Migrant Trauma and the Role of Healthcare Professionals and Systems in Enhancing Wellbeing

Main Article Content

Jordan Greenbaum, MD Ernesto Caffo, MD

Abstract

Millions of children and adults are forcibly displaced from their homes each year, with a significant proportion seeking refuge in the European Union. Before, during and after their migration journey they may experience multiple trauma events that may lead to significant stress and complicate their adjustment to the host country. Physical, emotional and behavioral responses to adversity (the traumatic stress response) vary and are influenced by numerous factors, notably by cultural beliefs and norms. Culturally responsive healthcare professionals who serve migrant patients are in a unique position to recognize signs and symptoms of traumatic stress, and provide basic, practical interventions. Given the large number of migrant individuals at risk for significant behavioral health issues and the relatively limited number of mental health professionals available to treat them, resources are best allocated if the primary healthcare provider is equipped to offer formal or informal “screening” for traumatic stress (e.g., use a culturally adapted and validated clinical tool or ‘screen’ with open-ended questions about the migration experience, current patient wellbeing, and daily stressors). They may then offer a basic intervention for the majority of patients with mild-moderate symptoms of stress, while referring those with severe symptoms to trained mental health specialists. This article reviews the types of trauma often experienced by migrant families and the nature of the traumatic stress response. It explores how culture may impact manifestations of traumatic stress and influence discussions of trauma between patients/caregivers and healthcare professionals. Moreover, it outlines the roles of the primary healthcare professional and their organization in recognizing and responding to the needs of these vulnerable patients. Screening options, basic psychoeducation strategies and the importance of community resources are discussed. The need for clinical protocols and a trauma-informed healthcare facility, as well as staff education regarding migration-related health and behavioral health needs, cultural responsivity, and trauma-informed care is emphasized, and resources are provided.

Keywords: Migrant Trauma, Role of Healthcare Professionals and Systems

Article Details

How to Cite
GREENBAUM, Jordan; CAFFO, Ernesto. Migrant Trauma and the Role of Healthcare Professionals and Systems in Enhancing Wellbeing. Medical Research Archives, [S.l.], v. 12, n. 1, jan. 2024. ISSN 2375-1924. Available at: <https://esmed.org/MRA/mra/article/view/5037>. Date accessed: 03 mar. 2024. doi: https://doi.org/10.18103/mra.v12i1.5037.
Section
Review Articles

References

1. Unicef, Garin E, Beise J, Hug L, You D. Uprooted: The growing crisis for refugee and migrant children. Available at https://datauniceforg/resources/uprooted-growing-crisis-refugee-migrant-children/; accessed on 7/12/22. 2016.

2. United Nations High Commissioner for Refugees. Figures at a glance. 2023;Available at https://www.unhcr.org/us/about-unhcr/who-we-are/figures-glance; accessed on Nov 13, 2023.

3. Eurostat. Annual asylum statistics. 2023;Available at https://ec.europa.eu/eurostat/statistics-explained/index.php?title=Asylum_statistics&oldid=558844#Age_and_sex_of_first-time_applicants; accessed on Nov 13, 2023.

4. Youngmann R, Bachner-Melman R, Lev-Ari L, Tzur H, Hileli R, Lurie I. Trauma, Post-Traumatic Stress Disorder, and Mental Health Care of Asylum Seekers. International journal of environmental research and public health. 2021;18(20).

5. Abdi S, Akinsulure-Smith AM, Sarkadi A, et al. Promoting positive development among refugee adolescents. Journal of Research on Adolescence.n/a(n/a).

6. UNICEF. Harrowing journeys: Children and youth on the move across the Mediterranean Sea, at risk of trafficking and exploitation. Available at: https://publicationsiomint/books/harrowing-journeys-children-and-youth-move-across-mediterranean-sea-risk-trafficking-and Accessed on 3/17/22. 2017.

