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VOICES OF THE DISPLACED: A QUALITATIVE STUDY OF POTENTIALLY TRAUMATISING AND
PROTECTIVE EXPERIENCES FACED BY REFUGEE CHILDREN
Shaymaa Abdelhamid, Jutta Lindert, Joachim Fischer, Maria Steinisch
doi: https://doi.org/10.1101/2022.07.26.22277918
Now accepted for publication in BMJ Open
Shaymaa Abdelhamid
1Medical Faculty Mannheim, Heidelberg University, Center for Preventive Medicine
and Digital Health (CPD), Division of General Medicine;
(MPH)
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* For correspondence: shaymaa.abdelhamid@medma.uni-heidelberg.de
Jutta Lindert
2University of Applied Science Emden/Leer, Department of Social Work and Health;
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Joachim Fischer
1Medical Faculty Mannheim, Heidelberg University, Center for Preventive Medicine
and Digital Health (CPD), Division of General Medicine;
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Maria Steinisch
3Medical Faculty Mannheim, Heidelberg University, Center for Preventive Medicine
and Digital Health (CPD), Division of Public Health, Social and Preventive
Medicine
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ABSTRACT
Refugee children experience potentially traumatic events that are distinct from
the general population, yet current Adverse Childhood Experience (ACE) research
addressing these specific adversities is scarce. This study uses qualitative
interviews to identify potentially traumatising and protective experiences
subjectively perceived as having an effect on the wellbeing of refugee children.
Semi-structured interviews with 47 refugee parents and 11 children (aged 8-17)
were conducted between November 2018 and January 2020 in the Rhine-Neckar region
in Germany. Sampling was based on the official languages of the major
nationalities seeking asylum in 2018, which were Arabic: Syria and Iraq, Farsi:
Afghanistan and Iran, and Tigrinya: Eritrea. Informed consent from participants
was obtained, and discussions focused on potentially traumatising and protective
experiences before, during and after flight. Data collection was complete when
data saturation occurred. Interviews were recorded, transcribed, coded and
analysed using thematic analysis. We used the socio-ecological model to organise
emerging themes that may arise at multiple levels and across all stages of
migration. These experiences revolved around eight major themes including six
themes reflecting on potentially traumatizing experiences: disruption,
rejection, isolation, violence, impediments and affliction; and two themes that
reflect on possible protective experiences: security/stability and connections.
This study highlights important aspects to consider when examining refugee
children’s experiences, such as addressing family dispersion, displacement,
tough immigration and national policies as ACEs. It is increasingly important to
identify these diverse experiences as the refugee population continues to grow
and the increased prevalence of poor health outcomes in refugee children has
been widely documented. Identifying ACEs specifically relevant for refugee
children could contribute to understanding potential pathways and could further
serve as a starting point for tailored interventions.
Key messages
* Experiencing multiple adversities in childhood may lead to undesirable health
and behavioural outcomes later in life. Current ACE literature does not
capture refugee-related experiences, thus underestimating the full magnitude
of the problems these vulnerable children could encounter.
* This qualitative study uncovered numerous potentially traumatizing and
protective experiences specific to refugee children, such as displacement,
cultural differences, insecure political climate as well as community support
and access to education. It also suggests that a child’s wellbeing is
influenced by multiple interacting components from the child’s family,
community and society.
* Knowledge of new concepts significant to refugee children builds the
foundation for developing an ACE questionnaire specifically for this
vulnerable population – which could be a starting point for tailored
interventions by identifying potential determinants for mental health and
behavioural outcomes specifically relevant in refugee children.
INTRODUCTION
By the end of 2021, 89.3 million people were forcibly displaced due to multiple
emergencies, of which 36.5 million (41%) were children [1]. The humanitarian
landscape is overwhelmed as new crises unfold. Within the last decade, the
number of refugee children increased by 132% [2]. Refugees are fleeing war,
violence, conflict or persecution to find safety [3]. Among refugees,
psychological suffering may occur at each stage of migration caused by traumatic
experiences in their home country and during flight, including the stress of
adapting to a new life and culture in the host country. The latter, often
unaddressed, can have a greater or equal effect than pre-flight stressors on the
psychological well-being of refugee children [4, 5].
