantitative and qualitative studies that reported resilience and mental health outcomes among forcibly displaced persons (aged 18+) by way of exploring associations, links, pathways and causative mechanisms were included. Fourteen bibliographic databases and seven humanitarian study databases/websites were searched and a four stage screening process was followed.
Results
Twenty three studies were included in the final review. Ten qualitative studies identified highlighted family and community cohesion, family and community support, individual personal qualities, collective identity, supportive primary relationships and religion. Thirteen quantitative studies were identified, but only two attempted to link resilience with mental disorders, and three used a specific resilience measure. Over-reliance on cross-sectional designs was noted. Resilience was generally shown to be associated with better mental health in displaced populations, but the evidence on this and underlying mechanisms was limited.
Discussion
The review highlights the need for more epidemiological and qualitative evidence on resilience in forcibly displaced persons as a potential avenue for intervention development, particularly in resource-poor settings.
Single adult females remain among the most vulnerable of all refugee populations. However, there is a lack of research on supporting and empowering these women. There is a new interest in identifying factors that reinforce resilience and, ultimately, adjustment to the host country. In line with the current work on resilience, semi-structured, indepth, personal interviews with single refugee women were conducted in the city of Hamilton, Ontario. A grounded theory approach revealed participants' perspectives on the support received from religious or cultural communities, non-governmental organizations, and the government in terms of their perceived contribution to adaptation. Both informal and formal support, along with individual characteristics, were found to be crucial for reinforcing resilience among these refugees, reflective of a collective resilience model that moves beyond individual and community resilience. Future research should aim to investigate the perspectives of those who did not receive social support from shelters as well as to assess the efficacy of current refugee support services.
This article offers a critical exploration of the concept of resilience, which is largely conceptualized in the literature as an extraordinary atypical personal ability to revert or ‘bounce back’ to a point of equilibrium despite significant adversity. While resilience has been explored in a range of contexts, there is little recognition of resilience as a social process arising from mundane practices of everyday life and situated in person-environment interactions. Based on an ethnographic study among single refugee women with children in Brisbane, Australia, the women’s stories on navigating everyday tensions and opportunities revealed how resilience was a process operating inter-subjectively in the social spaces connecting them to their environment. Far beyond the simplistic binaries of resilience versus non-resilient, we concern ourselves here with the everyday processual, person-environment nature of the concept. We argue that more attention should be paid to day-to-day pathways through which resilience outcomes are achieved, and that this has important implications for refugee mental health practice frameworks.
Forced internal displacement has been rising steadily, mainly due to conflict. Many internally displaced people (IDP) experience prolonged displacement. Global research evidence suggests that many of these IDP are at high risk for developing mental disorders, adding weight to the global burden of disease. However, individual and community resilience may act as protective factors. Return migration may be an option for some IDP populations, especially when conflicts end, although return migration may itself be associated with worse mental health. Limited evidence is available on effects of resettlement or return migration following prolonged forced internal displacement on mental health. Also, the role of resilience factors remains to be clarified following situations of prolonged displacement. The public health impact of internal displacement is not clearly understood. Epidemiological and interventional research in IDP mental health needs to look beyond medicalised models and encompass broader social and cultural aspects. The resilience factor should be integrated and explored more in mental health research among IDP and a clearly focused multidisciplinary approach is advocated.
Western fascination with Buddhism means that Westerners consider Buddhist psychology for building up resilience regarding mental disorders and for creating building blocks for “the art of happiness.” This study evaluates the effect of Buddhist spirituality on resilience to torture. In all, 102 Tibetan torture survivors were interviewed about their coping mechanisms in overcoming trauma; 36 of these survivors were receiving counseling, and both the 16 professionals and their clients were interviewed after the treatment with open-ended questions about what was helpful and not helpful. Our results from both the assessment and the counseling study support the claim that Tibetan torture survivors use their political engagement and Tibetan Buddhism as an important coping mechanism. All clients expressed satisfaction with the counseling even if it did not enhance the political and spiritual coping. But nobody mentioned counseling in any open-ended interview, except when directly asked.
Resilience may mean different things to different researchers and practitioners in psychology and public health: A process, an outcome, a dynamic steady state in the face of adversity, and defiance of risk/vulnerability are among the variety of understandings of the concept that are extant. This article summarizes the results of a systematic review of the literature on definitions and measurements of resilience. It is evident that resilience is more than the absence of “posttraumatic stress disorder,” just as health (and indeed mental health) is more than the absence of disease (or mental/behavioral disorder). A multidimensional construct, resilience a requires a multimethod and multilevel study design that combines both qualitative and quantitative techniques to be examined satisfactorily. Seven selected studies are discussed in detail, highlighting examples that offer a fuller understanding of resilience in its sociocultural and ecological context.
An ecological approach to the study of resilience, informed by Systems Theory and emphasizing predictable relationships between risk and protective factors, circular causality, and transactional processes, is inadequate to account for the diversity of people's experiences of resilience. In contrast, a constructionist interpretation of re- silience reflects a postmodern understanding of the construct that better accounts for cultural and contextual differences in how resilience is expressed by individuals, fam- ilies, and communities. Research supporting this approach has demonstrated a nonsystemic, nonhierarchical relationship between risk and protective factors that is characteristically chaotic, complex, relative, and contextual. This article critically reviews research findings that support an ecological perspective and explores the emerging literature that informs a constructionist approach to the study of resilience. It will show that an alternate constructionist discourse on resilience greatly enhances our understanding of resilience-related phenomena and our approach to interven- tions with at-risk youth populations.
