Refugees & Asylum Seekers: Background
The United Nations High Commissioner for Refugees (UNHCR) reports that we are experiencing the highest level of displacement on record and another individual becomes displaced every two seconds (2019).
Significant changes in migration patterns and the total number of forced migrants continue to increase as a result of political instability and armed conflict throughout the world (Morville et al., 2013). 70.8 million individuals are currently forcibly displaced worldwide (UNHCR, 2019). 41.3 million of them are internally displaced and 3.5 million of them are asylum seekers. 25.9 million of them are refugees, over which half are under the age of 18 years old.
An internally displaced individual has been displaced from their home but remains within their home country (UNHCR, n.d.). A refugee is an individual who has been forced to flee their country due to war, violence, or persecution and has a well-founded fear of persecution because of their nationality, race, political opinion, membership in a particular social group, and/or religion. They are most likely unable or afraid to return home. War, ethnic, religious, and tribal violence are the leading causes of people fleeing their countries. Refugees are eligible for legal protection and material assistance. An asylum seeker is also an individual who has fled their own country to find sanctuary in another country. However, they have applied for and are waiting on approval for asylum, which is the right to be recognized as a refugee and thus eligible for assistance. They must demonstrate that their fear of persecution in their home country is well-founded (UNHCR, n.d.). Forced migration as a consequence of unexpected circumstances often disrupts an individual's established occupations, impacts their sense of identity, and negatively affects their sense of competence, health, and overall well-being (Huot et al, 2016; Gupta, 2013).
Refugees and asylum seekers are commonly hosted in camps that are managed by humanitarian organizations or held in detention centers. Occasionally, individuals are resettled which means they have been transferred from their asylum country to another nation that has granted permission for permanent settlement (UNHCR, 2019). However, less than one percent of refugees are granted resettlement each year globally (UNHCR, 2019). The process for resettlement varies greatly from one country to the next, but it commonly involves strict vetting and meeting extensive legal criteria (Siddiqui et al., 2019). Throughout displacement, encampment, and resettlement, forced migrants face a variety of issues and challenges.
The health, occupational opportunities, and well-being of refugees and asylum seekers are greatly influenced by the contexts in which they resettle (Mayne et al., 2016). The socio-political context, which is represented through various discourses, is particularly significant (Mayne et al., 2016). The perceptions of forced migrants have been negatively shaped by powerful dialogue within North American and Australian contexts for many years (Mayne et al., 2016; Morville et al., 2014).
Upon arrival and while awaiting refugee status, asylum seekers are routinely placed under mandatory detention through policy justification that unexpected arrivals can pose a threat. In turn, this practice perpetuates a negative stigma towards these populations (Hightower, 2015; Rowe & O'Brien, 2014). Furthermore, political, media, and social dialogues often compound existing biases (Rowe & O'Brien, 2014; Run, 2013; McKay et al., 2011). Research has shown that communities, especially those experiencing economic hardship, may be inclined to perceive refugees and asylum seekers as dependent, destitute, and burdensome individuals who may deplete the community of its limited resources and welfare system (Every et al., 2013; Hightower, 2015; Laughland-Booy, Skrbis, & Tranter, 2014; Spinney & Nethery, 2013). It is also common for native members of communities to fear a decrease in employment opportunities and social cohesion as a result of forced migrants settling in their area (Hanson Easey & Augoustinos, 2011; McKay, Thomas, & Kneebone, 2011; Posselt et al., 2015).
Every et al. (2013) conducted a study in South Australia and discovered that communities may expressively oppose refugees and asylum seekers if members fear they will be negatively impacted and if threatening discourse is perpetuated. Whereas, other communities may maintain a more silent bias towards the forced migrants by perceiving them as unequal but not outwardly acknowledging it (Edgeworth, 2015). Refugees and asylum seekers are generally more likely to be viewed as a burden on society than immigrants due to the preconception that they will unlikely participate in the labor market (Menz, 2009). Overall, many forced migrants face stigma which contributes to economic burden and separation from society increasing the likelihood of occupational deprivation and difficulty adjusting to their new environments (Abur, 2016; Hocking, 2010). Therefore, advocacy for relaying factual information, promoting sympathy, practicing tolerance, and empowering refugees and asylum seekers is of prime importance.