7. United Nations High Commissioner for Refugees. Children on the run: Unaccompanied children leaving Central America and Mexico and the need for international protection. 2014;Available at http://www.unhcr.org/en-us/about-us/background/56fc266f4/children-on-the-run-full-report.html; accessed on 3/17/22.

8. Giordano F, Cipolla A, Ragnoli F, Brajda Bruno F. Transit Migration and Trauma: the Detrimental Effect of Interpersonal Trauma on Syrian Children in Transit in Italy. Psychological Injury and Law. 2019;12(1):76-87.

9. Dangmann C, Solberg Ø, Andersen PN. Health-related quality of life in refugee youth and the mediating role of mental distress and post-migration stressors. Qual Life Res. 2021;30(8):2287-2297.

10. International Organization for Migration. Fatal journeys: Volume 4: Missing migrant children. 2019;Available at https://publications.iom.int/books/fatal-journeys-volume-4-missing-migrant-children; accessed on Nov 17, 2023.

11. Burck C, Hughes G. Challenges and impossibilities of 'standing alongside' in an intolerable context: Learning from refugees and volunteers in the Calais camp. Clinical Child Psychology and Psychiatry. 2018;23:223-237.

12. Traffik Analysis Hub, Stop the Traffik. Ukraine response impact report: March-October 2022. 2022;Available at https://www.stopthetraffik.org/ukraine-response-impact-report-march-october-2022/#:~:text=We%20have%20begun%20the%20revolution,geo%2Dtargeted%20digital%20prevention%20campaign.; accessed on Nov 13, 2023.

13. Scharpf F, Kaltenbach E, Nickerson A, Hecker T. A systematic review of socio-ecological factors contributing to risk and protection of the mental health of refugee children and adolescents. Clin Psychol Rev. 2021;83:101930.

14. Nodzenski M, Kiss L, Pocock NS, Stoeckl H, Zimmerman C, Buller AM. Post-trafficking stressors: The influence of hopes, fears and expectations on the mental health of young trafficking survivors in the Greater Mekong Sub-region. Child Abuse Negl. 2020;100:104067.

15. National Child Traumatic Stress Network. The 12 core concepts: Concepts for understanding traumatic stress responses in children and families. Available at http://wwwnctsnorg/sites/default/files/assets/pdfs/ccct_12coreconceptspdf; accessed on May 17, 2020. 210.

16. National Child Traumatic Stress Network. Age-related reactions to a traumatic event. 2010;Available at https://www.nctsn.org/sites/default/files/resources//age_related_reactions_to_traumatic_events.pdf; accessed on 8/23/22.

17. National Scientific Council on the Developing Child. Connecting the brain to the rest of the body: Early childhood development and lifelong health are deeply intertwined: Working paper No. 15. 2020;Available at www.developingchild.harvard.edu; accessed on Nov 19, 2023.

18. Royal College of Psychiatrists. Asylum seeker and refugee mental health. Available at https://wwwrcpsychacuk/international/humanitarian-resources/asylum-seeker-and-refugee-mental-health; accessed on Dec 8, 2023. 2020.

19. La Rooy D, Brubacher SP, Aromaki-Stratos A, Cyr M, Hershkowtiz I, et al. The NICHD protocol: A review of an internationally-used evidence-based tool for training child forensic interviewers. J Criminological Research, Policy & Practice. 2016;2:76-89.

20. Cyr M. Conducting interviews with child victims of abuse and witnesses of crime: A practical guide. Oxon, OX and New York, N.Y.: Routledge, Taylor and Francis Group; 2022.

21. Lamb ME, Brown DA, Hershkowitz I, Orbach Y, Esplin PW. Tell me what happened: Questioning children about abuse. 2nd ed. West Sussex, U.K.: John Wiley & Sons, LTD; 2018.

22. Poole DA. Interviewing children: The science of conversation in forensic contexts. Washington, D.C.: American Psychological Association; 2016.

