Access to this full-text is provided by Frontiers.
Content available from Frontiers in Psychiatry
This content is subject to copyright.
ORIGINAL RESEARCH
published: 01 February 2021
doi: 10.3389/fpsyt.2021.595979
Frontiers in Psychiatry | www.frontiersin.org 1February 2021 | Volume 12 | Article 595979
Edited by:
Wulf Rössler,
Charité – Universitätsmedizin
Berlin, Germany
Reviewed by:
Sophie Yohani,
University of Alberta, Canada
Ali Abbas Samaha,
Lebanese International
University, Lebanon
*Correspondence:
Malek Bajbouj
malek.bajbouj@charite.de
Specialty section:
This article was submitted to
Public Mental Health,
a section of the journal
Frontiers in Psychiatry
Received: 18 August 2020
Accepted: 04 January 2021
Published: 01 February 2021
Citation:
Rayes D, Karnouk C, Churbaji D,
Walther L and Bajbouj M (2021)
Faith-Based Coping Among
Arabic-Speaking Refugees Seeking
Mental Health Services in Berlin,
Germany: An Exploratory Qualitative
Study. Front. Psychiatry 12:595979.
doi: 10.3389/fpsyt.2021.595979
Faith-Based Coping Among
Arabic-Speaking Refugees Seeking
Mental Health Services in Berlin,
Germany: An Exploratory Qualitative
Study
Diana Rayes 1,2 , Carine Karnouk 1, Dana Churbaji 3, Lena Walther 1and Malek Bajbouj 1
*
1Department of Psychiatry and Psychotherapy, Charité University Medicine Berlin, Berlin, Germany, 2Department of
International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States, 3Institute of
Psychology, University of Münster, Münster, Germany
Background: The benefits of faith-based coping or using religious and spiritual
beliefs as a stabilizing force for interpreting stressful or distressing events are largely
unexplored among the exodus of Arabic-speaking refugee populations from Muslim-
majority countries, particularly those resettled in Europe. The present study aimed
to explore the manifestation of faith-based coping strategies among Arabic-speaking
refugee adults seeking mental healthcare services in Berlin, Germany and explore
how favorable faith-based coping strategies can be optimized from a mental health
service-delivery and broader integration perspective.
Methods: A total of 17 qualitative interviews were conducted with Arabic-speaking
refugee adults (six females, 11 males) seeking mental health services at the Charité
Universitaetsmedizin in Berlin. Research questions aimed to solicit comprehensive
perspectives from refugee adults on their mental health, with an emphasis on faith-
based coping, and how this facilitated or impeded their integration into German society.
Interview transcripts were translated to English from Arabic and analyzed using MAXQDA
(2018) to highlight thematic patterns using a grounded theory approach.
Results: Findings were structured into four themes, including: (I) faith-based coping
methods during flight, (II) changes in faith practices upon arrival, (III) faith-based coping
methods to address distress during integration, and (IV) advice for German mental
healthcare providers. Participants who demonstrated a stronger commitment to faith
were more likely to utilize faith-based coping strategies when seeking mental health
services and facing the challenges of displacement and integration. Examples of faith-
based coping included prayer, supplication, reciting scripture, and seeking help from a
local religious leader.
Conclusion: The findings suggest how faith and faith practices play a significant role in
the mental health and integration of refugee populations in Germany and provide insight
on how mental healthcare can be delivered in a culturally-sensitive manner, providing
alternatives to the social, cultural, and linguistic barriers posed by the German health
Rayes et al. Faith-Based Coping Among Refugees in Germany
system. These findings are particularly relevant for mental health professionals,
non-governmental organizations, and humanitarian aid agencies providing mental
healthcare to Arabic-speaking populations recently resettled in Western contexts.
Keywords: asylum-seekers, refugees, Muslim, faith-based coping, integration, mental health, Germany
INTRODUCTION
As host countries continue to grapple with how to best
integrate recently arrived refugees and asylum-seekers into
their societies, the influence of faith, including religious or
spiritual beliefs and practices, on refugee mental health and
well-being remain largely unexplored. Refugees fleeing conflict
arrive in foreign countries having experienced the effects of
war, shock, upheaval, and the psychological burden of their
journeys (1). Studies in Germany suggest that over 40% of
refugees and asylum-seekers who have arrived since 2013
show signs of a mental disorder, a quarter of them with
diagnosable post-traumatic stress disorder, anxiety, or depression
(2–5). This distress is often exacerbated upon arriving to a
new host country given various social, economic, and legal
barriers imposed on refugees and asylum-seekers (5,6). Recent
studies also report high prevalence rates of up to 75% of
mental distress among Syrian refugees resettled in Germany
and an increased risk among refugees for developing a severe
mental illness in comparison to the host population (7,
8). Language barriers, culture shock, and lack of economic
opportunities (9) further discourage refugee populations from
engaging with host communities and therefore, delay or inhibit
successful integration.
Among the many European countries hosting refugees,
Germany has played a vital role in the future of many –
receiving nearly one million refugees from Syria, Afghanistan,
and Iraq in 2015 alone (10). Since then, Germany has seen
the arrival of more refugees and asylum-seekers than any
other European country (11). The large influx of refugees to
Europe from Muslim-majority countries has inevitably led to
a sharp rise in the number of Muslims in Germany (12).
Predictions by the Pew Research Center indicate that even with
no future net migration, Muslims in Germany will represent
9% of the population by 2050 (13). The sharp rise in numbers
of Muslims in Germany has inevitably led to a significant
shift in the sociopolitical landscape within Germany and in
Europe. This has partly led to the growing influence of populist
and nationalist groups with anti-immigration policy agendas,
provoking fear of the Muslim threat to Germany’s social and
religious cohesion (14–16). In addition, discrimination and
stereotyping of migrant populations, particularly those from
Muslim-majority countries, is often propagated by negative
media coverage and misinformation campaigns by the same
groups and can lead to feelings of discrimination or isolation
(9,17). This can potentially exacerbate psychological symptoms,
leading to isolation and alienation, and further complicate the
integration process for refugee communities, particularly those
from Muslim-majority countries (18).