Research has documented a link between political violence and the functioning of individuals and communities. Yet, despite the hardships that political violence creates, evidence suggests remarkable fortitude and resilience within both individuals and communities. Individual characteristics that appear to build resilience against political violence include demographic factors such as gender and age, and internal resources, such as hope, optimism, determination, and religious convictions. Research has also documented the protective influence of individuals' connection to community and their involvement in work, school, or political action. Additionally, research on political violence and resilience has increasingly focused on communities themselves as a unit of analysis. Community resilience, like individual resilience, is a process supported by various traits, capacities, and emotional orientations toward hardship. This review addresses various findings related to both individual and community resilience within political violence and offers recommendations for research, practice, and policy.
While studies on the consequences of trauma and forced migration on young refugees have focused mainly on their pathology, a focus on resilience in young refugees is needed to adequately represent their response to adversity and to help understand their needs. The aim of this article is to present a proposed study of resilience in young refugees which has been informed by an overview of achievements and challenges in the field of resilience.
In order to advance the field of resilience, several topics need clarification: definition and assessment of resilience, the relation of resilience to other constructs and the underlying biological and external factors influencing resilience. With respect to young refugees, the cross-cultural applicability of resilience has to be examined. Qualitative research, mixed method designs, comparative studies, and longitudinal studies seem especially promising in furthering this goal.
The proposed study compares refugee adolescents with Dutch adolescents. Data from qualitative evidence synthesis, interviews, questionnaires, experiments, and DNA analysis will be combined to provide a multifaceted picture of factors contributing to resilience, resulting in a better understanding and efficient use of “resilience” to meet the needs of traumatised youth.
This article defines social resilience as the ability of groups or communities to cope with external stresses and disturbances as a result of social, political and environmental change. This definition highlights social resilience in relation to the concept of ecological resilience which is a characteristic of ecosystems to maintain themselves in the face of disturbance. There is a clear link between social and ecological resilience, particularly for social groups or communities that are dependent on ecological and environmental resources for their livelihoods. But it is not clear whether resilient ecosystems enable resilient communities in such situations. This article examines whether resilience is a useful characteristic for describing the social and economic situation of social groups and explores potential links between social resilience and ecological resilience. The origins of this interdisciplinary study in human ecology, ecological economics and rural sociology are reviewed, and a study of the impacts of ecological change on a resourcedependent community in contemporary coastal Vietnam in terms of the resilience of its institutions is outlined.
This study reports findings from a qualitative investigation of seven Bosnian refugee women's coping strategies as they resettled in two cities of the Southeastern United States over five years. It focuses on their personal experiences as refugees and the factors that contributed to their resilience. Their personal narratives highlight the importance of family as well as extended family, spirituality expressed in the form of non-organized religion, and the availability of community social support services that helped them adjust to resettlement. The research discusses implications for practice and further studies to improve refugees' mental well-being.
The formal acceptance of posttraumatic stress disorder (PTSD) as a legitimate diagnostic category in the 1980 Diagnostic and Statistical Manual of Mental Disorders stimulated a torrent of research on psychological trauma. Not surprisingly, PTSD and its treatment had dominated that research. Another common approach has been to measure the average impact of different potentially traumatic events, as well as the factors that inform that impact. In this article, we consider the limitations of these perspectives and argue for a broader theoretical approach that takes into account the natural heterogeneity of trauma reactions over time. To that end, we review recent attempts to identify prototypical patterns or trajectories of trauma reaction that include chronic dysfunction, but also delayed reactions, recovery, and psychological resilience. We consider the advantages but also the limitations and ongoing controversies associated with this approach. Finally, we introduce promising new research that uses relative sophisticated advances in latent growth mixture modeling as a means of empirically mapping the heterogeneity of trauma responses and consider some of the implications of this approach for existing trauma theories. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
The construct of resilience was examined in a South Asian community impacted by natural and human-made disasters. Forty-three Sinhala, Tamil, and Muslim Sri Lankans (27 women; age range 21-62 years) participated in 6 focus groups, conducted in either Sinhala or Tamil, to elicit participants' own ideas about components of resilience. Schema analysis of transcripts revealed that although some elements of resilience were common across ethnocultural groups, others differed by ethnic group. The differences appeared to be as much a function of type of trauma exposure as of culture. Components of resilience included many that are recognized in the western construct of resilience as well as 2 culturally unique components: strong will relating either to religious faith or to karma and psychosocial gratitude. These components could be examined in future measures of resilience with similar populations. Findings also revealed that some components of resilience can be taught; thus they can be the focus of interventions and public health policies.
The authors report on their multidisciplinary and longitudinal studies of Afghan families that included paired interviews
with adolescents and adult caregivers. The authors argue that cultural values are the “bedrock” of resilience: they underpin
the meaning attributed to great suffering, hope for the future, and a sense of emotional, social, and moral order to ordinary
and extraordinary aspects of life. Remarkably, they show that war-related trauma is not the principal driver of poor mental
health: traumatic experiences are linked to fractured family relationships and a failure to achieve personal, social, and
cultural milestones. Resilience, meanwhile, rests upon a demonstration of family unity. In the context of structural disadvantage
that includes poverty, crowded living conditions, and exposure to violence, the authors also show that cultural dictates come
to entrap Afghans in the pursuit of honor and respectability, a core facet of psychosocial resilience. The chapter highlights
linkages between psychosocial and structural resilience, cautioning against a simplistic view of culture as a set of protective
resources. The authors discuss the ramifications of social policies that raise not just hope, but undue expectations without
sufficient resource provision.
Background
Realist synthesis is an increasingly popular approach to the review and synthesis of evidence, which focuses on understanding the mechanisms by which an intervention works (or not). There are few published examples of realist synthesis. This paper therefore fills a gap by describing, in detail, the process used for a realist review and synthesis to answer the question ‘what interventions and strategies are effective in enabling evidence-informed healthcare?’ The strengths and challenges of conducting realist review are also considered.
Methods
The realist approach involves identifying underlying causal mechanisms and exploring how they work under what conditions. The stages of this review included: defining the scope of the review (concept mining and framework formulation); searching for and scrutinising the evidence; extracting and synthesising the evidence; and developing the narrative, including hypotheses.