Refugees and asylum seekers often arrive in a new country and must learn a whole new way of life. Although they likely had many skills for daily living in their native country, not all of these skills will transfer to their new environment. Resettlement agencies provide a variety of services; however, many resettled refugees have difficulty learning the vast amount of new skills that are required for successful participation in activities that hold meaning to them (Huot et al., 2016). They also face new challenges with physical and mental health complications as a result of their experiences before, during, and after migration (Zimmerman et al., 2011).
Some detention centers for asylum seekers have been shown to impact the individuals' capacity to perform very basic ADLs (Morville & Erlandsson, 2013; Morville et al., 2015). Morville et al. (2014) suggest that the length of detention may also affect asylum seekers' ability to maintain competencies and skills related to ADLs due to lack of opportunity. Research has also provided evidence that many forced migrants arrive at detention facilities with preexisting deficits in their ability to perform ADLs (Morville et al., 2014). Moreover, trauma has been correlated with a reduced ability to adhere to daily routines, which can include activities such as bathing, grooming, dressing, sleep, eating, and home maintenance (Huo et al., 2020).
Many forced migrants who have resettled lack support in their new country for practical skills acquisition relating to everyday activities (Boyle, 2014; Whiteford, 2005). For example, they may require resources and support for grocery shopping and food preparation with unfamiliar local produce. Furthermore, they may need information and assistance for utilizing public transportation or obtaining their own driver's license in order to enable community mobility. Developing language skills such as reading, writing, and speaking are also paramount to integrating into their community and being successful participants in society. Research has also identified the need for support and resources as it pertains to securing employment, accessing education, and arranging childcare services. In general, support and resources in relation to every day basic skills facilitate sustainable hope, motivation, and integration in a new country (Boyle, 2014; Whiteford, 2005).
Social Participation & Play
Socio-economic deprivation and a lack of fundamental human rights often restrict forced migrant's ability to engage in social participation (Yamamoto et al., 2020). For example, institutional limitations, lack of access to necessary services, and difficulty acquiring employment have been shown to lead to social marginalization which contributes to mental decline and further diminished capacity to function (Bishop & Purcell, 2013; Morville et al., 2014). Due to social barriers, forced migrants often do not have easily accessible resources that are needed to survive, which leads many to experience "feelings of loneliness and social isolation, loss of identify, feelings of discouragement, and lack of knowledge of available options" (Simich et al., 2005, 253). Social participation is also a significant factor in forced migrants' ability to successfully integrate into their new host countries (Niemi et al., 2019). Overall, individuals have weakened social networks and poorer health outcomes due to occupational imbalance which includes a state of dissatisfaction, lack of cohesiveness, and lack of control in meaningful activities (Backman, 2010; Huot et al., 2016; Savic et al., 2013).
Opportunities for social interaction and play may also be affected by migrating into a new country with a new culture (Allport et al., 2019). Play is essential for children's social, emotional, and cognitive development as well as for developing resiliency and maintaining health (MacMillan et al., 2015). Through play, children are also able to gain problem-solving skills, leadership skills, and teamwork skills (MacMillan et al., 2015). A research study by MacMillan et al., (2015) found that play was more limited pre-migration than post-migration; however, the study highlighted that the quality of play post-migration is unknown and is likely impacted by pre-migration experiences.
Becoming a forced migrant can have both positive and negative effects on school education (Fransen et al., 2018). Before settling into a new permanent location, forced migrants are frequently in a transitory situation with limited or no access to schools (Educate a Child, n.d; Fransen et al., 2018). Where they settle when they stop physically fleeing has the most impact on education (Fransen et al., 2018).