23. Patel AR, Hall BJ. Beyond the DSM-5 Diagnoses: A Cross-Cultural Approach to Assessing Trauma Reactions. Focus (Am Psychiatr Publ). 2021;19(2):197-203.

24. Kohrt BA, Rasmussen A, Kaiser BN, et al. Cultural concepts of distress and psychiatric disorders: literature review and research recommendations for global mental health epidemiology. Int J Epidemiol. 2014;43(2):365-406.

25. Engebretson J, Mahoney J, Carlson ED. Cultural competence in the era of evidence-based practice. J Professional Nursing. 2008;24:172-178.

26. Bryant RA, Njenga FG. Cultural sensitivity: Making trauma assessment and treatment plans culturally relevant. J Clin Psychiatry. 2006;67(2):74-79.

27. Khamis V. Posttraumatic stress disorder and emotion dysregulation among Syrian refugee children and adolescents resettled in Lebanon and Jordan. Child Abuse Negl. 2019;89:29-39.

28. Kirmayer LJ. Confusion of the senses: Implications of ethocultural variations in somatoform and dissociative disorders for PTSD. Washington, D.C.: American Psychological Associaton; 1996.

29. Roberts LM, Achotegui J, Allen RC, Lopez M, Fakhri M. Understanding the Ulysses Syndrome, effective engagement, and ways to heal. Engage! Exodus & Entry. 2022;4:38-49.

30. Gormez V, Kılıç HN, Orengul AC, et al. Psychopathology and Associated Risk Factors Among Forcibly Displaced Syrian Children and Adolescents. J Immigr Minor Health. 2018;20(3):529-535.

31. Dangmann C, Dybdahl R, Solberg Ø. Mental health in refugee children. Current Opinion in Psychology. 2022;48:101460.

32. Kien C, Sommer I, Faustmann A, et al. Prevalence of mental disorders in young refugees and asylum seekers in European Countries: a systematic review. European child & adolescent psychiatry. 2019;28(10):1295-1310.

33. Burger I, van Hemert AM, Schudel WJ, Middelkoop BJ. Suicidal behavior in four ethnic groups in the Hague, 2002-2004. Crisis. 2009;30(2):63-67.

34. Forte A, Trobia F, Gualtieri F, et al. Suicide Risk among Immigrants and Ethnic Minorities: A Literature Overview. International journal of environmental research and public health. 2018;15(7):1438.

35. Zurek G, Schedlich C, Bering R. Target group intervention programme manual III: Manual for trauma-based psychoeducation for victims of disasters. European Network for Pscyho-Social Aftercare in Case of Disaster. 2008.

36. Walther L, Amann J, Flick U, Ta TMT, Bajbouj M, Hahn E. A qualitative study on resilience in adult refugees in Germany. BMC Public Health. 2021;21(1):828.

37. Abdullah T, Brown TL. Mental illness stigma and ethnocultural beliefs, values, and norms: an integrative review. Clin Psychol Rev. 2011;31(6):934-948.

38. Ellacott B. The journey north: A systemic review of the health risks experienced by Central American migrants in transit to the United States. 2021; DOI: 10.13140/RG.2.2.13551.36002.

39. World Health Organization. A human rights-based approach to health 2008;Available at: https://www.ohchr.org/sites/default/files/HRBA_HealthInformationSheet.pdf. accessed on July 31, 2023.

40. World Health Organization. Refugee and migrant health: Global competency standards for health workers. 2021;Available at https://reliefweb.int/sites/reliefweb.int/files/resources/9789240030626-eng.pdf; accessed on 2/22/22.

41. International Committee, British Medical Association. BMA refugee and asylum seeker health resource. 2019;Available at https://www.bma.org.uk/advice-and-support/ethics/refugees-overseas-visitors-and-vulnerable-migrants/refugee-and-asylum-seeker-patient-health-toolkit; accessed on Nov 15, 2023.