Results
Based on key terms and concepts related to various interventions to promote evidence-informed healthcare, we developed an outcome-focused theoretical framework. Questions were tailored for each of four theory/intervention areas within the theoretical framework and were used to guide development of a review and data extraction process. The search for literature within our first theory area, change agency, was executed and the screening procedure resulted in inclusion of 52 papers. Using the questions relevant to this theory area, data were extracted by one reviewer and validated by a second reviewer. Synthesis involved organisation of extracted data into evidence tables, theming and formulation of chains of inference, linking between the chains of inference, and hypothesis formulation. The narrative was developed around the hypotheses generated within the change agency theory area.
Conclusions
Realist synthesis lends itself to the review of complex interventions because it accounts for context as well as outcomes in the process of systematically and transparently synthesising relevant literature. While realist synthesis demands flexible thinking and the ability to deal with complexity, the rewards include the potential for more pragmatic conclusions than alternative approaches to systematic reviewing. A separate publication will report the findings of the review.
Somali migrants fleeing the civil war in their country face punishing journeys, the loss of homes, possessions, and bereavement. On arrival in the host country they encounter poverty, hostility, and residential instability which may also undermine their mental health.
An in-depth and semi-structured interview was used to gather detailed accommodation histories for a five year period from 142 Somali migrants recruited in community venues and primary care. Post-codes were verified and geo-mapped to calculate characteristics of residential location including deprivation indices, the number of moves and the distances between residential moves. We asked about the reasons for changing accommodation, perceived discrimination, asylum status, traumatic experiences, social support, employment and demographic factors. These factors were assessed alongside characteristics of residential mobility as correlates of ICD-10 psychiatric disorders.
Those who were forced to move homes were more likely to have an ICD-10 psychiatric disorder (OR = 2.64, 1.16-5.98, p = 0.02) compared with those moving through their own choice. A lower risk of psychiatric disorders was found for people with larger friendship networks (0.35, 0.14-0.84, p = 0.02), for those with more confiding emotional support (0.42, 0.18-1.0, p = 0.05), and for those who had not moved during the study period (OR = 0.21, 0.07-0.62, p = 0.01).
Forced residential mobility is a risk factor for psychiatric disorder; social support may contribute to resilience against psychiatric disorders associated with residential mobility.
ABSTRACT:
Mental health and psychosocial wellbeing are key concerns in displaced populations. Despite urban refugees constituting more than half of the world's refugees, minimal attention has been paid to their psychosocial wellbeing. The purpose of this study was to assess coping behaviour and aspects of resilience amongst refugees in Kathmandu, Nepal.
This study examined the experiences of 16 Pakistani and 8 Somali urban refugees in Kathmandu, Nepal through in-depth individual interviews, focus groups, and Photovoice methodology. Such qualitative approaches enabled us to broadly discuss themes such as personal experiences of being a refugee in Kathmandu, perceived causes of psychosocial distress, and strategies and resources for coping. Thematic network analysis was used in this study to systematically interpret and code the data.
Our findings highlight that urban refugees' active coping efforts, notwithstanding significant adversity and resulting distress, are most frequently through primary relationships. Informed by Axel Honneth's theory on the struggle for recognition, findings suggest that coping is a function beyond the individual and involves the ability to negotiate recognition. This negotiation involves not only primary relationships, but also the legal order and other social networks such as family and friends. Honneth's work was used because of its emphasis on the importance of legal recognition and larger structural factors in facilitating daily coping.
Understanding how urban refugees cope by negotiating access to various forms of recognition in the absence of legal-recognition will enable organisations working with them to leverage such strengths and develop relevant programmes. In particular, building on these existing resources will lead to culturally compelling and sustainable care for these populations.
To explore the salience of pre- and postmigration stresses as risk factors for posttraumatic stress disorder (PTSD) and to identify resilience factors and explore their mental health salience.
We conducted a mental health survey of 1603 Sri Lankan Tamils in Toronto, incorporating the World Health Organization Composite International Diagnostic Interview for PTSD.
According to the International Classification of Diseases, 10th Revision, criteria, lifetime prevalence for PTSD was 12%; according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria it was 5.8%. Female sex and the number of stresses of passage increased the probability of PTSD, whereas satisfaction with life and the availability of nonfamily social relations reduced it.
Consideration of pre- and postmigration stresses of passage and of the nature of resilience contributes to an improved understanding of PTSD among refugees.
David Moher and colleagues introduce PRISMA, an update of the QUOROM guidelines for reporting systematic reviews and meta-analyses
The evaluation of interventions and policies designed to promote resilience, and research to understand the determinants and associations, require reliable and valid measures to ensure data quality. This paper systematically reviews the psychometric rigour of resilience measurement scales developed for use in general and clinical populations.
Eight electronic abstract databases and the internet were searched and reference lists of all identified papers were hand searched. The focus was to identify peer reviewed journal articles where resilience was a key focus and/or is assessed. Two authors independently extracted data and performed a quality assessment of the scale psychometric properties.
Nineteen resilience measures were reviewed; four of these were refinements of the original measure. All the measures had some missing information regarding the psychometric properties. Overall, the Connor-Davidson Resilience Scale, the Resilience Scale for Adults and the Brief Resilience Scale received the best psychometric ratings. The conceptual and theoretical adequacy of a number of the scales was questionable.
We found no current 'gold standard' amongst 15 measures of resilience. A number of the scales are in the early stages of development, and all require further validation work. Given increasing interest in resilience from major international funders, key policy makers and practice, researchers are urged to report relevant validation statistics when using the measures.