More recently, there has been more emphasis on the provision
of culturally-sensitive mental health services to refugees and
asylum-seekers, especially those fleeing from conflict or those
who have experienced political or religious persecution in
their country of origin (19). This includes the adaptation of
existing mental health and psychosocial support services to
be more accessible in different languages and ensure that
mental health professionals are aware of various social norms
and dynamics that exist within a particular cultural group
(20). Coping methods, or efforts made by individuals to
manage or overcome their psychosocial distress, can also vary
across different cultures. For example, refugee populations
usually rely on a social pyramid of family and close friends
for support – one that might not exist anymore due to
displacement, separation, and the loss of loved ones during
conflict (21). With this knowledge, mental health professionals
can help their refugee clients identify other forms of social
support, including cultural, religious, or diaspora networks,
which can help newcomers navigate their new environment
and cope with the sudden changes following displacement (20,
22).
Within the umbrella of providing culturally-sensitive mental
healthcare, there is a small, yet growing body of evidence
on the benefits of faith-based coping, or using religious
or spiritual beliefs as a stabilizing force for interpreting
traumatic events (23,24). For example, a review published
by UNHCR emphasized the diversity of faith-based coping
methods utilized by Syrian refugees from various faiths
suffering from mental health problems (20). This includes
reading Quranic or verses from scripture, making prayers
or supplication, seeking treatment from a religious cleric or
traditional healer to keep away jinn or evil, or visiting holy
sites or completing hajj or Islamic pilgrimage. Similar coping
methods have been demonstrated by studies regarding Syrian
refugee adults resettled in the United States (25) and Somali
refugee women in Australia, who reported that daily prayers
required by their Islamic faith to be a source of comfort and
solace during bouts of depression and loneliness in their new
home (26).
Despite the significant implications of these findings
for mental health policy and practice, faith-based coping
strategies among refugee populations seeking specialized
mental health services remain largely unexplored,
particularly for those living in Germany and in Europe
more broadly. The objectives of this qualitative study
were to explore the manifestation of faith-based coping
strategies among Arabic-speaking refugee adults seeking
mental healthcare services in Berlin, Germany and
explore how favorable faith-based coping strategies can be
Frontiers in Psychiatry | www.frontiersin.org 2February 2021 | Volume 12 | Article 595979
Rayes et al. Faith-Based Coping Among Refugees in Germany
optimized from a mental health service-delivery and broader
integration perspective.
MATERIALS AND METHODS
Study Sample
This research was a sub-study of the Mental Health in Refugees
and Asylum-Seekers (MEHIRA) project, led by the Charité
Universitaetsmedizin Berlin (19,27). The MEHIRA project is
a multi-center randomized controlled trial aimed to investigate
the effects of a stepped and collaborative care model (SCCM)
for refugee and asylum-seekers suffering from mental health
issues in Germany. The study aimed to explore how mental
health care can be delivered in a culturally-sensitive manner.
This was done by exploring alternatives to the social, cultural,
and linguistic barriers posed by the German health system by
providing healthcare in the same language as the client, or
by a healthcare provider from the same cultural background.
Study participants were recruited from the larger MEHIRA study
sample, which included adults who were (i) between the age of
18 and 65 (ii) demonstrated no symptoms of neurodegenerative
disorder, psychotic disorder, or suicidal ideation (iii) had refugee
or asylum-seeker status in Germany (iv) spoke either Arabic
or Farsi.
From among the MEHIRA participants, this study sample
was limited to Arabic-speaking refugee and asylum-seeker
adults seeking care at the Central Clearing Clinic sponsored
by the Charité Universitaetsmedizin Berlin. After completing
the initial MEHIRA baseline data collection process, including
demographics and a number of questionnaires to assess overall
psychological well-being (determined via a score of ≥12 on items
1–14 or ≥5 item 15 in the Refugee Health Screener-15, and
“several days” or higher in a minimum of three responses in the
Patient Health Questionnaire-9), participants were invited to take
part in an anonymous interview designed to further solicit their
perspectives regarding the importance of their faith to promote
well-being and prevent mental illness.
Participants were purposively sampled from among the
MEHIRA study population to include a variety of age and
gender groups with demonstrated interest in participating in
the qualitative study following their baseline assessment. For
more information, please refer to the complete MEHIRA study
protocol available in (19).
Data Collection
A semi-structured interview guide (Appendix A) with 19
questions was designed using a grounded theory approach to
contextualize questions of mental health and faith-based coping
within a comprehensive backdrop of the participant’s lived
experience (28). This included questions regarding the nature
of the war and conflict they fled back home, the experience
of their displacement journey, and current challenges faced or
experienced following their arrival to Germany in order to
illustrate the chronology of mental health symptoms or illness.
Supplementary Information regarding aspects of their personal
lives, including their family, upbringing, traditions, and cultural
practices were also included to elicit a narratives (28). To
explore links between mental health, concepts of the self, and
faith, questions regarding general coping methods and religious
background were adapted from the HOPE Approach to Spiritual
Assessment. This included questions about general sources of
hope, meaning, comfort, and peace, as well as standard questions
regarding the importance of organized religion in the lives
of participants and extent of practices that are helpful to the
participant (29).
Informed consent was provided by participants before
initiating data collection. All interviews took place in a private
setting within a mental health clinic in central Berlin between
December 2018 and April 2019. Interviews were audio-recorded
following the consent of the participants. All interviews were
conducted in Arabic by a native Arabic speaker with a psychology
background and public health research training (DR). Interviews
were simultaneously transcribed and translated to English.
In vivo codes, including Arabic terms and phrases used to
describe culturally specific symptoms or methods of coping were
transliterated to English for later inclusion in the results. On
average, interviews lasted 36.5 min.
Qualitative Analysis
The interviews were anonymized, transcribed, and entered
to MAXQDA (20.0.8) in English to code and categorize the
data into relevant themes using a grounded theory approach
(28). Based on this framework, line-by-line coding by DR
(also the primary interviewer) was completed in order to
comprehensively reexamine the data collected. Codes were
then initially organized by topics listed in the interview
guide, including challenges, general coping methods, examples
of faith-based coping, to facilitate the coding of complex
perspectives shared by participants regarding mental health,
concepts of the self (including experience of displacement), and
faith. Code categories were later expanded based on emerging
ideas that were compiled at the end of each interview in
order to explore unexpected themes or corroborate certain
ideas or responses shared by other participants in subsequent
interviews. Interpretation of emerging ideas was triangulated
among three of the authors to ensure accuracy. This included
codes regarding coping strategies before, during, and after
displacement, seeking mental health support from a spiritual
leader, impact of integration on faith practices, and advice to
mental health professionals.