42. World Health Organization. Refugee and migrant health: One-stop resource for countries to advance the health and migration agenda. 2023;Available at: https://www.who.int/tools/refugee-and-migrant-health-toolkit; accessed on Nov 15, 2023.

43. National Committee for Quality Assurance. A practical guide to implementing the national CLAS standards: For racial, ethnic and linguistic minorities, people with disabilities and sexual and gender minorities. 2016;Available at https://www.cms.gov/About-CMS/Agency-Information/OMH/Downloads/CLAS-Toolkit-12-7-16.pdf; accessed on Nov 29, 2020.

44. Handtke O, Schilgen B, Mösko M. Culturally competent healthcare – A scoping review of strategies implemented in healthcare organizations and a model of culturally competent healthcare provision. PLOS ONE. 2019;14(7):e0219971.

45. UNICEF. Identification of victims/persons 'at-risk' of trafficking in human beings. 2022;Available at chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.unicef.org/eca/media/24371/file/Identification%20of%20Persons%20At-Risk%20of%20Trafficking%20in%20Human%20Beings.pdf; accessed on Dec 8, 2023.

46. Greenbaum J, Kaplan D, Young J, AAP Council on Child Abuse and Neglect, AAP Council on Immigrant Child and Family Health. Clinical report: Exploitation, labor and sex trafficking of children and adolescents: Health care needs of patients. Pediatrics 2023;151(1):e2022060416.

47. Chung RC. Cultural perspectives on child trafficking, human rights and social justice: A model for psychologists. Counselling Psych Quarterly. 2009;22(1):85-96.

48. Euro Med Info. How culture influences health beliefs. 2023;Available at https://www.euromedinfo.eu/how-culture-influences-health-beliefs.html/; accessed on Nov 15, 2023.

49. Arousell J, Carlbom A. Culture and religious beliefs in relation to reproductive health. Best Pract Res Clin Obstet Gynaecol. 2016;32:77-87.

50. Office for Health Improvement and Disparities. Culture, spirituality and religion: Migrant health gide: Advice and guidance on the health needs of migrant patients for healthcare practitioners. 2017;Available at: https://www.gov.uk/guidance/culture-spirituality-and-religion; accessed on Nov 15, 2023.

51. Koopmann-Holm B, Tsai JL. Focusing on the negative: cultural differences in expressions of sympathy. J Pers Soc Psychol. 2014;107(6):1092-1115.

52. American Psychological Association. Multicultural guidelines: An ecological approach to context, identity, and intersectionality. 2017;Available at https://www.apa.org/about/policy/multicultural-guidelines; accessed on 3/1/22.

53. Alonso J, Buron A, Bruffaerts R, et al. Association of perceived stigma and mood and anxiety disorders: results from the World Mental Health Surveys. Acta Psychiatr Scand. 2008;118(4):305-314.

54. Saewyc EM, Shankar S, Pearce LA, Smith A. Challenging the Stereotypes: Unexpected Features of Sexual Exploitation among Homeless and Street-Involved Boys in Western Canada. International journal of environmental research and public health. 2021;18(11).

55. Adjei JK, Saewyc EM. Boys are not exempt: Sexual exploitation of adolescents in sub-Saharan Africa. Child Abuse Negl. 2017;65:14-23.

56. von Hohendorff J, Habigzang LF, Koller SH. "A boy, being a victim, nobody really buys that, you know?": Dynamics of sexual violence against boys. Child Abuse & Neglect. 2017;70:53-64.

57. Meyer E. The culture map: Breaking through the invisible boundaries of global business. New York: Public Affairs; 2014.

58. Hofstede G. Dimsensionalizing cultures: The Hofsteded model in context. Online Readings in Psychology and Culture. 2011;2:https://doi.org/10.9707/2307-0919.1014.