There are increasing numbers of refugees worldwide, with approximately 16 million refugees in 2007 and over 2.5 million refugees resettled in the United States since the start of its humanitarian program. Psychologists and other health professionals who deliver mental health services for individuals from refugee backgrounds need to have confidence that the therapeutic interventions they employ are appropriate and effective for the clients with whom they work. The current review briefly surveys refugee research, examines empirical evaluations of therapeutic interventions in resettlement contexts, and provides recommendations for best practices and future directions in resettlement countries. The resettlement interventions found to be most effective typically target culturally homogeneous client samples and demonstrate moderate to large outcome effects on aspects of traumatic stress and anxiety reduction. Further evaluations of the array of psychotherapeutic, psychosocial, pharmacological, and other therapeutic approaches, including psychoeducational and community-based interventions that facilitate personal and community growth and change, are encouraged. There is a need for increased awareness, training and funding to implement longitudinal interventions that work collaboratively with clients from refugee backgrounds through the stages of resettlement.
Research with survivors of torture has generated considerable variability in prevalence rates of posttraumatic stress disorder (PTSD). Multiple risk and resilience factors may affect this variability, increasing or decreasing the likelihood of experiencing psychological distress. This study sought to investigate the effect of several such resilience factors, coping style, social support, cognitive appraisals, and social comparisons on PTSD symptom severity. Furthermore, this study examined whether coping style moderated the relationship between resilience variables and PTSD symptoms. Seventy-five torture survivors completed an intake interview and several self-report measures upon entry into a treatment program for survivors of torture. Results indicated that emotion-focused coping styles significantly moderated the relationship between cognitive appraisal and social comparison variables and PTSD, and usually increased the likelihood of developing severe symptoms. These results indicate that the salience of resilience variables may differ depending on the individual's coping style, which present implications for clinical practice with torture survivors.
From January to May, 2009, a population of 300,000 in the Vanni, northern Sri Lanka underwent multiple displacements, deaths, injuries, deprivation of water, food, medical care and other basic needs caught between the shelling and bombings of the state forces and the LTTE which forcefully recruited men, women and children to fight on the frontlines and held the rest hostage. This study explores the long term psychosocial and mental health consequences of exposure to massive, existential trauma.
This paper is a qualitative inquiry into the psychosocial situation of the Vanni displaced and their ethnography using narratives and observations obtained through participant observation; in depth interviews; key informant, family and extended family interviews; and focus groups using a prescribed, semi structured open ended questionnaire.
The narratives, drawings, letters and poems as well as data from observations, key informant interviews, extended family and focus group discussions show considerable impact at the family and community. The family and community relationships, networks, processes and structures are destroyed. There develops collective symptoms of despair, passivity, silence, loss of values and ethical mores, amotivation, dependency on external assistance, but also resilience and post-traumatic growth.
Considering the severity of family and community level adverse effects and implication for resettlement, rehabilitation, and development programmes; interventions for healing of memories, psychosocial regeneration of the family and community structures and processes are essential.
The resilience of post-war displaced persons is not only influenced partly by the nature of premigration trauma, but also by postmigration psychosocial circumstances and living conditions. A lengthy civil war leading to Eritrea separating from Ethiopia and becoming an independent state in 1991 resulted in many displaced persons.
A random sample of 749 displaced women living in the shelters in the Ethiopian capital Addis Ababa was compared with a random sample of 110 displaced women living in the community setting of Debre Zeit, 50 km away from Addis Ababa, regarding their quality of life, mental distress, sociodemographics, living conditions, perceived social support, and coping strategies, 6 years after displacement.
Subjects from Debre Zeit reported significantly higher quality of life and better living conditions. However, mental distress did not differ significantly between the groups. Also, Debre Zeit subjects contained a higher proportion born in Ethiopia, a higher proportion married, reported higher traumatic life events, employed more task-oriented coping, and perceived higher social support. Factors that accounted for the difference in quality of life between the shelters and Debre Zeit groups in three of the four quality of life domains of WHOQOL-BREF (physical health, psychological, environment), included protection from insects/rodents and other living conditions. However, to account for the difference in the fourth domain (social relationships), psychosocial factors also contributed significantly.
Placement and rehabilitation in a community setting seems better than in the shelters. If this possibility is not available, measures to improve specific living conditions in the shelters are likely to lead to a considerable increase in quality of life.
This paper seeks to bridge the divisive split between advocates of trauma-focused and psychosocial approaches to understanding and addressing mental health needs in conflict and post-conflict settings by emphasizing the role that daily stressors play in mediating direct war exposure and mental health outcomes. The authors argue that trauma-focused advocates tend to overemphasize the impact of direct war exposure on mental health, and fail to consider the contribution of stressful social and material conditions (daily stressors). Drawing on the findings of recent studies that have examined the relationship of both war exposure and daily stressors to mental health status, a model is proposed in which daily stressors partially mediate the relationship of war exposure to mental health. Based on that model, and on the growing body of research that supports it, an integrative, sequenced approach to intervention is proposed in which daily stressors are first addressed, and specialized interventions are then provided for individuals whose distress does not abate with the repair of the social ecology.
Findings from a 14 site mixed methods study of over 1500 youth globally support four propositions that underlie a more culturally
and contextually embedded understanding of resilience: 1) there are global, as well as culturally and contextually specific
aspects to young people’s lives that contribute to their resilience; 2) aspects of resilience exert differing amounts of influence
on a child’s life depending on the specific culture and context in which resilience is realized; 3) aspects of children’s
lives that contribute to resilience are related to one another in patterns that reflect a child’s culture and context; 4)
tensions between individuals and their cultures and contexts are resolved in ways that reflect highly specific relationships
between aspects of resilience. The implications of this cultural and contextual understanding of resilience to interventions
with at-risk populations are discussed.
Uncertainties continue about the roles that methodological factors and key risk factors, particularly torture and other potentially traumatic events (PTEs), play in the variation of reported prevalence rates of posttraumatic stress disorder (PTSD) and depression across epidemiologic surveys among postconflict populations worldwide.