Research shows that undergoing potentially traumatic events in childhood – known
as Adverse Childhood Experiences (ACEs) – is a potential pathway to social,
emotional, and cognitive impairments leading to increased risk of unhealthy
behaviours, violence, disease, disability, and premature mortality [6]. Previous
ACE studies focus on adversities between the child and their family (abuse,
neglect and household dysfunction) [7] and to some extent the community
(bullying, discrimination and neighbourhood crime)[8, 9]. However, it is
important to acknowledge that a range of factors on multiple levels influences a
child’s health and development, as suggested by the socio-ecological model (SEM)
[10]. In the SEM, the developing child is seen as being embedded in several
milieus that affect their wellbeing, including family, community, and society
[11]. Yet, not all studies consider such levels, often overlooking adversities
associated with society (political climate, health, economic, educational, and
social policies). Furthermore, adversities relevant to the refugee population
such as war, displacement, or acculturation appear to be missing. These gaps
highlight the need to acknowledge and explore the unique challenges refugee
children face from all SEM levels.
To date, the majority of qualitative studies focus on adult refugee experiences.
Of the studies that do discuss refugee children, many focus on a single
migration phase [12], a single aspect of the SEM (e.g. refugee parenting
behaviour) [13], or on internally displaced refugees (different experiences than
resettling abroad) [14]. While important, these studies offer insights into a
fraction of what refugee children experience, making it difficult to understand
the full picture.
Equally important but similarly understudied is the identification of protective
experiences that promote children’s development despite ACEs. The presence of
healthy parents and nurturing environments, for example, are associated with
fewer undesirable health outcomes [15]. In order to reduce further adversity,
promote the children’s developmental abilities in areas such as resilience,
discipline, stress-regulation, and empathy and encourage positive social,
emotional and educational outcomes, refugee protective experiences must be
identified.
In developing a clearer understanding of adversities refugee children encounter,
and circumstances that could protect them, we must solicit the input of the
individuals living these events. This study therefore explores the perceptions
of refugee parents and children experiencing conflict, migration, and
resettlement to uncover potentially negative and positive influences on the
wellbeing of refugee children. In so doing, this study seeks to provide refugees
with a voice, enabling a deeper understanding of sources of risk and resilience
affecting refugee children’s health.
METHODS
SETTING AND STUDY POPULATION
The current study represents a component of a larger project entitled Beyond
Refugee Adverse Childhood Experiences (BRACE) funded by the Deutsche
Forschungsgemeinschaft (DFG, German Research Foundation) – GRK2350/1. BRACE is a
mixed-methods project with two aims; the first involves qualitative interviews
with refugees to inform item development for a questionnaire. The second seeks
to establish the psychometric properties of the resulting questionnaire
(reported separately). This project received ethical approval by the Medical
Ethics Committee of the Medical Faculty Mannheim, Heidelberg University
(approval no. 2018-610N-MA) and follows the COREQ guidelines for reporting
results [16].
Interviews for the current study involved refugees in the Rhine-Neckar region in
Germany. Recruitment was via convenience sampling through non-profit
organisations, youth welfare facilities, and societies that organise civic
engagement for refugee families. These five organisations granted access to
locations where refugees lived/gathered. The target population included refugee
parents and children (6-17 years) who were fleeing a conflict area and spoke
either Arabic, Farsi, Tigrinya or German, the official languages of most asylum
seekers in Germany when the study began [17]. No exclusion criteria were
applied.
DATA COLLECTION –SEMI-STRUCTURED INTERVIEWS
Participants were approached in person, introduced to the purpose of the study
by the first author (SA, a female doctoral candidate), and invited to
participate and ask questions; no relationship was established prior to study
commencement. The interviews took place in either a room provided by an
aforementioned organisation or in the participant’s home. SA, fluent in Arabic
and English with intermediate German skills and fundamental knowledge of
qualitative research, conducted the interviews. When needed, she was supported
by a female Farsi-German interpreter, a female Farsi-English interpreter, a male
Tigrinya-German interpreter or a female native German-speaking assistant. To
offer support for participating children, a female child psychotherapist
attended those interviews.