For the analysis and compilation of themes, a top-down
approach was used for targeted interview questions (such as
“For some people, their religious or spiritual beliefs act as a
source of comfort and strength in dealing with life’s ups and
downs; is this true for you? If yes, how? If no, was it ever?”) to
develop concise, yet comprehensive categories. This led to the
development of themes regarding faith-based coping methods
utilized before, during, and after displacement, as well as advice
for German mental health providers. For more general interview
questions (such as “What are your sources of hope, strength,
comfort, and peace?”), a bottom-up analysis approach was used
to develop important themes based on cultural and religious
coping methods demonstrated across the study population,
including changes in faith practices upon arrival and integration.
Frontiers in Psychiatry | www.frontiersin.org 3February 2021 | Volume 12 | Article 595979
Rayes et al. Faith-Based Coping Among Refugees in Germany
TABLE 1 | Participant sociodemographics and clinical data.
No. Country of
Origin
Religion Months in
Germany
RHS
Score*
PHQ-9
Score*
Reasons for Migration
1 Syria Islam 15 21 13 War, individual, social
2 Syria Islam 38 29 17 War, economic
3 Syria Islam 29 32 17 War, individual
4 Syria Islam 39 17 10 War, political, religious persecution
5 Syria Islam 44 36 10 War, political, religious persecution
6 Iraq Islam 8 37 15 Economic, social, political, and religious persecution
7 Iraq Islam 21 38 17 War (Syria), political and religious persecution (Iraq)
8 Iraq Islam 35 41 21 Political and religious persecution
9 Iraq Islam 37 32 18 War, political situation, religious persecution. social
10 Syria Islam 31 44 25 War, social
11 Iraq Islam 47 43 23 War, political and religious persecution
12 Syria Islam 39 20 19 War
13 Syria Islam 24 35 16 War, economic, individual, political and religious
persecution, social
14 Syria Islam 31 17 7 Individual, social
15 Syria Islam 21 24 10 War, individual
16 Syria Islam 28 30 25 War, economic, social
17 Syria Islam 44 33 21 War, individual, political and religious persecution
*Scores of ≥12 on items 1–14 or ≥5 item 15 in the Refugee Health Screener-15 and “several days” or higher in a minimum of three responses the Patient Health Questionnaire-9
indicated psychological distress.
TABLE 2 | Summary of participant age and gender breakdown.
Gender
Males 11
Females 6
Age
20–29 8
30–39 4
40–49 5
Ethical Approval
The study was conducted as a part of the larger MEHIRA
project, which was approved by the Ethical Committee of the
Charité Universitaetsmedizin Berlin. The study was registered
in ClinicalTrials.gov (registration number: NCT03109028;
registration date 11.04.2017). As exhibiting symptoms of
depression or psychological distress was an inclusion criterion
for this study, particular approaches were taken to ensure the
comfort of the participant before, during, and after the interview.
This included taking note of the general affect of the participant
throughout the interview, including tone of voice, bodily
gestures, and facial expressions, in order to take any potential
steps to stop or halt the interview if the participant became upset
or uncomfortable. Before the interview, it was noted whether or
not the participant had an appointment in the clinic before or
after the interview in order to prevent any delays or interview
fatigue. Referrals to mental health professionals working in the
clinic were available for support and supervision in the event
that it was needed.
RESULTS
Participants
A total of 17 participants (11 male; six female) were interviewed
for the study (see Table 1). Participants were between the ages
of 22 and 47 years old, with an average age of 34.7 (see
Table 2). The majority of participants were originally from
Syria (N=12), followed by Iraq (N=5). A total of 6
participants were married, five were divorced or separated,
five were single, and one was widowed. Nine participants
had at least one child. On average, participants had been in
Germany for 2 years and 3 months (ranging between 8 and 47
months) and had completed 10.4 years of schooling. Reasons
for migration varied among participants; however, most had
fled ongoing war and conflict in their countries of origin, as
well as political or religious persecution. All participants had
temporary residency status except for one participant who was
residing in Germany without a legal residence permit. A total
of eight participants lived in private apartments, followed by
seven participants who lived in refugee accommodation centers,
and two participants who lived in shared flats. All participants
identified as Muslims, and two identified as non-religious
(or non-practicing) Muslims.
Themes
The main findings from the interviews were organized into
four themes including, (I) faith-based coping during flight (II)
changes in faith practices upon arrival (III) faith-based coping
during integration, and (IV) advice for mental health providers.
The first two themes capture an overview of general coping
Frontiers in Psychiatry | www.frontiersin.org 4February 2021 | Volume 12 | Article 595979
Rayes et al. Faith-Based Coping Among Refugees in Germany
strategies in line with ongoing challenges and shifts in faith
and faith practices experienced by participants upon arrival to
Germany, and for the latter themes they provided examples of
faith-based coping methods and how they can be incorporated
into mental health care provided by non-Arab or non-Muslim
mental health providers.
Faith-Based Coping During Flight
Participants provided examples of faith-based coping methods
they utilized throughout their migration journey and after
witnessing war and conflict in countries of origin. Among
participants from Syria, these experiences were particularly
acute since many had fled shortly following the onset of
violence, experienced abrupt interruptions to schooling and
livelihoods, witnessed the arrival of armed groups and were
exposed to death or detention. Participants from Iraq described
more protracted migration experiences, including living through
multiple generations of war throughout childhood, experiencing
long-term separation from family and children, and cited
multiple experiences of displacement from Iraq.
Examples of faith-based coping methods were reported
among participants who endured difficult or challenging
displacement journeys, such as those who crossed multiple
countries and borders to arrive to Germany, placing their families
at risk in the process. One participant from Iraq shared:
Once we took off by boat on the ocean, I asked God, “If I have a
place in this world, let me and my entire family” to arrive. If you
have written for someone in my family to drown, let me drown in
their place. I hope I arrive to Germany in peace and safety. And
if that anything was going to happen, it would be me instead of
someone in my family.
Two participants from Iraq also mentioned the importance of
thanking God during or after the end of the journeys they
endured by sea and foot to arrive to Germany:
I said to myself, once I arrive, I will pray about 20 rakat
(supplications) for God once we arrive to Germany. When I arrived
to Germany, after about 10 days, I had a dream where God asked
me, “Why did you not pray?” I felt someone was holding me
accountable, why didn’t you pray as promised? This was the first
time something like this ever happened to me.