59. Dune T, Ayika D, Thepsourinthone J, Mapedzahama V, Mengesha Z. The Role of Culture and Religion on Sexual and Reproductive Health Indicators and Help-Seeking Attitudes amongst 1.5 Generation Migrants in Australia: A Quantitative Pilot Study. International journal of environmental research and public health. 2021;18(3).

60. Lewis-Fernández R, Aggarwal NK, Bäärnhielm S, et al. Culture and psychiatric evaluation: operationalizing cultural formulation for DSM-5. Psychiatry. 2014;77(2):130-154.

61. Linton JM, Green A. Providing Care for Children in Immigrant Families. Pediatrics. 2019;144(3).

62. Substance Abuse and Mental Health Services Administration. SAMHSA's concept of trauma and guidance for a trauma-informed approach. Substance Abuse and Mental Health Services Administration. 2014.

63. Global Alliance Against Traffic in Women, Foundation Against Trafficking in Women, International Human Rights Law Group. Human rights standards for the treatment of trafficked persons. Accessed at http://wwwhrlawgrouporg/resources/content/IHRLGTraffickin_tsStandardspdf on July 29, 2016. 1999.

64. United Nations Human Rights, Office of the High Commissioner for Human Rights. Convention on the Rights of the Child. Available at: http://wwwohchrorg/EN/ProfessionalInterest/Pages/CRCaspx; Accessed on 7/23/22. 1990.

65. World Health Organization. Agenda for zero discrimination in healthcare. Geneva, Switzerland Available at https://wwwwhoint/workforcealliance/media/news/2016/agenda-zero-discrimination-healthcare_enpdf?ua=1; accessed on May 3, 2020. 2016.

66. World Health Organization. Responding to children and adolescents who have been sexually abused: WHO clinical guidelines. 2017;Available at: https://apps.who.int/iris/bitstream/handle/10665/259270/9789241550147-eng.pdf;jsessionid=37ADD6616474C995A0D79A2EE83BC1DD?sequence=1; accessed May 12, 2020.

67. World Health Organization. Technical report: W.H.O. guidelines for the health sector response to child maltreatment. 2019;Available at https://www.who.int/violence_injury_prevention/publications/violence/Technical-Report-WHO-Guidelines-for-the-health-sector-response-to-child-maltreatment-2.pdf; accessed on Nov 17, 2020.

68. World Health Organization. Caring for women subected to violence: A WHO training curriculum for health care providers. Revised edition. 2021;Available at https://www.who.int/publications/i/item/9789240039803; accessed on 2/22/22.

69. Arenson M, Forkey HC. Violence exposure and trauma-informed care. Pediatr Clin N Am. 2023; https://doi.org/10.1016/j.pcl.2023.06.010.

70. Lanehurst A, Gordon M, Coverdale J, White CN, Nguyen P. Integrating trauma-informed care into clinical practice with trafficked persons. Bull Menninger Clin. 2022;86(Supplement A):44-55.

71. Forkey H, Szilagyi M, Kelly ET, Duffee J. Trauma-Informed Care. Pediatrics. 2021;148(2):e2021052580.

72. Racine N, Killam T, Madigan S. Trauma-Informed Care as a Universal Precaution: Beyond the Adverse Childhood Experiences Questionnaire. JAMA Pediatrics. 2020;174(1):5-6.

73. Miller AB, Hahn E, Norona CR, et al. A socio-culturally, linguistically-responsive, and trauma-informed approach to mental health interpretation. 2019;Los Angeles, CA, and Durham, NC: National Center for Child Traumatic Stress.

74. Fischer KR, ., Bakes KM, Corbin TJ, et al. Trauma-informed care for violently injured patients in the emergency department. Annals Emerg Med. 2019;73:193-202.

75. Substance Abuse and Mental Health Services Administration. SAMHSA's concept of trauma and guidance for a trauma-informed approach. HHS Publication No. (SMA) 14-4884. Rockville, MD: Substance Abuse and Mental Health Services Administration;2014.