To undertake a systematic review and meta-regression of the prevalence rates of PTSD and depression in the refugee and postconflict mental health field.
An initial pool of 5904 articles, identified through MEDLINE, PsycINFO and PILOTS, of surveys involving refugee, conflict-affected populations, or both, published in English-language journals between 1980 and May 2009.
Surveys were limited to those of adult populations (n > or = 50) reporting PTSD prevalence, depression prevalence, or both. Excluded surveys comprised patients, war veterans, and civilian populations (nonrefugees/asylum seekers) from high-income countries exposed to terrorist attacks or involved in distal conflicts (> or = 25 years).
Methodological factors (response rate, sample size and design, diagnostic method) and substantive factors (sociodemographics, place of survey, torture and other PTEs, Political Terror Scale score, residency status, time since conflict).
A total of 161 articles reporting results of 181 surveys comprising 81,866 refugees and other conflict-affected persons from 40 countries were identified. Rates of reported PTSD and depression showed large intersurvey variability (0%-99% and 3%-85.5%, respectively). The unadjusted weighted prevalence rate reported across all surveys for PTSD was 30.6% (95% CI, 26.3%-35.2%) and for depression was 30.8% (95% CI, 26.3%-35.6%). Methodological factors accounted for 12.9% and 27.7% PTSD and depression, respectively. Nonrandom sampling, small sample sizes, and self-report questionnaires were associated with higher rates of mental disorder. Adjusting for methodological factors, reported torture (Delta total R(2) between base methodological model and base model + substantive factor [DeltaR(2)] = 23.6%; OR, 2.01; 95% CI, 1.52-2.65) emerged as the strongest factor associated with PTSD, followed by cumulative exposure to PTEs (DeltaR(2) = 10.8%; OR, 1.52; 95% CI, 1.21-1.91), time since conflict (DeltaR(2) = 10%; OR, 0.77; 95% CI, 0.66-0.91), and assessed level of political terror (DeltaR(2) = 3.5%; OR, 1.60; 95% CI, 1.03-2.50). For depression, significant factors were number of PTEs (DeltaR(2) = 22.0%; OR, 1.64; 95% CI, 1.39-1.93), time since conflict (DeltaR(2) = 21.9%; OR, 0.80; 95% CI, 0.69-0.93), reported torture (DeltaR(2) = 11.4%; OR, 1.48; 95% CI, 1.07-2.04), and residency status (DeltaR(2) = 5.0%; OR, 1.30; 95% CI, 1.07-1.57).
Methodological factors and substantive population risk factors, such as exposure to torture and other PTEs, after adjusting for methodological factors account for higher rates of reported prevalence of PTSD and depression.
The effects of traumatization among the elderly is a neglected topic in research and clinical settings. Forced displacement of civilians is one of the main traumatic features of modern armed conflict. Roughly 12 million German people were displaced in World War II (WWII) and to our knowledge there has been no representative study investigating the mental health outcomes of such trauma in the elderly population. The survey assessed whether current depression, anxiety, resilience and life satisfaction were significantly associated with forced displacement in WWII.
A nationwide representative face-to-face household survey was conducted in Germany. A representative sample of the German population aged 61 years or older (N = 1513 participants, N = 239 displaced in WWII) was approached using 258 sample points. Measurements included depressive symptoms (PHQ-2), anxiety (GAD-7), resilience (RS-11), general and domain-specific life satisfaction (FLZ(M)) and sociodemographic variables.
Forced displacement in WWII is significantly associated with higher levels of anxiety and lower levels of resilience and life satisfaction 60 years later. In regression analyses, forced displacement in WWII significantly predicted current anxiety (beta 0.07; p < 0.01), life satisfaction (beta -0.06; p < 0.05) and resilience (beta -0.07; p < 0.01).
To our knowledge this is the first nationwide representative survey to examine the late-life effects of forced displacement, particularly of persons displaced during WWII in Germany. Further research is needed to identify mediating variables and to evaluate psychotherapeutic interventions in elderly trauma survivors.
Western health professionals and the public have a misguided image of war and its aftermath that is often far removed from the actual experience of non-westernised societies. A British psychiatrist looks at the effects of war and at the belief that the emotional reactions of victims of war should be modified.
More than two decades after Michael Rutter (1987) published his summary of protective processes associated with resilience, researchers continue to report definitional ambiguity in how to define and operationalize positive development under adversity. The problem has been partially the result of a dominant view of resilience as something individuals have, rather than as a process that families, schools,communities and governments facilitate. Because resilience is related to the presence of social risk factors, there is a need for an ecological interpretation of the construct that acknowledges the importance of people's interactions with their environments. The Social Ecology of Resilience provides evidence for this ecological understanding of resilience in ways that help to resolve both definition and measurement problems. © Springer Science+Business Media, LLC 2012. All rights reserved.
Mental health in the Tibetan refugee community has been studied extensively, but like most research on political violence, these studies focus almost exclusively on trauma. Studies suggest this exile community seems to be unusually resilient; but from where does this capacity to thrive stem? On the basis of ethnographic research in Dharamsala, India, conducted over 14 months, this article demonstrates how Tibetans conceive of resilience as a learned and active process of making the mind more spacious and flexible. Drawing on extended participant observation and in-depth interviews with 80 Tibetan refugees, this work explores why negative emotions associated with trauma exposure are considered toxic and how many Tibetans exposed to political violence engage in a Buddhist practice known as mind training (lojong in Tibetan) to abate its harmful effects. Attending to culturally sanctioned responses to political violence and displacement, this study challenges the notion that trauma is a universal experience.