Changes in Faith Practices Upon Arrival
Displacement to Germany resulted in processes of reflection
among participants, who found that they had the opportunity,
for the first time, to reflect on their personal beliefs and become
more “open” to new perspectives and experiences that were
not available in their country of origin. Upon displacement,
participants reported that the cultural and religious disparity
between Arab and German cultures made young refugee adults
seek behaviors taboo to Islamic principles, such as drinking,
smoking, and partying. On the other hand, participants reported
that their displacement led to a greater understanding of
individuals and religions outside of their own. This included
exposures to churches, synagogues, as well as individuals who do
not believe in God(s) or follow a specific faith. One participant
from Syria stated:
Of course, I became a lot more aware. I learned how to interact with
people from different faiths and walks of life. I think this experience
has made me a lot more aware. I do not think I will regret coming
to Germany. On the contrary, I say, alhamdulilah (thank God) I
arrived here and tried this. If I had stayed in Syria, I would have
never experienced what it is like to be expatriated, to integrate in
a new society, or with new religions, how to maintain yourself,
culture and traditions in a new place, so I consider this [not only]
an opportunity, but a nice chance.
Another participant from Iraq stated:
Things have changed here in Germany. I could go out whenever I
want, I can do whatever I want. If I want to pray, I pray. If I want
to drink, I drink. Whatever I want, I can do it. No one will tell me
that this is against religion, or bad for the environment. I want my
children to live their life without being judged.
Most participants felt that the integration process was not
contingent on or impeded by their faith. One participant from
Syria stated that it was the responsibility of the refugee or
migrant to acclimate, and that Germans were not responsible for
acclimating to Arab or Muslim culture. While all participants
interviewed identified as Muslims, two participants described
themselves as “non-practicing” Muslims, noting changes that had
occurred since they had arrived to Germany. One of these “non-
practicing” participants, originally from Syria, used the example
of seeing people from all walks of life on the metro to demonstrate
his shift in thinking regarding religion:
After a short time here [in Germany], you start thinking in a
different way. You get on the metro, you start to see a lot of
people – you ask why do these people think in a different way?
Lots of incentive to ask yourself the question – “why am I this
way? Why did I choose this religion [to follow]?” You then arrive
to different convictions, you establish new convictions, depending
on the circumstances.
Other participants noted the consistency of their faith identity
throughout their displacement and integration process,
emphasizing that they felt no pressure or would not succumb to
the pressure of changing their faith for the sake of integration.
The following participant from Syria stated:
If a German is to accept me, they will accept me as I am. I am
not going to change so someone else can accept me. For those
who are changing religiously, ethically, or culturally for others to
accept them...I think that when Germans see someone like this [i.e.
drinking alcohol in violation of their religious beliefs], then they will
not respect them.
Another participant from Syria shared how their faith has grown
stronger since their arrival to Germany, particularly what they
refer to as “the permanence” of God as a source of continuity,
protection, and company in her new surroundings:
Frontiers in Psychiatry | www.frontiersin.org 5February 2021 | Volume 12 | Article 595979
Rayes et al. Faith-Based Coping Among Refugees in Germany
In Syria, honestly, I was a bit more distracted with the world. I was
living my normal life. Here, I am trusting of God, since I felt that my
God is permanent, more so than people. In terms of my faith, God is
everlasting and always there for me. Before, in Syria, I was always
with my family, I had a routine, we were happy. All of a sudden,
when you are alone...this is all from God. He permits you to travel
safely, you come here, you walk by yourself, and you think of how
much hardship there is in the world.
When prompted to answer about changes in frequency of and
commitment to faith practices, many participants cited having
been more committed to practices in their country of origin than
in Germany. For example, some participants reported praying
less throughout the week, especially for those who worked full-
time and could no longer attend Friday prayer or had limited
access to an Arabic-speaking mosque or mosque of their Islamic
sect. One participant from Syria stated:
I feel this sort of hajiz (barrier) ever since I arrived to Germany. I
miss the sound of the call to prayer (athan). I feel unable to pray and
unmotivated to pray when I am here. Living in a Muslim country,
like when I lived in Turkey, made a difference for me. It felt closer
to home and reminded me of my faith practices more often. When
I arrived to Germany, I developed averse feelings to religion and
religious practices, which may be a result of my depression. In my
worst moments, I am no longer motivated to seek help from God
and feel demotivated from praying or practicing my faith.
Some participants, mainly male, were also concerned about
access to mosques and expressed distrust regarding religious
leaders and mosques in Germany:
I am finding some difficulties in maintaining prayer here. In Syria,
I used to never miss a prayer, but not because I am less convinced
[by my faith]. It is a shortage on my end. Near my house, there is no
mosque near my house. The closest one is an hour away. My faith
practice is inside my house, mainly.
One of the main reasons I do not go to the mosques in Germany
is because there are no imams (religious clerics) in Germany like
there were in Syria. Here, we do not know their backgrounds. They
may be really good, but I do not know where they came from or
the education they received to become an imam. In Syria, the imam
was known by the village or city he lived in. Someone who is good,
someone who is a hafiz (memorizer of the Qur’an) – you know
that the society has nominated this person. Here, you do not know
his background, and he could be influenced by foreign ideologies.
Faith-Based Coping Methods to Address Distress
During Integration
The majority of participants expressed that particular aspects
of their faith and faith practices served as a positive source of
comfort and reassurance throughout their mental distress and
integration experience in Germany. Examples included attending
religious services, making supplications, meeting other Muslims,
and seeking help from a religious leader.
Some participants mentioned the importance of remembering
and thinking of God as a means of coping with distress. One
participant from Syria noted:
Honestly, my faith in God is what keeps me going. I am
convinced that the world is temporary. . . We know that there is
a Hereafter, there is Heaven, there is something more beautiful,
endless happiness, no anxiety, no sadness, no depression. This is
something very comforting and brings me patience.
Another participant from Iraq stated:
I remember God without going to the mosque. While I am walking,
I ask God to forgive me, to guide me, to release me, to keep me safe.
A prayer is listened to no matter where you are, as long as it comes
with an intention and a heart that is really broken or needs help.
Other participants focused on the sense of calm they feel when
reading Qur’an, praying, or supplicating. One participant from
Syria shared:
Religion helps those who understand it. Reading or hearing Quran
cools (calms) the nerves. Sometimes I make supplication in order to
ask for help, and I cry. You feel a weight on your body, that nothing
in this world is worthwhile. When you read Quran or pray, you feel
comfort all over your body, God makes you feel this sense of calm.
