Q1: Does migration affect the migrants’ mental health conditions?
A1: Yes, it directly influence. People are now moving faster and further and in larger numbers than ever before. One million people emigrate permanently, and over a million more seek asylum each year. Migration affects health. Immigrants have higher rates of cardiovascular disease, colorectal carcinoma and melanoma than non-immigrant populations. In the United States, immigrants have higher mortality from stomach cancer, brain cancer and infectious disease. In the United Kingdom, children with ethnic origin in south Asia have higher rates of leukemia, lymphoid carcinoma, lymphoma and hepatic tumors. In Israel, cardiac disease in immigrants is markedly more severe than in the native population. Clinical manifestations of physical disease, such as tuberculosis, are also significantly altered in immigrant populations.
Migration also affects mental health. In the United Kingdom, Irish, Caribbean and Pakistani men have higher rates of suicidal thoughts and deliberate self-harm. In Oslo, post-traumatic stress disorder affects 46.6% of refugees.8 Egyptian and Asian immigrants have higher rates of bulimia and anorexia nervosa.
Q2: How does culture affect health and illness?
A2: Because migration often brings people together from very different cultural backgrounds, it is important to give explicit attention to cultural dimensions of the illness experience. Place of origin can affect exposure to endemic diseases, childhood immunization and health care experiences. Culture can profoundly influence every aspect of illness and adaptation, including interpretations of and reactions to symptoms; explanations of illness; patterns of coping, of seeking help and response; adherence to treatment; styles of emotional expression and communication; and relationships between patients, their families and health care providers.
Q3: How does traumatic experiences affect migrants’ psychology?
A3: Many refugees have experienced persecution, war, or trauma. It is normal for people to miss family members and loved ones who are still in their home country. Many people have difficulties because they do not read, speak, or understand English.
Because of the many difficulties faced by refugees, they may:
- Feel sad, experience changes in their appetite, have difficulty sleeping, cry often, and lose interest in doing things that they once enjoyed.
- Worry about their jobs, their health, or life in the new country.
- Suffer from physical symptoms, such as headaches, dizziness, or restlessness.
- Experience nightmares about war or trauma.
- Have difficulty keeping bad memories out of their minds.
Try to avoid things that remind them of the terrible things they saw or experienced. The social worker/youth worker should emphasize that these symptoms do not reflect weakness in the person, but are normal reactions to past stressful and traumatic experiences. While experiencing some of these symptoms is normal, if the symptoms are very disturbing and cause significant difficulties in functioning, then the patient or family should be encouraged to discuss them with a health provider.
Q4: What is the burden of illness of posttraumatic stress disorder in immigrant populations?
A4: Most persons who experience traumatic events have a favorable mental health prognosis. When symptoms of post-traumatic stress disorder or acute stress disorder develop, there is, in most cases, substantial natural recovery (estimated at about 80%). However, those in whom posttraumatic stress develops may remain symptomatic for years and are at risk of secondary problems, such as substance abuse. A meta-analysis of studies involving adult refugees resettled in developed countries reported a 9% prevalence of post-traumatic stress disorder, and 5% had major depression. Among refugees with major depression, 71% also had posttraumatic stress disorder. Conversely, 44% of refugees with post-traumatic stress disorder also had major depression. Studies of child refugees report 11% prevalence of posttraumatic stress disorder. Symptoms may be reactivated when faced with new traumas, particularly if reminiscent of earlier traumatic experiences. Torture and cumulative trauma are the strongest predictors of post-traumatic stress disorder and are associated with chronic physical and mental health problems. Fear of repatriation may exacerbate consequences of promigratory traumas.
Q5: In which ways should the trainer/youth worker/social worker handle diversity in a multicultural group?
A5: Personal experience indicates that, one of the biggest fears of youth workers who are getting involved with inclusion-oriented topics constitutes the way in which they should handle the factor of diversity within a multicultural group. Needless to say, embracing different ways of seeing things might not be an easy path for some and it is wise to consider how to manage doubts and discontent without alienating anyone. Sometimes the biggest problem lies on the fact the trainer will not necessarily be aware of individuals’ ingrained social norms or/ and social identities and while the time goes he may realize that some people of the group encounter some problems with diversity, thus making inclusion harder from the trainer’s perspective. Whatever the case is, the trainer should always attempt to make the group focus on the advantages of the diversity, which are not to be, by no means, underestimated.
As a first step, based on the assumption that proper communication constitutes the key, it would be good for the trainer to set from the beginning of the course a directory which will contain clear and easy-to-understand policies and rules, as well as group ethos that everyone will be aware of, and which in parallel could be easily interpreted. The trainer should carefully discuss the content of this directory with the participants, thus trying to identify any ambiguities or misunderstandings. On the basis of this assumption, a priority should be given to be ensured that everyone should be treated equally. On the other hand, the trainer should always keep in mind that a diverse group enables a culture of recognizing participants as individuals, and not stereotypes. The conquest of such rationale, should be the main aim of the relation-building and ‘breaking-the-ice’ activities which should be conducted in the beginning of the training/workshop.