Participants were given the option to be interviewed either individually or in a
group. The aim of this approach was to decrease refusals or withdrawals, since
some participants were unable or unwilling to attend a group interview. To build
trust with participants and ensure that they felt safe to talk openly, the study
team decided not to collect any identifying data, thus preventing the
opportunity for future contact [18].
Semi-structured interviews progressed between November 2018 and January 2020. An
interview guide (appendix A) developed by SA welcomed participants, defined
adversities and emphasised the importance of their participation. Child
participants or parents speaking for their child were asked about potentially
traumatising and positive experiences that may have occurred during each
migration stage. Interview duration averaged 35 minutes (range: 15– 75 minutes).
None ended prematurely and no incentives were provided. Data collection ended
when theme saturation was reached.
DATA MANAGEMENT AND ANALYSIS
Written consent to audiotape interviews, take field notes and publish the
results was given in each case, children under 16 assented and required a
guardian’s consent. The recordings were transcribed by a professional
transcription agency. Descriptors were removed to maintain anonymity. An
independent native German-speaking collaborator translated German transcripts
into English that were then checked for content accuracy by SA. Transcripts in
English and Arabic were imported into MAXQDA 2018 (VERBI Software GmbH) for
qualitative data management.
The transcripts underwent thematic analysis [19], SA developed and defined codes
and assigned these to all transcripts in a descriptive manner. Using an online
number generator, four transcripts were randomly selected for coding by a second
independent individual to assess inter-coder agreement. Once coding assignment
was complete, SA grouped the codes into possible emerging themes that were then
reviewed and discussed within the research team until consensus was achieved.
Following the SEM, codes were also organised to reflect influences on multiple
levels. Codes with limited support (discussed by only a few participants) were
documented for future exploration. Member checking to confirm accuracy of
findings was not possible as no contact data was collected.
RESULTS
Thirty-six interviews with 58 participants were completed (Table 1). Eleven
children (six unaccompanied and five accompanied) with a mean age of 14.6 years
(range: 8-17 years) and 47 parents, mean age of 35.4 years (range: 23-63 years)
participated. Most participants were female (45), the majority spoke Arabic and
came from Syria (31), Iraq (6) and Palestine (4), followed by participants who
spoke Farsi from Afghanistan (13), and Tigrinya from Eritrea (4). Many appeared
to come from low socioeconomic backgrounds, evidenced by limited educational
attainment (39) and unemployment (41). At the time of the interview,
participants had spent an average of two years in Germany (range: 1 week to 4.5
years).
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Table 1.
Participant distribution in interview groups
Participants discussed numerous experiences, giving rise to eight emerging
themes. We found evidence supporting six risk-related themes that appeared to
represent disruption, violence, impediments, affliction, isolation and
rejection; and two potentially protective themes: security/stability and
connections. Experiences unique to refugee children were widely represented in
the transcripts, not limited to the family milieu, but also appeared
attributable to the community and society at all stages of migration.
Representative quotations provided below for the respective themes and subthemes
(in italics) reflect experiences mentioned by children themselves and by parents
discussing what they considered to affect their child(ren).
THEME 1: DISRUPTION
One of the first themes to emerge from interviews revolved around disruption. A
family-level disruption that several participants mentioned was family
bereavement (death of a loved one). Others perceived family dispersion as
disruptive, since members of a family were scattered in different countries.
Almost half identified that their families were separated either because a
family member was at greater risk (e.g., forced military recruitment) or because
the financial costs for traveling as a family were considered too high. This led
some to send a child to a safe European country with the hope that family
reunification applications for minors would be accepted faster.
Community life was also perceived to have been disrupted through displacement.
Nearly all respondents recalled how they were forced to move several times,
missing the opportunity to build bonds with others or establish roots:
> “We have only been from camp to camp…we have been in camps for 3
>
> years. From Greece to…we went to Holland…they rejected us. The situation
>
> was very bad. I mean I have my [child], this little one,
>
> [s/he] is [an infant], [s/he]is psychologically unbalanced. I mean [s/he]
> doesn’t know the
>
> meaning of a home.” - Syrian parent
Similarly, more than half of the children and parents commented on disruption in
education before and during flight due to societal events related to an insecure
political climate, forced school closures and problematic policies in transit
countries.