Another participant from Iraq emphasized their reliance
on prayer:
Prayer makes me feel better because it makes me closer to God. He
may forgive me, bless me, help me lead a path that is more different.
More than one participant shared their thoughts on how faith-
based methods of coping should be supplemented with medical
treatment. The following was shared by a participant from Syria:
I know people who use religion for everything. God said, “For
everyone who tastes, there is medicine.” God says, “Ask for help [my
worshipper], and I will help you,” if you want to seek treatment, and
I will help you find it through your prayer. I will make the heart of
the doctor feel for you, the pharmacist will help you. If I am sitting at
home, and wait for God to treat me. God will not send us treatment
in an envelope.
Two participants from Syria, noted the lack of nearby mosques,
which would have otherwise been a source of support when
feeling distressed:
If there was a mosque near my house, I think this would really help
me. Sometimes depression and an overall mental health situation
can impact one’s mental health situation in a way that doesn’t
allow one to think realistically. The one thing that really helps
me become stronger is religion, such as reading Quran or to pray
(feel connected to God), makes me feel a sense of psychological
well-being, to be honest.
Even if you have trouble in the real world, and you feel pressure,
you go inside the mosque and start to cry. Once I leave, I feel like I
am back to reality. Your negative thoughts start to escape you, your
sadness. I start to feel much happier. I started to feel so depressed,
and when I was hospitalized, I asked for a Quran and to visit a
mosque. The translator came and he said he would bring me one as
a gift.
Frontiers in Psychiatry | www.frontiersin.org 6February 2021 | Volume 12 | Article 595979
Rayes et al. Faith-Based Coping Among Refugees in Germany
A few participants stated that they had sought help from a
religious cleric. While some participants, particularly females,
had positive experiences seeking support from religious clerics,
one participant from Iraq noted a different experience:
I tried to ask for help about my depressive symptoms, and the sheikh
(religious cleric) told me to be make dua (supplication), to pray, to
be patient, and to ask for forgiveness. I told him that I do not think I
did anything wrong, that this depression that has existed for 4 years,
it needs to be solved somehow.
Advice for German Mental Health Providers
When participants were asked what they would like German
(i.e., non-migrant) mental health providers about their cultural
or spiritual backgrounds in order to optimize mental health
treatment, a range of response was provided. In particular, the
importance of the presence of a family and community for well-
being were addressed, for example, by one Syrian participant:
[It is] important that they [non-Arab health providers] understand
Arab culture, such as where happiness comes from a societal
perspective. For example, family is one of the most important pillars
of happiness in Arab culture.
Participants expressed their preference for Arabic-speaking
mental health professionals (although, not necessarily Muslim)
who could understand them directly, both in language, as well
as the trauma they experienced before, during, and after their
displacement. Put simply, by a participant from Iraq:
I would like this person [the German mental health professional] to
understand where I come from.
The lack of a shared language for communication between
patient and provider can also inhibit non-Arabic speaking
mental health professionals from understanding culturally-
specific manifestations of mental health conditions, such as a type
of hair loss described by the same Iraqi participant, may be an
explanation for particular mental health symptoms:
For example, da’ al tha’lab [in English: sudden hair loss or Alopecia
areata] is a situation where you lose your hair as a result of fear or
poor mental health. I had a year where I was dealing with this. The
[German] doctor told me that this was a psychological condition.
However, I know that it could be from fear (if you were robbed for
example, someone robbed you) in addition to poor mental health.
Another participant from Iraq also shared the need for empathy
or a broader understanding of the trauma that was experienced
by the client by the German or non-Arabic speaking mental
health professional:
If I told a German psychiatrist about the trauma I have endured, I
would want them to be able to help with these experiences and to
see it as a reality, not something that is fictional.
Participants expressed the specific need for awareness among
mental health professionals in Germany on specific aspects of
their culture, religion, or traditional methods of coping, such
as spiritual forms of mental health support, as described by a
Syrian participant:
A German psychiatrist would just treat your symptoms and give you
a diagnosis. If someone who wants any kind of spiritual support,
it might not be allowed. The doctor must really focus on religion.
Because a renewal of the soul requires this sort of attention.
DISCUSSION
This is one of few studies addressing faith-based coping methods
among distressed Arabic-speaking refugees and asylum-seekers
from Muslim-majority countries in Germany. Using a grounded
theory approach, our analysis demonstrated a wide spectrum of
definitions and interpretations of faith among Arabic-speaking
refugees and asylum-seekers seeking mental health services, most
of which had been shaped by challenging and often traumatic
experiences before, during, and throughout their displacement
and extending into the integration process. This was most
explicitly demonstrated in the first three themes: (i) faith-
based coping during flight, (ii) changes in faith practices upon
arrival, and (iii) faith-based coping methods to address distress
during integration.
Most participants in this sample had experienced significant
challenges ahead of their arrival to Germany, including exposure
to stressful events in Syria and Iraq before departure, multiple
displacements and attempts to integrate into other host country
contexts, detention and torture, and dangerous journeys by
land or boat to arrive to Europe. Following arrival, participants
cited social and economic barriers to integrating into German
society, including difficulties learning the language, becoming
accustomed to new culture, finding housing and employment,
and the chronic uncertainty of what the future held for them.
This had resulted in significant distress and negative mental
health symptoms among those in the study sample, who had
all decided to seek mental health treatment at the Charité
Universitaetsmedizin-sponsored mental health clinic, where
interviews took place.
Upon inquiry, our study found that the participants’ dynamic
relationship with their faith following their arrival to Germany
played a direct role in how faith-based coping methods were or
were not utilized when experiencing mental health symptoms.
Most of those interviewed had only ever lived in Syria or Iraq,
or had been displaced to Muslim-majority countries before their
arrival to Germany. Particularly for male participants in this
study, Germany provided a novel landscape for the exploration
and interpretation of varying faith practices outside of own’s own,
and the integration process often involved a determination of
which practices were helpful, or not so helpful, to their mental
health and well-being. These trends are similar to findings from
a recent study of Syrian refugees in the Netherlands, which
demonstrated that levels of commitment to faith or religious
practices influence coping strategies and overall feelings of
integration (30). Those demonstrating a stronger commitment
to faith were more likely to utilize faith-based coping strategies
Frontiers in Psychiatry | www.frontiersin.org 7February 2021 | Volume 12 | Article 595979
Rayes et al. Faith-Based Coping Among Refugees in Germany
when seeking mental health services, including seeking support
from religious leaders or local religious institutions.