Additionally, the trainer should be aware that different religions may have different taboos, therefore trying to be prepared beforehand in terms of the basic peculiarities of each religion. The trainer should be sensitive to those peculiarities; this would be a sign of respect and it will definitely be appreciated by the participants. Respect, tolerance and compassion are always the core of a ‘well-oiled’ group. As a conclusion, the first and the last thing that the trainer should take into consideration is that all these rules and codes come form the top; accordingly, it is up to the trainers to show (and not necessarily to tell) that they are proactive in embracing all kind of people who will bring value to the group, as well as that it could always be healthy and beneficial to learn from the differences of one another.
Q6: How does the trainer become able to distinguish participants with low self-confidence from those with high indications of self-belief?
A6: Those participants who present signs of low self-confidence could be identified from the following behaviours:
-they tend to be uneasy and shy;
-they tend to show uncertainty or contradictory moods/ideas in terms of what they want and who they are;
-they tend to present indications of worthlessness when they are invited to complete a task;
-they tend to make negative thoughts about themselves and their abilities in general;
-sometimes they seem unable to enjoy and feel relaxed in different phases of the training course;
-from personal discussions, the trainer draws the conclusion that such individuals do not maintain a clear direction in life.
Contrarywise, individuals with indications of enhanced self-confidence tend to:
-feel and seem comfortable when facing new challenges, as well as when they are invited to accomplish particular tasks;
-show a greater enjoyment when they have been invited to do something, and of life in general;
-express how excited they are about new challenges and opportunities, whilst they are not afraid of taking risks;
-express with confidence their opinions, ideas and feelings, without hurting or offending anyone and without being critical;
-show respect for other individuals;
-be at ease in social situations;
-be able to be themselves;
-seem sure of what they want.
Q7: Could low self-esteem be considered as a mental health problem?
A7: The situation of presenting indications of low self-esteem could not be considered as a mental health problem, although the two are closely linked. As psychologists have proven, some of the manifestations of low self-esteem could be symptoms of mental health problems, such as for instance, the absence of hope, hating of oneself, being worried about being unable to do things, blaming oneself without being a real reason. Although, it is proven that, in case that many of such factors affect for a long time one’s self-esteem, such ongoing negative situation is able to cause a serious mental health problem, such as depression and anxiety. Conversely, when individuals encounter a mental health problem, this situation could bring about low self-esteem indications, therefore making it more difficult for the individuals to cope with, or even to take further steps that would increase their self-confidence.
Is it appropriate to expose refugees and displaced people to traumatic memories?
Generally speaking, yes it is. Indeed, prolonged exposure, a cognitive behavioral therapy including both in vivo and imaginal exposure to the traumatic memory, is one of several empirically supported treatments for chronic posttraumatic stress disorder, however these should always be done by a mental health professional.
Where can I volunteer?
Everyone can help refugees by welcoming them as new and valuable members of European society. You can help refugees by volunteering at a local resettlement agency, becoming a language tutor, a tour guide, a mentor to a family, donating money, furniture and household items, teaching other people about refugees, and employing or encouraging local businesses to employ refugees. Many organizations offer volunteering opportunities but the two following websites are great resources to start with:
Q8: What are the common health problems of refugees and migrants arriving in the European Region?
A8: The health problems of refugees and migrants are similar to those of the rest of the population, although some groups may have a higher prevalence. The most frequent health problems of newly arrived migrants include accidental injuries, hypothermia, burns, cardiovascular events, pregnancy and delivery-related complications, diabetes and hypertension. Female migrants frequently face specific challenges, particularly in maternal, newborn and child health, sexual and reproductive health, and violence.
The exposure of migrants to the risks associated with population movements – psychosocial disorders, reproductive health problems, higher newborn mortality, drug abuse, nutrition disorders, alcoholism and exposure to violence – increase their vulnerability to noncommunicable diseases (NCDs). The key issue with regard to NCDs is the interruption of care, due either to lack of access or to the decimation of health care systems and providers; displacement results in interruption of the continuous treatment that is crucial for chronic conditions.
Vulnerable children are prone to acute infections such as respiratory infections and diarrhoea because of poor living conditions and deprivation during migration, and they require access to acute care. Lack of hygiene can lead to skin infections. Furthermore, the number of casualties and deaths among refugees and migrants crossing the Mediterranean Sea has increased rapidly, with a reported 1867 people drowned or missing at sea in the first 6 months of 2015, according to the United Nations High Commissioner for Refugees (UNHCR).
Q9: What are the WHO recommendations for triage and screening of migrants upon arrival?