THEME 2: VIOLENCE
Almost all participants mentioned violence primarily at/within the
community-level. Refugees expressed concerns for extortion, exploitation, fraud,
kidnapping, human trafficking, destruction, bombings, killing, fighting and
physical harm:
> “The [foreign] guards caught us and beat us. They hit…you see my [child]?
>
> [S/he] was [an infant] when we left. The [foreign] guards hit [him/her], the
>
> situation is really… [shaky voice, crying]” - Syrian parent
In addition, societal conditions encountered by many included surviving in the
midst of political insecurity, forced military recruitment, systematic violation
of human rights, police/soldier brutality (as mentioned by Speaker 4.1) and
militarisation:
> “The thing is there are the Taliban…We go through a lot of things…for
>
> example, I was at school for one day, not a week, because every day was
>
> war…I wanted to go…you could not go to school…there is no safe place when
>
> there is war.” - Afghan child
THEME 3: IMPEDIMENTS
Strong support existed for the perception of impediments to progress, especially
in the form of economic hardship. Many participants reported losing their jobs
and homes, making it difficult to afford necessities and escape safely.
Dangerous and long travel routes were also given as examples of impediments to
community life, with one unaccompanied minor taking four years to arrive in
Germany.
Immigration policies were perceived as impediments as they complicated family
reunification and often involved travel restrictions and long processing times
for asylum applications:
> “You [the government] are doing something good, for example, for the
>
> children, you are bringing [his/her parents for him/her], but what about
>
> [his/her] siblings? Are they not from the rest of [his/her] family? And they
> are
>
> minors. I mean the [child] has been waiting for [his/her parents] and family
>
> for three and a half years.” Palestinian parent
National policies were recognised as another impediment with participants citing
instances in which countries closed their border to prevent refugees from
crossing, leading to their detention. Some described the Europe-wide
fingerprinting scheme as a policy obliging refugees to return to the first
European country in which their fingerprints were taken, impeding efforts in
choosing their resettlement country.
THEME 4: AFFLICTION
Many respondents commented on afflictions in the form of unfavourable
psychological and physical health conditions their children developed like
asthma, skin infections and somatic symptoms from the stresses of migration.
This is the only theme in which participants mentioned individual-level
characteristics related to biological or personal history aspects. Many shared
familial afflictions in the form of parent’s distress, recognising that their
worry and fear was reflected in their children:
> “The children only were afraid due to that stress that we had, [the
>
> parents].” - Afghan parent
Other forms of affliction included being homeless, living in a tent/container or
living in overcrowded places under unhygienic conditions, or in other forms of
inadequate shelter:
> “We lived four years in a camp in Iraq …If it’s raining it would pour on us.
>
> When the weather is getting hot the tents burn, because of the electricity …
>
> the tents were burning.” Iraqi child
THEME 5: ISOLATION
Both parents and children mentioned matters regarding a sense of isolation.
Several children missed in-person interactions and were yearning for their
relatives. Strong support described how cultural differences due to multiple
views, attitudes, languages, and traditions seem to elicit feelings of isolation
for children trying to balance both cultures:
> “There are huge differences between the way we raise our kids and our
>
> culture and between the way they raise their kids and their culture. Of course
>
> this will make us suffer. Our kids want to integrate “ Syrian parent
THEME 6: REJECTION
There was strong evidence in support of a theme centred on rejection in various
forms including discrimination at the community-level and refusal of asylum,
revocation of refugee status or forced repatriation at the societal-level:
> “They didn’t want to see so many Syrian people in Jordan. And that’s why
>
> we can’t do so many things. For example, this year, when I changed my
>
> school, we can’t talk to the Jordanian students. So they think we just have to
>
> have a Syrian school. We are separated. And you just think that, we are
>
> not normal.” - Syrian child
While the quotation above represents an example of discrimination refugee
children faced during flight, many also described instances of discrimination
pre-flight and a few mentioned post-flight prejudice.
THEME 7: SECURITY/STABILITY
Evidence for potential protective experiences was supported in comments about
the theme of security/stability. For instance, constructive parenting where
parents teach and model strength by encouraging patience, hope, gratitude, and
depending on the child’s age either masking reality or explaining the
circumstances was also viewed as important:
> “I mean, when we lived in the tent and in the caravans, in the camps, a year
>
> and a half… I tell them it’s ok, this is a small phase and we will be patient.