We found notable differences in perspectives between male
and female participants, female participants demonstrated of
which demonstrated a greater reliance on faith-based coping
mechanisms, including attending regular religious lectures and
support groups in mosques, asking religious clerics for support
with mental health symptoms, and reading Quran or praying
in one’s personal time. Male participants, on the other hand,
expressed greater dissent than females with the religious
infrastructures in Germany, including distrust of imams and
particular religious bodies, lack of engagement with clerics for
treatment and lower attendance of weekly (Friday) prayers.
Nonetheless, and consistent with previous studies published on
this topic (20,26,31) which highlight the intertwined nature of
cultural and religious norms in these populations, faith was an
enduring force in the lives of the majority of the Syrian and Iraqi
refugee adults interviewed in this study, regardless of level of
commitment to faith practices.
The fourth and final theme (iv) identified in this study
included constructive advice from participants for German
mental health providers, particularly providers who do not
have a shared migrant background. These findings, which
include a call for greater empathy and understanding of
Syrian and Iraqi culture and faith practices, as well as specific
ways of interpreting distress, could be particularly useful for
German mental health providers engaging refugee and asylum-
seeking populations. This includes the significance of family
and community in the healing process, a common source
of social support mechanism that may be absent for most
refugees and asylum-seekers in Europe who are restricted from
visiting family or have pending family reunification status.
Positive faith-based coping strategies identified by participants
to improve mental health outcomes, such help-seeking from
religious leaders, reading Qur’an, remembering God, or making
supplication can help inform service delivery by sharing these
insights with mental health care providers in Germany (32).
These perspectives also help identify themes of broader religious
and social support in order to facilitate the integration of this
population in their current context. The results of this study
have implications for a variety of actors and stakeholders invested
in facilitating both the short- and the long-term integration of
such populations, including the need to develop culturally- and
faith-sensitive interventions and to introduce cultural mediators
to the clinical setting in order to facilitate the relationship
between mental health provider and patient. Furthermore, results
regarding positive faith-based coping methods demonstrate
opportunities for local engagement from mosques and Islamic
organizations with the Syrian, Iraqi, or broader Muslim refugee
population, particularly in providing basic psychosocial support,
mental health awareness, and expanding referrals to mental
health professionals.
The cultural and context-specific interpretations of optimal
mental healthcare by refugee communities provide insight
on how non-profit organizations, faith-based organizations,
and religious institutions can collaborate with mental health
professionals to provide faith-based training and culturally-
sensitive approaches to working with refugee populations as well
as pose alternatives to the linguistic and cultural barriers posed
by the German health system. This includes training for German
mental health providers regarding the cultural and religious
backgrounds of refugee clients they often provide care for, as well
as overall sensitivity to the sociopolitical circumstances refugee
clients escaped from ((33,34). Religious clerics and spiritual
leaders who are approached by refugee clients seeking faith-
based treatment should also be trained to provide referrals to
specialized mental health services for refugee populations (35).
An unanticipated finding was that many participants,
when answering questions about their own faith identity and
integration experiences, cited the experiences of others. This
included current and former friends, members of their families,
acquaintances, roommates, and a broader description of the
refugee community at large (often identified as “the Syrians”
or “the Arab community”). These generalizations provided
a useful comparison for the participant, in order to either
differentiate or state their similarity to this broader refugee
community, particularly when describing shifts in their faith
identities, their integration process, and their reliance on faith as
a coping mechanism.
Furthermore, an important ethnographic consideration was
the interchangeability of the concepts of religion, spirituality,
cultures, and traditions that were utilized during the interviews.
For example, expressing the extent of “religiosity” led to
discussions regarding Syrian and Iraqi culture and traditions
and how they differed extensively from those in Germany. The
term “spirituality” was less understood by participants and is
less referred to in the literature describing faith-based coping
methods among Arab or Muslim populations (25,36). Although
there is limited information regarding the application of religious
and spiritual healing methods for refugee populations who may
have endured religious or ethnic persecution, there is significant
literature on the application of these concepts in Islam and on
Muslim populations broadly (37).
Due to the conceptual nature of the interviews, there were a
number of limitations that emerged throughout the study.
The first limitation was that questions regarding faith-based
coping often required an additional layer of explanation by the
interviewer to each participant in order to clarify the intentions
of the questions asked. This may have influenced answers given
by participants following examples posed by the interviewer
regarding faith-based coping, which included relying on prayer,
reciting or reading scripture, or attending the mosque, in order
to cope with particular mental health challenges. This was
particularly the case given that these concepts, although designed
using frameworks regarding faith-based coping in English, were
inquired about and discussed in Arabic.
Another limitation of this study was the sensitive nature of
the questions asked, particularly of participants who had faced
religious persecution in their countries of origin. To address this
issue, we aimed to clarify during interviews that these questions
were aimed to support the improvement of mental health care
and treatment provided to Arabic-speaking patients in Germany
Frontiers in Psychiatry | www.frontiersin.org 8February 2021 | Volume 12 | Article 595979
Rayes et al. Faith-Based Coping Among Refugees in Germany
and in other Western contexts. This may have also led to answers
that seemed more favorable or acceptable to the interviewer.
Lastly, all participants in this study were receiving treatment
for their mental health symptoms and were therefore considered
patients of the clinic in which the study was being conducted.
This may have resulted in an overall wariness regarding what
could be shared during the interviews, particularly criticisms of
German or Arab mental health professionals who were currently
working in the clinic. Furthermore, our sampling procedure
included only Arabic-speaking individuals who demonstrated an
interest in the topic of the study regarding faith-based coping
and mostly represented individuals from Syria and Iraq. Future
studies should attempt to represent the experiences of other
refugee and asylum-seeking populations living in Germany and
in Europe, more broadly.