If a child settles in a desolate area, there may be no schools available and thus lack access to education (Fransen et al., 2018). On the contrary, if a child settles in a camp or hosting area and has been granted refugee status, they may have access to a school because the 1951 UN Refugee Convention relating to the Status of Refugees states that they a right to protection and assistance, which includes the right to basic education (Fransen et al., 2018; UN General Assembly, 1951). The primary education facilities within camps or hosting areas are usually financed by international agencies and/or NGOs (United Nations Educational, Scientific and Cultural Organization, 2011). However, having the legal right to education does not necessarily guarantee access and not all locations have the privilege of being able to provide education facilities (Fransen et al., 2018). Moreover, UNESCO (2015) has found that class failure and drop-out rates are much higher for refugee children when compared to the general population. Unfortunately, over half of the 7.1 million refugee children who are of school age did not have access to education as reported by a UNHCR report released in 2019 (UNHCR, 2019c).
Strict restrictions on required documentation, such as identification and course completion certificates, and lack of funding are presenting significant barriers for children to remain in school (UNHCR, 2019c). Overcoming barriers to education becomes more difficult as a child ages and there is a significant decline in enrollment between primary and secondary school. Furthermore, less than 3 percent of individuals will have the privilege to participate in higher education (UNHCR, 2019c).
Education is important for many reasons including that it can protect children who are refugees or asylum seekers from forced recruitment into child labor, child marriage, and sexual exploitation (UNHCR, 2019c). It can also help build resilience in communities and empower individuals by providing them knowledge and skills to live fulfilling, independent, and productive lives (The UN Refugee Agency, 2018). Schools are also a great place for social participation and language learning.
Refugees and asylum seekers experience a lack of opportunities for work engagement due to multiple barriers. Asylum seekers who are not detained in camps are often prohibited from working whatsoever (Burchett & Matheson, 2010). A host country's policies and legislation intended to protect the economy and national security often deny groups of people the benefits of citizenship while waiting on a determination of their status in other countries (Hocking, 2010). Meanwhile, some forced migrants who are permitted to work lack credentials necessary to access work or to progress beyond menial labor due to sociopolitical influences. Having limitations in job prospects and advancement often means these individuals face the likelihood of poverty. Poverty also means likely compromises in their children's future educational and vocational opportunities. Other individuals have credentials and job experience but encounter difficulty with having them recognized in their new country (Hocking, 2010). Many of those individuals are over-qualified for the low-wage jobs that they are limited to accepting (Huot et al., 2016). A lack of transferable skills from one cultural or geographic environment to another can also pose as an obstacle (Huot et al., 2016). Difficulties with language and educational requirements also present significant barriers to obtaining work (Hocking, 2010, Smith, 2012; Smith et al., 2013; Werge-Olsen & Vik, 2012; Whiteford, 2005).
The challenges encountered by forced migrants who have disabilities are compounding (Smith-Khan & Crock, 2019). Disabilities are not always easily identifiable and some individuals may actively strive to hide or refute disabilities due to cultural or other factors. Therefore, host country governments and welfare agencies face significant hardship in being able to accurately and thoroughly identify disabilities in large groups of forced migrants (Smith-Khan & Crock, 2019). Using the World Health Organization's (WHO) estimates, Smith-Khan & Crock (2019) estimate that there were more than ten million forced migrants with disabilities in 2018. A study by Mirza (2012) found that there is a substantial policy emphasis on paid work and economic self-sustainability within the United States' resettlement program for refugees. As a result, these policies impact the perceptions and actions of service providers contributing to them and they often label refugees with disabilities as non-employable. Ergo, many are funneled into the welfare system without consideration for the individual's personal aspirations, disregard for their overall occupational needs, and neglecting possibilities for alternative/adaptive employment opportunities. Support services for developing vocational skills and assistance in job acquisition are also scarce (Mirza, 2012).
It is widely accepted that individuals who have experienced premigration trauma commonly suffer from sleep disturbance (Lies et al., 2019). A study out of Australia found that three out of four participants experienced sleep disturbances. Sleep disturbances were found to be positively correlated with social isolation, interpersonal struggles, dysfunction within the family, age, and migration status for adults and children of refugee and asylum seeker status (Lies et al., 2019). Another study involving refugees residing in Jordan found unemployment, a secondary education level or less, older age, and difficulty accessing medication were predictors of higher insomnia (Al-Smadi et al., 2019).