>
> And we acclimatized and we got to know other people, refugees like us who
>
> were also unlucky and they were stuck in Greece, and we spent our days…” -
>
> Syrian parent
Many children considered educational value as a form of stability, because they
started believing that learning was important and it offered a pathway to a
better future.
Strong evidence for this theme also emerged in reference to community support,
which existed in different forms. Participants shared stories of community
members providing them with practical (protection/transportation), informational
(guidance) and emotional support as examples of security. Likewise, remarks
about stability were made when participants discussed receiving material and
practical (accommodation/translations) support that met their basic needs, for
example, having a safe place to stay.
In addition, living in a non-violent environment with basic human rights and
social security (family benefits, health insurance, social assistance,
unemployment benefits and habitual residence) were societal-level conditions
participants commonly mentioned. Such aids were perceived to inherently benefit
and provide security for their children.
THEME 8: CONNECTIONS
Lastly, a common theme emerged around the value of connection with Germans,
relatives nearby, people from their original culture, and forming true
friendships:
> “I had a ‘brother,’ to be honest and we were really fit on this path because
> he
>
> helped me and I helped him and so on…He was a good friend. And that was
>
> good, because it touched your heart so much. One does
>
> not think, one does not feel lonely in such situation…We were mutually healing
> for each other, so
>
> to speak.” - Afghan child
SUBTHEMES WITH LIMITED EVIDENCE
Other experiences were also discussed; however, evidence for each was limited as
a few participants only mentioned them. Some recalled disruptive events such as
divorce, parent arrest and a missing parent (whereabouts unknown). Similarly,
violence in the form of sexual abuse and family physical abuse had weak
evidence. A number of participants recalled impediments such as lack of job
opportunities and medical care and a few noted afflictions such as changes in
their child’s development and behaviour, poor parental mental/physical health
and parental drug use. Additionally, evidence for circumstances that were
interpreted as isolating such as no family or community support and loss of
network had limited evidence. Lastly, rejection in the form of neglect, bullying
and rejecting own cultural customs (e.g. arranged/child marriage) had limited
support in the interviews.
Similarly, limited evidence also existed for perceived protective circumstances
that could provide security/stability such as presence of parents, financial
stability, being rescued, fast resolution of asylum applications and opening of
borders. Also, only a few participants mentioned connections that maintained
ties to the child’s original culture and fitting in at school.
DISCUSSION
Our analysis suggests that refugee children encounter many experiences at all
stages of migration, on multiple socio-ecological levels. In this study, refugee
ACEs appear to revolve around six themes whereas protective experiences revolve
around two.
POTENTIALLY TRAUMATIZING EXPERIENCES
We can confirm that many ACEs reported in previous research among the general
population (parent arrest, divorce, family death, parental neglect, physical
abuse, sexual abuse and parental mental health [7]) are perceived as relevant
for refugee children, too. Even though only a minority of participants mentioned
some of these events, it seems worthwhile to examine the role of such
adversities in the lives of refugee children in future research. In this study,
however, participants appeared to emphasise stressors related to war, flight,
and resettlement. Interviewees mentioned numerous experiences specific to the
refugee population that, to our knowledge, have not been previously reported in
ACE research.
Several experiences participants discussed are frequently mentioned in refugee
literature, yet have not been accounted for when considering the types of
adversities refugee children face. In considering each, we use the SEM to
organise all emerging adversities, separated by the level at which they may
arise and illustrate their potential interconnections (Figure 1).
* Download figure
* Open in new tab
Figure 1.
Six proposed themes and experiences* perceived as potentially traumatic (adapted
from Dahlberg, L.L. et al. 2002 [20])
*Experiences in grey had weak evidence (mentioned by a limited number of
participants)
Figure 1 represents the wide range of experiences throughout different levels of
the SEM. We found evidence that interactions may occur and may have a direct or
combined effect on the child’s wellbeing. For instance, refugees often
experience dispersion of family, which may cause anxiety in children due to
uncertainty regarding their parent’s whereabouts [21]. Additionally without
parents’ physical presence, children tend to have behavioural problems, low
academic achievement motivation and lack of self-esteem [22]. Similar
consequences have been reported for disruption of education. Despite efforts to
offer schooling to refugee children, accessibility depends more on the
migration/asylum phase than on the child’s educational needs [23] leaving many
children without education. A child’s critical thinking, confidence and
stability are hindered by this societal-level disruption, consequently affecting
their wellbeing [24].