CONCLUSION
Overall, the results of this study demonstrate a variety of faith-
based strategies for coping with displacement and the integration
process among refugees and asylum-seeking populations from
Arabic-speaking and Muslim-majority countries. The study also
addresses changes in faith that this population may experience
during integration and includes recommendations from refugees
themselves to make mental healthcare services more culturally-
sensitive. These findings also indicate the importance of
understanding cultural- and faith-specific interpretations of
mental health symptoms and subsequent actions for diagnosis
and treatment of mental health conditions experienced by
these populations. As European and North American countries
remain top destinations for refugees and asylum-seekers, studies
exploring culturally-specific mental health needs of refugees
from Muslim-majority countries across Germany are critical
to improving the quality of mental health services and in
turn, facilitating social integration for these populations. The
outcomes of this research could be beneficial for mental
health professionals, non-governmental organizations, faith-
based organizations, humanitarian aid agencies, and hospitals
providing mental health and psychosocial support services to
Arabic-speaking refugees in Western contexts. Future studies
should take note of the perspectives of mental healthcare
providers and other healthcare workers and mediators working
with refugees throughout mental health clinics in Germany
and in other Western contexts where a large majority of
refugees from Arabic-speaking or Muslim-majority countries
have been resettled.
DATA AVAILABILITY STATEMENT
The raw data supporting the conclusions of this article will be
made available by the authors, without undue reservation.
ETHICS STATEMENT
The studies involving human participants were reviewed
and approved by Ethical Committee of the Charité
Universitaetsmedizin Berlin. The patients/participants provided
their written informed consent to participate in this study.
AUTHOR CONTRIBUTIONS
DR conceived of the study, collected the data, and coded the
transcripts with inputs from MB throughout. DR performed the
thematic analysis with feedback and input from MB and LW. DR
wrote the manuscript with multiple revisions from MB, CK, DC,
and LW. All authors contributed to the article and approved the
submitted version.
FUNDING
DR was funded by the U.S. Fulbright Scholar Program to
complete this study. The MEHIRA study is funded by the
Innovations fond, Federal Ministry of Health in Germany
(01VSF16061).
ACKNOWLEDGMENTS
The authors would like to thank Nico Lindheimer and Kerem
Böge (Charité University of Medicine) for their assistance and
coordination throughout this project, as well as Caitlin Kennedy
and Pamela Surkan (Johns Hopkins Bloomberg School of Public
Health) for feedback on the final manuscript.
SUPPLEMENTARY MATERIAL
The Supplementary Material for this article can be found
online at: https://www.frontiersin.org/articles/10.3389/fpsyt.
2021.595979/full#supplementary-material
REFERENCES
1. Silove D, Ventevogel P, Rees S. The contemporary refugee crisis: an
overview of mental health challenges. World Psychiatry. (2017) 16:130–9.
doi: 10.1002/wps.20438
2. Elbert T, Wilker S, Schauer M, Neuner F. Dissemination
psychotherapeutischer Module für traumatisierte Geflüchtete. Der
Nervenarzt. (2017) 88:26–33. doi: 10.1007/s00115-016-0245-3
3. Kaltenbach E, Härdtner E, Hermenau K, Schauer M, Elbert T. Efficient
identification of mental health problems in refugees in Germany: the
Refugee Health Screener. Eur J Psychotraumatol. (2017) 8:1389205.
doi: 10.1080/20008198.2017.1389205
4. Winkler J, Brandl E, Bretz H, Heinz A, Schouler-Ocak M. Psychische
Symptombelastung bei Asylsuchenden in Abhängigkeit vom
Aufenthaltsstatus. Psychiatr Praxis. (2018) 46:194. doi: 10.1055/a-0806-3568
5. Walther L, Kröger H, Tibubos AN, von Scheve C, Schupp J, Tam Ta TM,
et al. Psychological distress among refugees in Germany: A cross-sectional
analysis of individual and contextual risk factors and potential consequences
for integration using a nationally representative survey. Br Med J Open. (2020)
10:e033658. doi: 10.1136/bmjopen-2019-033658
Frontiers in Psychiatry | www.frontiersin.org 9February 2021 | Volume 12 | Article 595979
Rayes et al. Faith-Based Coping Among Refugees in Germany
6. Sandalio RN. Life After Trauma: The Mental-Health Needs
of Asylum Seekers in Europe. Washington, DC: Migration
Policy Institute (2018).
7. Georgiadou E, Zbidat A, Schmitt GM, Erim Y. Prevalence of mental distress
among Syrian refugees with residence permission in Germany: a registry-
based study. Front Psychiatry. (2018) 9:393. doi: 10.3389/fpsyt.2018.00393
8. Brandt L, Henssler J, Müller M, Wall S, Gabel D, Heinz A. Risk of psychosis
among refugees: a systematic review and meta-analysis. JAMA Psychiatry.
(2019) 76:1133–40. doi: 10.1001/jamapsychiatry.2019.1937
9. World Health Organization. Mental Health Promotion and Mental Health
Care in Refugees and Migrants: TECHNICAL guidance. Knowledge Hub on
Health and Migration (2018). Available online at: https://www.euro.who.
int/__data/assets/pdf_file/0004/386563/mental-health- eng.pdf (accessed May
18, 2020).
10. UNHCR. Global Trends: Forced Displacement in 2018. UNHCR (2018).
Available online at: https://www.unhcr.org/en-us/statistics/unhcrstats/
5d08d7ee7/unhcr-global-trends-2018.html (accessed December 31, 2020).
11. Romei V, Ehrenberg-Shannon B, Maier-Borst H, Chazan G. How Well Have
Germany’s Refugees Integrated? Financial Times (2017). Available online
at: https://www.ft.com/content/e1c069e0-872f- 11e7-bf50- e1c239b45787
(accessed December 31, 2020).
12. Siegart M, Refugees’ Religious Affiliation, Religious Practice, and Social
Integration. Nuremberg: German Federal Office for Migration and Refugees
(BAMF) (2020).
13. Pew Research Center. Europe’s Growing Muslim Population. Pew Forum
(2017). Available online at: https://www.pewforum.org/2017/11/29/europes-
growing-muslim- population/ (accessed May 18, 2020).
14. Falk R. Refugees, Migrants and World Order. The Refugee Crisis and Religion.
(2017). p. 23–34. London: Rowman and Littlefield International.
15. Human Rights Watch. European Union: Events of 2018. Human Rights Watch
(2018). Available online at: https://www.hrw.org/world-report/2019/country-
chapters/european-union (accessed May 18, 2020).
16. Waagnvoorde R. How Religion and secularism (don’t) matter in the
refugee crisis. In: Mavelli L, Wilson EK, editors. The Refugee Crisis
and Religion. London: Rowman and Littlefield International (2017).
p. 61–74.