Challenges within multiple areas of occupation simultaneously, as experienced by forced migrants, places them at high risk for social, economic, linguistic, and cultural isolation which impacts their ability to participate. Overall, refugees and asylum seekers often experience occupational deprivation which is an imbalance or lack of opportunities to participate in occupations that bring meaning to their lives (Hocking, 2012). Individuals are often inhibited from participating in meaningful occupations due to limitations from war, civil unrest, local restrictions, and legal regulations (Wilcock, 2006). Loss of meaningful occupation also commonly results from the absence of occupational choice leading to feeling a lack of control and powerlessness (Duque et al., 2012; Gupta, 2012; Polatajko et al., 2013; Steindl et al., 2008). In fact, maintaining a sense of control has been found to be a significant factor in the ability to cope as a forced migrant (Quiroga, 2005). Some camps and organizations aim to organize workshops and activities for forced migrants. However, it has been found that many of the activities are arbitrary and do not reflect the interests of the individuals. As a result, the individuals are disappointed with the activities because they are perceived as a way to pass the time but not meaningful (Darawsheh, 2019; Morville et al., 2015). Health, well-being, and quality of life are impacted by the opportunity to participate in meaningful and necessary occupations (Hammell, 2015; Wilcock & Hocking, 2015).
Forced migrants are at risk for several physical and mental illnesses which commonly require management that is specific to their population group (Burnett & Ndovi, 2018; Fazel et al., 2005; Hollifield et al., 2002). It is characteristic for individuals to have lived several years in refugee camps or urban environments before arriving in their final host country (Divito et al., 2016). During that time, they typically experience limited access to basic necessities such as adequate shelter, food, clean water, and healthcare services (Divito et al., 2016). Many refugees arrive in the United States with significant medical conditions such as traumatic injuries resulting from war, unmanaged chronic health conditions, and communicable diseases (Centers for Disease Control and Prevention, 2012).
A majority of forced migrants will experience a mental illness, such as depression or anxiety, at some level (Brundtland, 2000). They also have a high prevalence of PTSD; however, very few individuals seek help for their mental health issues (Byrow et al., 2019). Research suggests that cultural barriers such as stigma associated with mental illness, structural barriers such as lack of stable housing, and citizenship status are barriers to care (Byrow et al., 2019). They are at risk for developing psychological disorders as a result of witnessing numerous traumatic events such as ongoing conflict, murders of loved ones, violence, significant injury, torture, and persecution (Alpak et al, 2015; Steel et al., 2009). Unfortunately, experiences during settlement into a new community can be worse than living in refugee camps (Abur, 2016). Upon resettlement, reduced support and unrelenting stress in their new country can also affect mental health and exacerbate previous trauma (Whiteford, 2004; Miller & Rasmussen, 2010; Steel et al., 2006).
Identity and role loss are prevalent with these populations and have the potential to interfere with the mental capacity necessary to carry out occupations (Whiteford, 2005). Feelings of dissatisfaction and stress can also come about when individuals feel that they are wasting away critical years of their lives. Research shows that decreased QOL is due to displacement from homes, separation from family or friends, limited income resources, and lack of healthcare (Abur, 2016).
Some refugee populations, such as Bhutanese refugees that have settled in the U.S., are at increased risk for suicide (Ellis et al., 2015; Cochran et al., 2013; Meyerhoff et al., 2018; Meyerhoff & Rohan, 2020; Vonnahme et al., 2015). This population's suicide rate is near twice the rate of the general U.S. population (Ao et al., 2012). Risk factors that have been identified include mental health disorders, poor health in general, social isolation, perceived burdensomeness, employment concerns, stress related to providing for their families, illiteracy, and family dysfunction (Ellis et al., 2015; Cochran et al., 2013; Meyerhoff et al., 2018; Meyerhoff & Rohan, 2020; Vonnahme et al., 2015).
According to Reed & Yrizar Barbosa (2017), refugees have a greater disadvantage in regards to functional limitations, chronic conditions, and overall health status when compared to other documented immigrants. However, the current standard for refugee screening primarily focuses on infectious diseases and nutritional disorders which is likely leading to a variety of health issues and needs going unnoted and thus untreated (Reed & Yrizar Barbosa, 2017).