Background
Researchers focused on mental health of conflict-affected children are increasingly interested in the concept of resilience. Knowledge on resilience may assist in developing interventions aimed at improving positive outcomes or reducing negative outcomes, termed promotive or protective interventions.Methods
We performed a systematic review of peer-reviewed qualitative and quantitative studies focused on resilience and mental health in children and adolescents affected by armed conflict in low- and middle-income countries.ResultsAltogether 53 studies were identified: 15 qualitative and mixed methods studies and 38 quantitative, mostly cross-sectional studies focused on school-aged children and adolescents. Qualitative studies identified variation across socio-cultural settings of relevant resilience outcomes, and report contextually unique processes contributing to such outcomes. Quantitative studies focused on promotive and protective factors at different socio-ecological levels (individual, family-, peer-, school-, and community-levels). Generally, promotive and protective factors showed gender-, symptom-, and phase of conflict-specific effects on mental health outcomes.Conclusions
Although limited by its predominantly cross-sectional nature and focus on protective outcomes, this body of knowledge supports a perspective of resilience as a complex dynamic process driven by time- and context-dependent variables, rather than the balance between risk- and protective factors with known impacts on mental health. Given the complexity of findings in this population, we conclude that resilience-focused interventions will need to be highly tailored to specific contexts, rather than the application of a universal model that may be expected to have similar effects on mental health across contexts.
Refugee research, to date, has predominantly focused on factors that make refugees more vulnerable for developing posttraumatic stress disorder (PTSD) and/or psychological distress. Few articles have studied potential protective factors such as resilience. A targeted nonrandom sample of Iraqi refugees (n = 75) and a control group of non-Iraqi Arab immigrants (n = 53) were recruited from a number of Iraqi/Arab community institutions in Michigan to complete a questionnaire that included measures for psychological distress, PTSD symptoms, exposure to trauma, and resilience. The refugees reported significantly more PTSD symptoms (t-test, p < 0.01) and psychological distress (p < 0.05) compared with the immigrants. There was no difference in resilience between the two groups. In linear regression, premigration exposure to violence was a significant predictor of psychological distress (p < 0.01) and PTSD symptoms (p < 0.01). After controlling for migrant status and violence exposure, resilience was a significant inverse predictor of psychological distress (p < 0.001) but not of PTSD. Resilience is associated with less trauma-related psychological distress and should be considered in assessing risk and protective factors among victims of war-related violence.
Objectives:
In comparison to other traumatic events, the impact of a childhood during war on resilience later in life has been seldom examined. The aim of this study was therefore to examine the long term outcomes of post-traumatic responses and resilience of a sample of adult Indigenous Quechua women, who were girls or adolescents during the Peruvian armed conflict (1980-1995).
Methods:
The study instruments (Harvard trauma questionnaire part I and IV; Connor-Davidson resilience scale; life stress questionnaire) were translated to Quechua and cross-culturally validated. A cross sectional survey design was used in 2010 to collect data from a convenience sample of 75 participants (25-45 years old) in Ayacucho, Peru, the region most affected by the conflict. Data was examined using hierarchical regression analyses.
Results:
Participants reported extreme exposure to violence (e.g., sexual violence, torture, combat, death of family members, and forced displacement) during the armed conflict, but surprisingly, only 5.3% reported a current level of symptoms that may indicate a possible post-traumatic stress disorder (PTSD). Resilience scores and number of years exposed to conflict as a child were not associated with PTSD symptoms; instead only the degree of exposure to violence, and current level of stress contributed to the variance of PTSD-related symptoms. Conversely, resilience and current stress contributed to the variance of trauma symptoms when measured by local idioms of distress.
Conclusions:
Findings should be interpreted with caution, due to limitations in the content validity of instruments, risk of inaccurate recall, use of individual explanations of distress (such as PTSD) for collective experiences of violence, use of non-indigenous frameworks to examine Indigenous resilience, and other methodological concerns. The study however highlights the high degree of traumatic exposure of these former war children. While the prevalence of potential PTSD was astonishingly low in this sample, a number of women still suffer from significant distress two decades after the traumatic events. Therefore, post-conflict interventions should renew efforts to foster the resilience of marginalized populations disproportionately targeted by violence and advocate for enhanced protection of women and children in current armed conflicts.
Forced relocation has been recognised as a traumatic event, which can generate pathological and positive responses. The current study focused on the situation of Israeli residents who were forced to relocate from their homes in the Gaza Strip. Two main questions were examined: the association between post-traumatic symptoms and post-traumatic growth responses following the forced relocation; and the contribution of contextual variables to the variance in those reactions. A sample of 269 participants completed questionnaires, which assessed post-traumatic symptoms and growth following the relocation. The relationship between post-traumatic symptoms and growth was found to be curvilinear, depending on the levels of the post-traumatic symptoms. Participants who expressed a high sense of belonging to the country showed relatively high levels of growth and relatively low levels of post-traumatic symptoms. In addition, participants living in temporary housing reported lower levels of growth than did those in independent housing. These findings highlight the importance of contextual variables that affect people's ability to cope with traumatic events such as forced relocation. The findings also indicate that the strengths perspective and the Person in Environment approach might help social workers better understand the phenomenon of forced relocation and determine the level of their interventions.
Three principles can help guide the study of resilience among children and youth: (1) Facilitative environments are more influential than individual-level variables to the processes associated with resilience; (2) The characteristics of environments that are most facilitative of resilience reflect the ease with which individuals, families, and communities are able to navigate to resources, the availability and accessibility of resources, and the meaningfulness of the resources provided to those who need them most; and (3) The greater an individual's exposure to risk, the more he or she benefits from contextually and culturally specific protective factors. Mixed methods approaches to researching resilience provide the means to document the homogeneity and heterogeneity of protective processes that reflect these three principles. The resulting social ecological conceptualization of resilience shows sensitivity to cultural and contextual factors related to protective processes. A brief discussion is provided of the implications of this understanding of resilience for social policy and health promotion.
