Research Commentary [18] May 2018

May 1, 2018

This review focuses on the health and mental health of Syrian refugees. The Syrian conflict, which began in 2011, has resulted in the largest refugee crisis since World War II, with millions of Syrian refugees fleeing to neighbouring countries including Lebanon, Jordan, and Turkey. Syrian refugees have also fled to Europe, with many crossing the Mediterranean Sea in order to reach safety. Syria’s pre-war population of 22 million people has been reduced to approximately 17 million, with an estimated 5 million having fled the country, and more than 6.5 million displaced within Syria. 

In September 2015, the New Zealand Government committed to accepting 750 Syrian refugees over the next three years.  Of the 750 places, 600 places were allocated as a special emergency intake above New Zealand’s annual quota, and 150 places were offered within the quota. Syrian refugees have been settled in Hamilton, Wellington and Dunedin.  

Prior to the onset of civil unrest and war in Syria, the country’s citizens were considered to be relatively healthy overall. Given the sustained hardships that many Syrian refugees have endured, their overall health and well-being has suffered and deteriorated. Syrians are familiar with and engage with the Western medical model. They see doctors as the decision makers, and may have less confidence in non-medical health professionals. Although most Syrians are familiar with Western medical practices, like most populations, they have certain care preferences, attitudes, and expectations driven by cultural norms, particularly religious beliefs, and expectations. While many Syrians may have similar preferences due to shared cultural norms and past experiences, it is important to recognise that individuals in this population may have diverse preferences, attitudes, and expectations toward healthcare.

Syria, until March 2011 had a reasonably functioning health system.  Since that time the conflict has left most systems in disarray. As the following articles will show Syrian refugees have experienced significant trauma, both physical and mental. High rates of sexual assault have been reported. Women may have not had access to contraception or antenatal care. There have been many injuries resulting in longer term disability.

Commentary provided by Dr Annette Mortensen, eCALD® Services Project Manager: Research and Development 

The following articles are reviewed:

Article 1: Early observations on the health of Syrian refugees in Canada

This Canadian study shows that no major communicable disease concerns have arisen from the intake of Syrian refugees since 2015.  The two most immediate care needs were catch-up immunisations and dental care. Dr Anna Banerji, a paediatric infectious disease specialist in Toronto who provided care to Syrian refugee families in immigrant reception centres in the period immediately following their arrival, observed that up to one third of refugee children suffered from common viral illnesses, such as upper respiratory tract, ear and throat infections and gastrointestinal illness. There was an influenza outbreak among 450 Syrian refugees who arrived in Edmonton, Alberta at the end of January 2016 as they  arrived at the height of the influenza season and before they could all receive the influenza vaccine, approximately half the adults and most of the children became ill.  

Consistent with the experience in the European Union, major mental health issues had not been identified to date among the Syrian refugees. Post-traumatic stress disorder is likely to emerge over the long term. Cultural psychiatrists in Ontario and Quebec are providing e-consultations as part of an effort to build capacity for culturally sensitive mental health services across the country. 

It is expected that chronic medical conditions will be revealed over time. Out of fear, refugees may under-report health issues in the assessment process, and it is expected that in otherwise ‘healthy’ refugees who have undergone the on arrival health screening, 5% may have some form of ongoing health care need. In referring refugees to Canadian authorities, the UNHCR, advised that the Syrian refugee population could be expected to have “high medical needs”. These needs may include diabetes, developmental disabilities and conflict-related injuries. The paediatrician in the immigrant reception centre in Toronto agreed with this estimate and has found conditions ranging from seizures and developmental disorders, to blood transfusion dependent thalassemia and childhood cancers. Malnutrition has been observed, and physicians have identified a number of children with intellectual disabilities, although it is too early to identify whether this is higher than the average incidence in North American populations. 

Authors: Hansen, L., Maidment, L. & Ahmad, R.

Citation: Hansen, L., Maidment, L. & Ahmad, R. (2016). Early observations on the health of Syrian refugees in Canada. Can Comm Dis Rep, 42 (Suppl 2), S8-10.

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Article 2: Health considerations in the Syrian refugee resettlement process in Canada

In the fall of 2015, the Canadian Government committed to resettle 25,000 Syrian refugees by early 2016 under “Operation Syrian Refugee”. This article describes the plan for the identification, screening and resettlement of Syrian refugees immigrating to Canada, with a specific focus on known and anticipated health needs. 

 Helpfully, Canadian primary health care services cover supplemental services such as dental and vision care as well as prescription medications for refugees and their families. 

Based on the UNHCR Report, many Syrian refugees have experienced psychological and social distress after living in a war zone, being displaced from their home and coming to a new country (Hassan et al., 2015). Many have lost family members and friends and may have witnessed or experienced violence. This can lead to emotional reactions (eg sadness, grief, anger), physical symptoms (eg fatigue, insomnia) and somatic complaints, or social and behavioural problems (eg withdrawal or aggression). Refugees’ experiences after arriving in a settlement country may worsen their distress. These post-displacement experiences may include challenges in securing appropriate housing and employment, and overcoming linguistic barriers, discrimination and social isolation. 

Syrians, like other new immigrants, may be uncomfortable discussing feelings of isolation or distress, especially in a new environment. Current recommendations to health care providers are to actively address the health issues but not probe for trauma — as this may make things worse — and to be alert for signs of post-traumatic stress disorder, depression and other mental health problems that may emerge months following arrival. 

Reference: Hassan, G., Kirmayer, L.J, Mekki-Berrada, A., Quosh, C., el Chammay, R., Deville-Stoetzel, J.B., Youssef, A., Jefee-Bahloul, H., Barkeel-Oteo, A., Coutts, A., Song, S. & Ventevogel, P. (2015). 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. http://www.unhcr.org/55f6b90f9.pdf.