17. Su A. Why Germany’s New Muslims Go to the Mosque Less. The Atlantic
(2017). Available online at: https://www.theatlantic.com/international/
archive/2017/07/muslim-syrian-refugees-germany/534138/ (accessed May
18, 2020).
18. Buber-Ennser I, Goujon A, Kohlenberger J, Rengs B. Multi-layered roles of
religion among refugees arriving in Austria around 2015. Religions. (2018)
9:154. doi: 10.3390/rel9050154
19. Böge K, Karnouk C, Hahn E, Schneider F, Habel U, Banaschewski
T, et al. Mental health in refugees and asylum seekers (MEHIRA):
study design and methodology of a prospective multicentre randomized
controlled trail investigating the effects of a stepped and collaborative
care model. Eur Arch Psychiatry Clin Neurosci. (2020) 270:95–106.
doi: 10.1007/s00406-019-00991-5
20. Hassan G, Kirmayer LJ, Mekki-Berrada A, Quosh C, el Chammay R,
Deville-Stoetzel JB, et al. Culture, Context and the Mental Health and
Psychosocial Wellbeing of Syrians: A Review for Mental Health and Psychosocial
Support Staff Working With Syrians Affected by Armed Conflict. Geneva:
UNHCR (2015).
21. Rathod S, Kingdon D, Pinninti N, Turkington D, Phiri P. Cultural Adaptation
of CBT for Serious Mental Illness: A Guide for Training and Practice. Hoboken,
NJ: John Wiley and Sons (2015).
22. Böge K, Karnouk C, Hahn E, Demir Z, Bajbouj M. On perceived stress and
social support: depressive, anxiety and trauma-related symptoms in arabic-
speaking refugees in Jordan and Germany. Front Public Health. (2020) 8:239.
doi: 10.3389/fpubh.2020.00239
23. Walker P, Mazurana D, Warren A, Scarlett G, Louis H. The role of
spirituality in humanitarian crisis survival and recovery. Sacred Aid: Faith and
Humanitarianism. New York, NY: Oxford University Press. (2012). p. 115–39.
24. Pargament KI. The Psychology of Religion and Coping: Theory, Research,
Practice. New York, NY: Guilford Press (2001).
25. Hasan N, Mitschke DB, Ravi KE. Exploring the role of faith in resettlement
among Muslim Syrian refugees. J Religion Spirit Soc Work. (2018) 37:223–38.
doi: 10.1080/15426432.2018.1461045
26. McMichael C. ‘Everywhere is Allah’s place’: Islam and the everyday life of
Somali women in Melbourne, Australia. J Refugee Stud. (2002) 15:171–88.
doi: 10.1093/jrs/15.2.171
27. Charité MEHIRA Health Service Research. Available online at: https://www.
charite.de/en/research/charite_research/research_projects/innovation_fund/
mehira/ (accessed December 31, 2020).
28. Charmaz K. ‘Discovering’chronic illness: using grounded theory.
Soc Sci Med. (1990) 30:1161–72. doi: 10.1016/0277-9536(90)
90256-R
29. Anandarajah G, Hight E. Spirituality and medical practice:
using the HOPE questions as a practical tool for spiritual
assessment. Am Fam Phys. (2001) 63:81. doi: 10.1016/s1443-8461(01)
80044-7
30. Safak A, Kunuroglu FK, van de Vijver F, Yagmur K. Acculturation
of Syrian refugees in the Netherlands: religion as social identity
and boundary marker. J Refugee Stud. (2020) 18–9. doi: 10.1093/jrs/
feaa020
31. Grupp F, Moro MR, Nater UM, Skandrani S, Mewes R. ‘Only God
can promise healing.’: help-seeking intentions and lay beliefs about
cures for post-traumatic stress disorder among Sub-Saharan African
asylum seekers in Germany. Eur J Psychotraumatol. (2019) 10:1684225.
doi: 10.1080/20008198.2019.1684225
32. Schweitzer R, Van Wyk S, Murray K. Therapeutic practice with refugee clients:
a qualitative study of therapist experience. Counsel Psychother Res. (2015)
15:109–18. doi: 10.1002/capr.12018
33. Hassan G, Ventevogel P, Jefee-Bahloul H, Barkil-Oteo A, Kirmayer
LJ. Mental health and psychosocial wellbeing of Syrians affected
by armed conflict. Epidemiol Psychiatric Sci. (2016) 25:129–41.
doi: 10.1017/S2045796016000044
34. Patel NSA, Sreshta N. The role of psychiatrists in the growing
migrant and refugee crises. Am J Psychiatry Residents’ J. (2017) 12:6–8.
doi: 10.1176/appi.ajp-rj.2017.120703
35. Ali OM, Milstein G. Mental illness recognition and referral practices
among imams in the United States. J Muslim Mental Health. (2012) 6:10.
doi: 10.3998/jmmh.10381607.0006.202
36. Ai AL, Tice TN, Huang B, Ishisaka A. Wartime faith-based reactions among
traumatized Kosovar and Bosnian refugees in the United States. Mental Health
Religion Cult. (2005) 8:291–308. doi: 10.1080/13674670412331304357
37. Pridmore S, Pasha Mi. Religion and spirituality: Psychiatry and Islam. Aust
Psychiatry. (2004) 12:381–5. doi: 10.1080/j.1440-1665.2004.02131.x
38. Walther L, Fuchs LM, Schupp J, von Scheve C. Living conditions
and the mental health and well-being of refugees: evidence from a
large-scale German survey. J Immigr Minor Health. (2020) 22:1–11.
doi: 10.1007/s10903-019-00968-5
Conflict of Interest: The authors declare that the research was conducted in the
absence of any commercial or financial relationships that could be construed as a
potential conflict of interest.
The handling editor declared a shared affiliation with the authors at time
of review.
Copyright © 2021 Rayes, Karnouk, Churbaji, Walther and Bajbouj. This is an open-
access article distributed under the terms of the Creative Commons Attribution
License (CC BY). The use, distribution or reproduction in other forums is permitted,
provided the original author(s) and the copyright owner(s) are credited and that the
original publication in this journal is cited, in accordance with accepted academic
practice. No use, distribution or reproduction is permitted which does not comply
with these terms.
Frontiers in Psychiatry | www.frontiersin.org 10 February 2021 | Volume 12 | Article 595979
Content uploaded by Carine Karnouk
Author content
All content in this area was uploaded by Carine Karnouk on Feb 09, 2021
Content may be subject to copyright.