Programmes costing millions of dollars to address 'posttraumatic stress' in war zones have been increasingly prominent in humanitarian aid operations, backed by UNICEF, WHO, European Community Humanitarian Office and many nongovernmental organisations. The assumptions underpinning this work, which this paper critiques with particular reference to Bosnia and Rwanda, reflect a globalisation of Western cultural trends towards the medicalisation of distress and the rise of psychological therapies. This paper argues that for the vast majority of survivors posttraumatic stress is a pseudocondition, a reframing of the understandable suffering of war as a technical problem to which short-term technical solutions like counselling are applicable. These concepts aggrandise the Western agencies and their 'experts' who from afar define the condition and bring the cure. There is no evidence that war-affected populations are seeking these imported approaches, which appear to ignore their own traditions, meaning systems, and active priorities. One basic question in humanitarian operations is: whose knowledge is privileged and who has the power to define the problem? What is fundamental is the role of a social world, invariably targeted in today's 'total' war and yet still embodying the collective capacity of survivor populations to mourn, endure and rebuild.
This article draws upon articles published since 2009 to identify research evidence about the psychosocial aspects of children and young people's responses to their exposure to war, collective violence and terrorism.
Recent research describes children's distress and the disorders they may develop consequent on their direct and indirect exposure to war. This article covers general responses as well as those that affect refugees, displaced children, and child soldiers. Dose of exposure is the main predictor of their degree of distress. Often, loss of parental support predicts distress or disorder. Research on children who are refugees and internally displaced persons has found that they cope better with the distressing events surrounding their flight if their parents accompany them. Studies of child soldiers show that they suffer from guilt as well as experiencing many violent distressing events. Research has identified the factors that contribute to their resilience, which include their acceptance by the communities to which they return. There are personal and social sources of resilience, including emotion regulation, parenting, and social support, for children who are exposed to war.
Much of the recent research confirms earlier findings, which demonstrate that their exposure to war and collective violence leads to distress for many children and/or mental disorders for a smaller but substantial minority of them. The literature shows interest in identifying and measuring protective factors. The emphasis in the articles we reviewed on social as well as personal factors that confer psychosocial resilience reflects the broad interest in the two canons of literature on children's development and disasters. The findings point powerfully to people's needs for holistic and community-level interventions.
The internally displaced persons (IDPs) during the July 2006 war in Lebanon exhibited a high level of community resilience, affirmed by relief agencies and public health professionals. Data from personal observations, interviews, meetings and published material were used to examine factors contributing to this resilience. Findings suggested that community resilience is a process rather than an outcome. The sense of a collective identity, prior experience with wars and social support networks have contributed to building up IDP's resilience over time, while community cohesiveness, adequate public health interventions, social solidarity and a connected political leadership helped to sustain it during and shortly after the war. This paper examines implications for public health professionals and argues for a paradigm shift in disaster relief practice.
The aim of this study was to identify long-term effects of diagnostic criteria on the Post Traumatic Stress Disorder Checklist (PCL-C) for a test group of Finnish evacuees from World War II and compare the outcome effect with a control group of children who lived in Finland during the war in 1939-1945.
152 participants were recruited by the local leader of the Finnish War Child Association in Sweden and Finland. The selected group answered questions on the Post Traumatic Stress Disorder Checklist (PCL-C) and the EMBU (Swedish acronym for "Own Memories of Parental Rearing").
Evidence suggests a link between childhood parental separation and termination of the internalized attachment hierarchy of origin in a detachment process among Finnish evacuees. Based on the Post Traumatic Stress Disorder Total (PCL-C) diagnosis an extreme traumatization for 36.7% of the test group subjects was identified, including a hidden Holocaust trauma in the population of Finnish evacuees.
The study met the criteria for satisfying global evidence value. Sixty-five years after the end of World War II and in line with other studies on war children, the data show high levels of different trauma exposures from the war with 10.6 higher risk (odds ratio) for the exposed group of Finnish evacuees. Despite some limitations, the data highlight the need for further investigation into different parts of the detachment process among seriously traumatized groups to reveal resilience and other dimensions of importance in professional mental health creation.
Survivors of human-initiated disaster are at high risk for mental disorder, most notably post-traumatic stress disorder (PTSD). Studies of PTSD have tended to focus on soldiers returning home after combat or on refugees living in resettlement countries under conditions of relative safety. However, most survivors of human-initiated disasters continue to live in or near the places where they initially experienced trauma. Insufficient attention has been paid to social disorganization in situations of continuing unrest and to its role in creating or stabilizing the symptoms of PTSD. The current study took place in the Niger Delta region of Nigeria, the scene of long-standing violence and human rights abuse that reached its apogee in 1995. The investigation, which took place in 2002, focused on two villages, one that was heavily exposed to the conflict (A, the affected village), the other relatively spared (NA, not affected). Probability samples of 45 adult residents from A and 55 from NA were interviewed with a schedule that contained the PTSD module from the WHO Diagnostic Interview Schedule. The schedule also contained a measure of exposure to the violence and abuses during the height of the conflict, as well as measures of structural and social capital that are components of community resilience. These included economic security, a sense of moral order, a sense of safety and perceived social support. The six month period prevalence of PTSD was 60 percent in A, and 14.5 percent in NA. Degree of exposure to stress as well as compromised sense of moral order, not feeling safe, and perceived lack of social support were independent predictors of PTSD. In places like the Niger Delta, where people do not physically escape from past trauma, sociocultural disintegration may interfere with communal functioning, thereby eroding community capacity to promote self-healing.
While the current knowledge base on the mental health effects of displacement is mainly limited to refugees residing in industrialised countries, this paper examines the impact of war-induced displacement and related risk factors on the mental health of Eastern Congolese adolescents, and compares currently internally displaced adolescents to returnees and non-displaced peers.