A9: WHO does not recommend obligatory screening of refugee and migrant populations for diseases, because there is no clear evidence of benefits (or cost-effectiveness); furthermore, it can trigger anxiety in individual refugees and the wider community.
WHO strongly recommends offering and providing health checks to ensure access to health care for all refugees and migrants in need of health protection. Health checks should be done for both communicable and NCDs, with respect for migrants’ human rights and dignity.
The results of screening must never be used as a reason or justification for ejecting a refugee or a migrant from a country.
- Obligatory screening deters migrants from asking for a medical check-up and jeopardizes identification of high-risk patients.
- In spite of the common perception that there is an association between migration and the importation of infectious diseases, there is no systematic association. Refugees and migrants are exposed mainly to the infectious diseases that are common in Europe, independently of migration. The risk that exotic infectious agents, such as Ebola virus, will be imported into Europe is extremely low, and when it occurs, experience shows that it affects regular travelers, tourists or health care workers rather than refugees or migrants.
Triage is recommended at points of entry to identify health problems in refugees and migrants soon after their arrival. Proper diagnosis and treatment must follow, and the necessary health care must be ensured for specific population groups (children, pregnant women, elderly).
Each and every person on the move must have full access to a hospitable environment, to prevention (e.g. vaccination) and, when needed, to high-quality health care, without discrimination on the basis of gender, age, religion, nationality or race. This is the safest way to ensure that the resident population is not unnecessarily exposed to imported infectious agents. WHO supports policies to provide health care services to migrants and refugees irrespective of their legal status as part of universal health coverage.
Q10: What does WHO recommend with regard to vaccination for newly arrived migrants?
A10: Transmission of vaccine-preventable diseases to host country populations is just as likely to happen after the return of a resident of that country from a holiday in an endemic country as after the arrival of a migrant from the country. There are still large gaps in the immunity of populations across the Region, either because countries decide not to avail themselves of the benefits of vaccination or because of limited access to vaccination services.
The WHO Regional Office for Europe does not routinely collect information on transmission of vaccine-preventable diseases among migrants or on their immunization coverage. However, well-documented outbreaks of measles have originated by transmission from migrants, mobile populations, international travelers and tourists alike.
Equitable access to vaccination is of prime importance and is one of the objectives of the European Vaccine Action Plan 2015–2020. The plan proposes that all countries in the Region pay special attention to ensuring the eligibility and access of migrants, international travelers and marginalized communities to (culturally) appropriate vaccination services and information. We applaud the many countries, such as those receiving large influxes of migrants, that are including migrants into their routine vaccination programmes.
Q11: What health care access does WHO recommend for refugees and migrants?
A11: Legal status is one of the most important determinants of the access of migrants to health services in a country. Each and every refugee and migrant must have full, uninterrupted access to a hospitable environment and, when needed, to high-quality health care, without discrimination on the basis of gender, age, religion, nationality or race. WHO supports policies to provide health care services irrespective of migrants’ legal status. As rapid access to health care can result in cure, it can avoid the spread of diseases; it is therefore in the interest of both migrants and the receiving country, to ensure that the resident population is not unnecessarily exposed to the importation of infectious agents. Likewise, diagnosis and treatment of NCDs such as diabetes and hypertension can prevent these conditions from worsening and becoming life-threatening.
Q12: What is WHO doing to address the public health implications of the large influxes of refugees and migrants into the European Region?
A12: WHO works to:
- develop migrant-sensitive health policies;
- strengthen health systems to provide equitable access to services;
- establish information systems to assess migrant health;
- share information on best practices;
- increase the cultural and gender sensitivity and specific training of health service providers and professionals;
- and promote multilateral cooperation among countries in accordance with resolution WHA61.17 on the health of migrants endorsed by the Sixty-first World Health Assembly in 2008.
WHO has been working on the health issues related to people’s movements for many years. The WHO European health policy framework Health 2020 has drawn particular attention to migration and health, with population vulnerability and human rights. Following the political, economic and humanitarian crises in the north of Africa and the Middle East, WHO, in collaboration with the Italian Ministry of Health, established the Public Health Aspects of Migration in Europe project in April 2012. The aims are:
- to strengthen health system capacity to meet the health needs of mixed inflows of migrants and host populations;
- promote immediate health interventions;
- ensure migrant-sensitive health policies;
- improve the quality of the health services delivered;
- and optimize use of health structures and resources in countries receiving migrant populations.
Up to August 2015, the Regional Office had conducted joint assessment missions with ministries of health in Bulgaria, Cyprus, Greece, Italy, Malta, Portugal, Serbia and Spain, with the new “Toolkit for assessing health system capacity to manage large influxes of migrants in the acute phase,” to respond to and address the complex, resource-intensive, multi sectoral, politically sensitive issues in health and migration.
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