Moreover, strong support existed for displacement in which community life is
disrupted due to countless relocations. With resettlement efforts being slow
(less than one percent of the 20.7 million refugees of concern to UNHCR in 2020
were resettled [25]) refugees are compelled to take long and dangerous routes
with numerous obstacles sometimes leading to psychological and physical health
consequences due to traumatic events during flight [21]. Displacement may
prolong uncertainty, impede access to education and health care, hinder
opportunities for parents to earn a sustainable living and impedes arrival in a
safe/secure environment. This illustrates the perceived consequences of
displacement which interacts with other community-level and family-level
circumstances innately influencing a child’s wellbeing.
Community violence is sometimes experienced during displacement, and most often
war is the reason behind it [3]. Interestingly, none of the children under 13
(ages eight, ten and twelve) discussed community violence, perhaps because they
were too young when they fled their home country or they might not have
personally experienced it. On the other hand, nearly all other participants
regardless of their origin mentioned the many forms of community violence shown
in Figure 1, suggesting that it is uniformly of high importance. Previous
research has disclosed the relationship between this community-level adversity
and individual afflictions, citing high levels of mental distress, depression,
anxiety and post-traumatic stress disorder as unfavourable outcomes [26].
Additionally, strong support in our study existed for the perceived detrimental
effects of militarisation, its negative impact seldom mentioned in other
studies. Constant blockades preventing children from going to schools,
preventing goods or people from entering or leaving, continuous interrogations
and unwarranted raids of homes cause children to constantly feel in danger. This
gap is critical because societal violence disrupts other societal constructs
such as education and often triggers community violence in turn affecting
children’s health and yielding mistrust in police and soldiers that are meant to
keep citizens safe. Militant presence and police/soldier brutality are exposures
rarely discussed in ACE or refugee qualitative literature.
Economic hardship is another element related to refugee children’s struggles.
Many participants discussed how parental job loss and depreciation of the local
currency caused difficulties in affording necessities and safe refuge. However,
economic hardship goes beyond these implications. When parents become unemployed
for a long time there are negative consequences for children’s academic
achievement and some are encouraged into early marriage or child labour [27].
Our data suggest these difficulties are ones that refugees appear to face
primarily before and during flight. The consequences of economic hardship have
also shown an impact on the well-being of refugee parents, in turn potentially
affecting the emotional health of their children [13], as previous research has
established a correlation between parental health and children’s mental health
[28].
The majority of child and adult participants also discussed inadequate shelter
as a potential adversity. The UNHCR defines shelter as “a habitable covered
living space that provides a secure and healthy living environment with privacy
and dignity in order to benefit from protection from the elements, space to live
and store belongings as well as privacy, comfort and emotional support” [29].
However, that was not what refugees described when discussing the different
forms of shelter they lived in. Inadequate shelter is a potential health problem
for refugee children both physically through the spread of diseases that may
occur in overcrowded settings, and mentally due to stress/anxiety of living in
an insecure environment [30].
Another adversity perceived as stressful on the community-level is cultural
differences [31]. Participants stated this was mostly owing to the difficulties
in communicating in German and juggling two cultures. Interestingly, refugee
children were more likely to comment on cultural differences than refugee
parents. This could be because children are more likely to be in contact with
the host culture, due to school enrolment, and that the majority of the
participants in this study were homemakers, thus limiting their contact with
other people.
Previous work highlights the salience of discrimination that refugees perceive
in their resettlement countries [12, 13, 32-34]. However, in this study,
discrimination was more commonly encountered in participants’ home countries and
en route, arising from historical conflicts such as the intolerance Kurdish
people face in Iraq, Syria, and Turkey [35]. As with cultural differences,
discrimination can affect children’s feeling of belonging, cause lower
self-esteem, reduce their aspirations and negatively impact their mental and
physical health [26].