Data were collected from a community sample of 819 adolescents aged 13 to 21 years, attending one of 10 selected schools across the Ituri district in the Democratic Republic of Congo. Respondents completed culturally adapted self-report measures of posttraumatic stress symptoms (using the Impact of Event Scale - Revised) and internalising and externalising behaviour problems (by means of the Hopkins Symptoms Checklist - 37 for Adolescents). Associated factors studied were age, sex, parental death, exposure to war-related violence and daily stressors.
Internally displaced persons (IDPs) reported highest mean scores for the IES-R and the HSCL-37A internalising scale, followed by returnees, while non-displaced adolescents scored significantly lower. However, ANCOVA tests showed that posttraumatic stress and internalising symptoms were mainly associated with traumatic exposure and daily stressors and not with displacement status. Externalising problem scores were associated with traumatic exposure, daily stressors and displacement. Remarkably, death of father was associated with fewer externalising problems. Sex was differently associated with internalising and externalising problems through traumatic and daily stressors.
As IDPs are highly exposed to violence and daily stressors, they report most psychological distress, when compared to returnees and non-displaced peers. The distinct mental health outcomes for returned youngsters illustrate how enhancing current socio-economic living conditions of war-affected adolescents could stimulate resilient outcomes, despite former trauma or displacement.
Refugees suffer from a higher rate of mental health symptoms than the general population since they have experienced extreme suffering and the accumulated effects of trauma. Because of the diversity of regions from which refugees originate, there is a need to understand some of the unique experiences that are specific to each sub-groups of immigrants. The purpose of the present study was to explore mental health symptoms in Iraqi refugee clients who immigrated to the United States after the Gulf War of the early 1990's. As part of a larger study, 116 adult Iraqi immigrants to the United States (46 male, 70 females) who were seeking mental health services completed measures of anxiety, depression, and posttraumatic stress disorder. As expected, the majority of refugees reported intense anxiety and depression, and many met the DSM IV criteria for posttraumatic stress disorder. Like refugees from other countries-of-origin, Iraqi refugees are in need of culturally sensitive assessment and mental health treatment. The results are discussed in light of the treatment needs of Iraqi refugee clients, their resilience and motivation for a better life, and the ways that health professionals can assist in optimizing their adjustment.
A retrospective cohort study of 35 refugee Tibetan nuns and lay students who were arrested and tortured in Tibet matched with 35 controls who were not arrested or tortured was carried out in India. Subjects were administered the Hopkins Checklist-25, evaluating anxiety symptoms, effective disturbances, somatic complaints, and social impairment. The prevalence of symptom scores in the clinical range for both cohorts was 41.4% for anxiety symptoms and 14.3% for depressive symptoms. The torture survivors had a statistically significant higher proportion of elevated anxiety scores than did the nontortured cohort (54.3% vs. 28.6%, p = .05). This was not true for elevated depressive scores. The results suggest that torture has long-term consequences on mental health over and above the effects of being uprooted, fleeing one's country, and living in exile as a refugee, though the additional effects were small. Political commitment, social support in exile, and prior knowledge of and preparedness for confinement and torture in the imprisoned cohort served to foster resilience against psychological sequelae. The contribution of Buddhist spirituality plays an active role in the development of protective coping mechanisms among Tibetan refugees.
Programmes costing millions of dollars to address 'posttraumatic stress' in war zones have been increasingly prominent in humanitarian aid operations, backed by UNICEF, WHO, European Community Humanitarian Office and many nongovernmental organisations. The assumptions underpinning this work, which this paper critiques with particular reference to Bosnia and Rwanda, reflect a globalisation of Western cultural trends towards the medicalisation of distress and the rise of psychological therapies. This paper argues that for the vast majority of survivors posttraumatic stress is a pseudocondition, a reframing of the understandable suffering of war as a technical problem to which short-term technical solutions like counselling are applicable. These concepts aggrandise the Western agencies and their 'experts' who from afar define the condition and bring the cure. There is no evidence that war-affected populations are seeking these imported approaches, which appear to ignore their own traditions, meaning systems, and active priorities. One basic question in humanitarian operations is: whose knowledge is privileged and who has the power to define the problem? What is fundamental is the role of a social world, invariably targeted in today's 'total' war and yet still embodying the collective capacity of survivor populations to mourn, endure and rebuild.
The wars in Southeast Asia displaced thousands of families from Cambodia, Laos, and Vietnam. The upheavals led to a number of waves of immigration to the United States. Current research supports hypotheses of post-traumatic stress disorder diagnoses in refugees from the wars in Vietnam but omits pertinent cultural factors. This phenomenological study of 19 women from Southeast Asia examines the meanings of their refugee experiences. Open-ended interviews with these women reveal themes of survival, despair, and isolation. Health care providers may notice cultural bereavement as opposed to post-traumatic stress disorder, reflecting a psychological resilience not extensively explored previously. Developing empathetic interactions and including important ethnic identity factors in caring for refugee women appear essential in providing appropriate health care.
In 1999 the US Committee for Refugees estimated that there were 14 million refugees and 21 million internally displaced persons (IDPs) worldwide. The distinction between refugees and IDPs has important public health implications. It is noted that unlike refugees IDPs cannot invoke the same legal protections as refugees. Additionally no specific international humanitarian agency is responsible for providing them with protection and humanitarian assistance. To address the shortfalls in the protection of the rights of IDPs non-binding legal principles on internal displacement which draw on existing humanitarian and human rights as well as on analogous refugee law have been developed and disseminated. These principles list the important essential services that IDPs are entitled to: food potable water sanitation shelter and medical services. However responsibility for the protection of and provision of basic services to IDPs still rests with national governments. There is an urgent need for a specific international humanitarian agency to be given the mandate for providing such services so that tangible improvements in the health and welfare of IDPs to be attained.