76. Zimmerman C, Borland R. Caring for trafficked persons: Guidance for health providers. In. Vol Available at https://publications.iom.int/books/caring-trafficked-persons-guidance-health-providers; accessed on 2/26/22.: International Organization for Migration; 2009.

77. National Council for Behavioral Health. Fostering resilience and recovery: A change package for advancing trauma-informed primary care.Available at https://www.thenationalcouncil.org/fostering-resilience-and-recovery-a-change-package/; accessed on May 14, 2020.

78. Berthold SM, Mollica RF, Silove D, Tay AK, Lavelle J, Lindert J. The HTQ-5: revision of the Harvard Trauma Questionnaire for measuring torture, trauma and DSM-5 PTSD symptoms in refugee populations. European Journal of Public Health. 2018;29(3):468-474.

79. Mollica RF, McDonald LS, Massagli MP, Silove DM, . Measuring trauma, measuring torture: Instructions and guidance on the utilization of the Harvard Program in Refugee Trauma’s versions of the Hopkins Symptom Checklist-25 (HSCL-25) & the Harvard Trauma Questionnaire (HTQ) Cambridge, MA: : Harvard Program in Refugee Trauma; 2004.

80. Mollica RF, Caspi-Yavin Y, Bollini P, Truong T, Tor S, Lavelle J. The Harvard Trauma Questionnaire. Validating a cross-cultural instrument for measuring torture, trauma, and posttraumatic stress disorder in Indochinese refugees. J Nerv Ment Dis. 1992;180(2):111-116.

81. National Child Traumatic Stress Network. Measures that are appropriate for refugee children and families. 2023;Available at https://www.nctsn.org/resources/measures-are-appropriate-refugee-children-and-families; accessed on Dec 7, 2023.

82. Gadeberg AK, Montgomery E, Frederiksen HW, Norredam M. Assessing trauma and mental health in refugee children and youth: a systematic review of validated screening and measurement tools. Eur J Public Health. 2017;27(3):439-446.

83. Bean T, Mooijaart A, Eurelings-Bontekoe E, Sprinhoven P. Validation of the teacher’s report form for teachers of unaccompanied refugee minors [Clinical psychological testing 2224] SagePublications, US. 2007;1:53-68.

84. Bean T, Mooijart A, Eurelings-Bontekoe EHM, Spinhoven P. Validation of the Child BehaviorChecklist for guardians of unaccompanied refugee minors. ChildrenYouth ServRev. 2006;28:867–887.

85. National Child Traumatic Stress Network. Information on child trauma. Available at https://wwwnctsnorg/what-is-child-trauma/about-child-trauma; Accessed on Aug 21, 2023.

86. Migration IOf. Migrants and their vulnerability to human trafficking, moder slavery and forced labour. 2019;Available at https://reliefweb.int/report/world/migrants-and-their-vulnerability-human-trafficking-modern-slavery-and-forced-labour; accessed on Dec. 8, 2023.

87. The Joint Commission. The Joint Commission: Advancing effective communication, cultural competence, and patient- and family-centered care: A roadmap for hospitals. . 2010;Oakbrook Terrace, IL.

88. Mig-HealthCare. Minimize health inequalities and improve the integration of vulnerable migrants and refugees into local communities. 2020;Available at chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.mighealthcare.eu/resources/MIG_HEALTHCARE_REPORT_A4_07_final.pdf; accessed on Dec. 8, 2023.

89. Common Approach for Refugees and Other Migrants' Health. Healthcare model. 2020;Available at http://careformigrants.eu/healthcare-model/; accessed on Dec. 8, 2023.

90. Phillips H, Lyon E, Fabri M, Warshaw C. Promising practices and model programs: Trauma-informed approaches to working with survivors of domestic and sexual violence and other trauma. National Center on Domestic Violence, Trauma & Mental Health;2015.