Furthermore, discussions about immigration rejection and policies that impede
refugee progress are known. The former causes children to feel rejected by
society and are in constant fear and anxiety of another rejection or deportation
[33]. The latter increases the duration of uncertainty, insecurity and distress
[12, 34, 36]. Yet conversations about national policies such as the Dublin
regulation [37] and negotiations such as the European Union-Turkey deal of 2016
[38] are often made without acknowledging the outcomes such policies might have
on refugee children. Although the implementation of such national polices are
meant to aid the humanitarian crisis, these policies are perceived by some
refugees as forms of rejection because in certain instances they result in
transfers of asylum seekers, detentions and travel restrictions.
In short, these interviews suggest patterns of interconnectedness among ACEs at
all levels of the SEM, affecting the child’s wellbeing. We must therefore
further examine these interrelated pathways that have been linked to undesirable
outcomes.
POTENTIAL PROTECTIVE EXPERIENCES
Our data appears to reflect predominately the perceived hazards and risks
incurred during the refugee experience that may be explained by negativity bias,
a natural human tendency to attend more to negative than to positive experiences
[39]. For that reason, the majority of possible positive experiences were only
mentioned by a limited number of people, thus recognised as having weak
evidence. Despite this, two positive themes emerged (Figure 2).
* Download figure
* Open in new tab
Figure 2.
Two proposed themes and potentially protective experiences* (adapted from
Dahlberg, L.L. et al. 2002 [20])
*Experiences in grey had weak evidence (mentioned by a limited number of
participants)
It might seem that the experiences perceived as protective are merely the
opposite of experiences perceived as potentially traumatic, which is true in
some instances such as opening of borders and fast resolution of asylum
applications. Open borders allow for safe passage of refugees instead of having
to take dangerous routes or detention at borders, while the latter allows for
refugees to settle into the new country, reduces stress regarding the acceptance
of their application and allows them to be enrolled in schools all of which are
good for the wellbeing of the child. However, potentially protective or adverse
events can also be considered as extreme ends of a continuum [40]. For instance,
constructive parenting is not simply the opposite of an absent parent; it is the
presence of parents who are actively trying to provide their children with
security and stability. Similarly, the majority of our interviewees vocalised
the perception that they were now living in a place committed to ensuring their
basic human rights including the right to life, freedom, work and education.
This example of a safe and stable society is not merely the opposite of war or
else it could have been found in transit/neighbouring countries. Refugees in
Germany are provided with social security to be able to live with dignity as
full, equal members of society [41], an important factor potentially
contributing to stability and a sense of belonging in refugee children.
Similarly, community support in all its different forms builds important
connections. One might argue that these connections are the opposite of
isolation, yet the absence of isolation does not ensure a sense of
connectedness. Support networks from the community help promote resilience by
aiding refugees with their needs [42]. Likewise, connections either with
relatives or other refugees allows for continuity of culture [43] while
connections with people from the host community allows for sociocultural
adaptation [32]. Additionally, school attendance offers children the opportunity
to integrate with people from the community, possibly building friendships [44],
while leisure activities such as football establishes relationships, enhances
social integration and well-being [45].
STRENGTHS AND LIMITATIONS OF THE STUDY
This qualitative study is the first, to our knowledge, to explore refugee
children’s experiences at all stages of migration in different socio-ecological
contexts and uncovers experiences not described in previous ACE work. Through
the employment of interpreters, we were able to access refugees from a variety
of ethnic backgrounds, making it possible to recognise emerging themes that were
salient across cultures. Moreover, we aimed to ensure the rigor of this study by
using qualitative methods such as using a semi-structured interview guide, audio
recording, professional transcription, use of a computer software to organise
codes, duplicate coding, and thematic extraction derived from the data via
research team discussions. Another strength is that we interviewed refugee
children about their own experiences, allowing them to add their own perceptions
and voice matters that were important to them. Additionally, the combination of
group and individual interviews, even though different data collection
techniques, can be beneficial as they have the potential to increase knowledge
of a phenomenon [46]. Group interviews offer opportunities to obtain a sense of
the range of mutual views [47] while individual interviews provide more in-depth
information [48].