Authors: Hansen, L. & Huston, P.

Citation: Hansen, L. & Huston, P. (2016). Health considerations in the Syrian refugee resettlement process in Canada. Can Comm Dis Rep, 42, Suppl 2,S3-7.

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Article 3: Mental health and psychosocial wellbeing of Syrians affected by armed conflict

This paper, based on a report commissioned by the UNHCR which aims to provide information on cultural aspects of mental health relevant to the care and support of Syrian refugees is useful for mental health service providers in New Zealand (Hassan et al., 2015). 

Clients’ expectations of mental health services 

Mental health services should address the full range of needs and priorities of their clients by identifying their non-psychological or social needs and referring clients to relevant services in their area. Bodily or somatic symptoms accompany most forms of emotional and psychological distress. People who perceive the origins of psychological distress as somatic usually expect their treatment to follow medical lines. As a result of such perceptions and attributions, some Syrians may be reluctant to speak in detail about their memories and experiences, because they do not see the relevance of such personal information to medical conditions. Clients who attribute their ailments to bodily problems or social stressors may also expect interventions that assist them in regaining internal and social balance, as well as control over their lives. Practitioners who avoid using psychological jargon and psychiatric labelling may generate less stigma and be more easily understood, resulting in better collaboration and treatment adherence.

Culturally relevant assessments

For mental health professionals, it is critical to realise that their clients’ understanding and manifestation of mental illness and psychosocial wellbeing is rooted in social, cultural and religious contexts. Clinical assessment will be more accurate and appropriate when it integrates questions on the local modes of expressing distress and understanding symptoms. The Cultural Formulation Interview in the Diagnostic and Statistical Manual (DSM-5) of the American Psychiatric Association provides one simple approach to assist mental health practitioners in this aspect of assessment (Lewis-Fernández et al., 2014). Extensive information on cultural aspects of mental health such as Syrian explanatory models of illness, idioms of distress and cultural/religious modes of coping is provided in the full UNHCR report (Hassan et al., 2015).It is important for mental health programmes to engage with the many qualified and educated Syrians refugees. They can provide crucial links to community and act as culture brokers or mediators within clinical and social service settings by explaining background assumptions, in order to improve communication and mutual understanding between helper and client.

References: Hassan, G., Kirmayer, L.J, Mekki-Berrada, A., Quosh, C., el Chammay, R., Deville-Stoetzel, J.B., Youssef, A., Jefee-Bahloul, H., Barkeel-Oteo, A., Coutts, A., Song, S. & Ventevogel, P. (2015). 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. http://www.unhcr.org/55f6b90f9.pdf.

Lewis-Fernandez, R., Aggarwal, N.K., Baarnhielm, B. et al. (2014). Culture and psychiatric evaluation: Operationalizing cultural formulation for DSM-5. Psychiatry: Interpersonal and Biological Processes,77, 130-154. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4331051/

Authors: Hassan, G., Ventevogel, P., Jefee-Bahloul, H., Barkil-Oteo, A. & Kirmayer, L.J.

Citation:   Hassan, G. et al. (2016). Mental health and psychosocial wellbeing of Syrians affected by armed conflict. Epidemiology and Psychiatric Sciences, 25, 129–141. doi:10.1017/S2045796016000044

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Article 4:  Health care needs and use of health care services among newly arrived Syrian refugees: a cross-sectional study

This study was funded by health care planners in Toronto to help them develop an appropriate service response to the intake of Syrian refugees. The specific aims of the study were to examine the health care needs of Syrian refugees in Toronto within their first few months of arrival; document self-reported use of health care services among newly arrived Syrian refugees; and investigate the perceived health of this population. Although the sample perceived their health as good, over one-quarter reported one or more chronic illnesses or disabilities. This is not surprising considering that diabetes and cardiovascular diseases are noted as the most prevalent health concerns among Syrian refugees who are screened through the immigration medical examination before coming to Canada. The findings also coincide with reports indicating the high prevalence of non-communicable diseases in the Syrian population. The literature suggests that non-communicable diseases among Syrian refugees in Jordan posed the highest burden on the Jordanian health care system.  

It has been reported that refugees are at risk for deteriorating mental and physical health soon after arriving in Canada. The findings on unmet health care needs suggest a course toward this outcome. In addition to the pre-existing health problems before migration, such as injuries and chronic illnesses, after they resettle in Canada, refugees are more likely than the general population to experience socioeconomic barriers, which may also contribute to deterioration of their health status. 

Participants were asked about the language they would feel most comfortable speaking with health care providers in. Interestingly, the study found that 40.5% would prefer a language other than Arabic which is consistent with data indicating that the mother tongue of over 10% of Syrian refugees in Ontario was not Arabic. This finding suggests that Syrian refugee minorities such as Armenians and Kurds resettled in Toronto may prefer to speak their mother tongue, which has potential implications for the provision of health care services. Similarly, it is important to ask the preferred language of the Syrian refugees settled in New Zealand who come from Kurdish, Turkmen, and Assyrian Christian, as well as Arabic backgrounds. 

Authors: Ode, A., Tuck, A., Magic, B., Hynix, M., Roche, B. & McKenzie, K.

Citation: Ode, A., Tuck, A., Magic, B., Hynix, M., Roche, B. & McKenzie, K. (2017). Health care needs and use of health care services among newly arrived Syrian refugees: a cross-sectional study. CMAJ OPEN, 5 (2) E354-E358.

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