Despite these strengths, a few limitations should be acknowledged. As common in
qualitative research restraints on generalisability occur. The majority of
interviews were with Arabic speaking participants. However, Arabic speaking
refugees made up more than 36% of the refuge seeking population in Germany [17],
and at the time of data collection the majority of refugees globally were from
Syria [1]. The necessary use of interpreters might have resulted in comments
that were under-translated or entirely lost in translation. However, Arabic is
the first language of SA, who conducted the interviews, thus leading to fewer
misinterpretations. Furthermore, the research team was aware of limitations
caused by translations and tried to overcome this difficulty by employing
interpreters that were bilingual and had interpreting experience with refugees.
All interpreters were also coached prior to the interview regarding the
importance of their work, the aims of this study and methods to avoid sections
in the interviewee’s answer being untranslated/rephrased or interpreted.
Similarly, an inability to confirm the presented findings through member
checking raises the possibility of misinterpretation. However, member checking
may also have a harmful impact on participants: recommendations exist that this
process should either be avoided or implemented with caution when studying
marginalised populations or traumatised participants [49] as re-engagement with
the study topic and reading the presented findings might cause re-traumatisation
[50]. Future research with refugees from other backgrounds, internally displaced
people or refugees resettling in low-income countries may add to the findings
presented in this study and shed more light on issues related to the
generalisability of our findings.
CONCLUSION
Refugee children clearly face multiple and ongoing challenges, yet numerous gaps
in our understanding of the refugee child experience exist. Given continuous
growth in the refugee population and previous research highlighting an increased
prevalence of mental and physical health disorders among children associated
with ACEs, it is increasingly important to understand the adversities affecting
the wellbeing of refugee children and experiences that may be protective. This
study adds new concepts to consider when examining ACEs in refugee children such
as family dispersion, displacement, immigration and national policies. In
addition, participants discussed constructive parenting, attaining basic human
rights and having opportunities to build connections as potential protective
experiences.
Refugee children’s encounters differ greatly from the general or even immigrant
populations. Identifying and analysing their needs through qualitative research
can add valuable insights to build a groundwork for future research and
interventions but also for policy development. Drawing on this study’s results,
several conclusions regarding potential interventions and policy re-evaluations
can be drawn: For instance, re-evaluation of policies concerning children’s
detention and reunion with their family is supported by our data, which is
outlined by the Convention on the Rights of the Child (CRC) including the right
for an education [51]. Other potential interventions supported by our findings
include going beyond government based coverage of housing, medical care and
minimum living expenses [41], for instance cash-based interventions [52]. Also,
modifying emergency responses into more durable long-term solutions, like
relocating refugees from camps to more private/suitable accommodation [53]; and
parenting programs in refugee settings which have previously shown to have
successful outcomes in reducing parental stress, improving parent-child
interactions, thus improving development in young children [54].
In addition to the gaps in understanding the refugee child’s experience,
screening and measurement tools to identify individuals that could benefit the
most from targeted interventions are missing [55]. We anticipate our future work
in the BRACE project will fill this gap.
DATA AVAILABILITY
All data produced in the present study are available upon reasonable request to
the authors.
FUNDING
The Deutsche Forschungsgemeinschaft (DFG-GRK2350) supported this research. This
work is part of the first author’s dissertation project.
CONFLICTS OF INTEREST
The authors have declared that they have no competing or potential conflicts of
interest.
ACKNOWLEDGEMENTS
We gratefully thank all parents and children who shared their experiences with
us, as well as the organisations for enabling access to the study population and
the interpreters for their assistance in making this research possible. We also
thank David Litaker MD, PhD (Center for Preventive Medicine and Digital Health,
Medical Faculty Mannheim, Heidelberg University) for his valuable
recommendations throughout the writing process.
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Voices of the displaced: A qualitative study of potentially traumatising and
protective experiences faced by refugee children
Shaymaa Abdelhamid, Jutta Lindert, Joachim Fischer, Maria Steinisch
medRxiv 2022.07.26.22277918; doi: https://doi.org/10.1101/2022.07.26.22277918
Now accepted for publication in BMJ Open
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Voices of the displaced: A qualitative study of potentially traumatising and
protective experiences faced by refugee children
Shaymaa Abdelhamid, Jutta Lindert, Joachim Fischer, Maria Steinisch
medRxiv 2022.07.26.22277918; doi: https://doi.org/10.1101/2022.07.26.22277918
Now accepted for publication in BMJ Open
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