Health and Family Support Issues of Women Refugees and Related Nursing Interventions: Literature Review

Aim: Migration has become one of global human security issues of the 21st century. Women refugees face a unique set of problems and their health is often compromised. The aim of this study was to describe health and family support issues encountered by women refugees in refugee setting and related nursing interventions. Methods: A literature review was performed using Academic Search Premier, CINAHL and Medline databases, and the following keywords were used separately and in combination to retrieve related abstracts and articles: `women refugees`, `health`, `nursing`. Only original articles from qualitative studies published in English and focusing on women's health and family support in the refugee setting were selected for the review. Results: Three major themes related to women refugees' health issues were identified: `Culture sensitivity`, `Seeking life balance` and `Gender-based violence`. In addition, nine major themes related to family support were found: `Family reunion (difficulty to emigrate)`, `Changes in family's connections and roles`, `Unsatisfactory family life`, `Discrimination and contempt by community`, `Health problems in children`, `Mental health problems in family member`, `Adjustment and adaptation of life pattern in a new country`, `Family time and togetherness` and `Concern about forgetting one's homeland`. On the other hand, we identified 11 major themes related to nursing interventions implemented for women refugees. Conclusion: Disaster nurses have important role to protect and promote human security among women refugees. Future studies should determine how disaster nurses can efficiently promote human security for women in refugee setting.


Introduction
Migration has become one of the global human security issues of the twentyfirst century [1]. The United Nations High Commission for Refugees (UNHCR) [2] reported that 45.2 million people were forcibly displaced persons worldwide, including 15.4 million refugees at the end of 2012. Those are people who have been forced to leave their home countries due to the occurrence of a catastrophe (armed conflict, natural disaster), conflict, discrimination or religious oppression and resettling in other countries in search of better living conditions, peace and security; and their number is still increasing.
Refugees face a unique set of problems. Mollica et al. (3) reported that exposure to severe traumatic events in the refugees' home countries, and the medical and psychological effects of this exposure are known to influence the possibilities for resettlement in a new country critically. Moreover, numerous adverse health consequences have been reported in refugee populations especially when relocation is forced in the case of severe conflict in the home country associated with violence and human-made trauma [4]. These conditions make it difficult for them to adapt to their host communities. Thus, they need protection, health, and social assistance, as well as basic needs such as education, food, water, shelter, family reunion and integration in a safe environment.
In general, women refugees are one of the most vulnerable groups in the camps or relocation shelters in their host communities. The World Health Organization (WHO) [5] has reported that women refugees have a higher risk of experiencing an unwanted pregnancy, induced abortion and obstetric complications than women in the host population. Furthermore, refugee camps are often poorly lit, putting girls and women at risk at night, even on their way to the toilet [6]. This may have significant consequences as they often lack access to quality health and supportive care while facing family disintegration due to separation. They have to struggle for life in their new living environment and are often exposed to other issues such as malnutrition, reproductive health problems, human rights violation and diseases.
Disaster nurses should recognize the need to support women refugees holistically. However, there have been limited resources in the literature regarding disaster nursing studies that provide linkages to life transitions such as migration, resettlement, and health conceptualization in refugee populations.

Objective
The study aimed to describe health and family support issues encountered by women refugees in their resettlement settings and related nursing interventions.

Method
A literature review was performed using Academic Search Premier, CINAHL, and Medline databases, and the following keywords were used separately and in combination to retrieve related abstracts and articles: `women refugees`, `health`, `nursing`. Only original articles from qualitative studies, published in English and focusing on women refugees, were selected for the review. Figure 1 illustrates the flow diagram of the literature search strategy conducted for the review. From this search, 249 articles and abstracts were retrieved. Once the inclusion criteria were applied, 62 articles were excluded from the review as they were either related to asylum seekers, immigrants, quantitative studies, published before 1993 in languages other than English or did not focus on women refugees. Of the 62 articles that related to women refugees, 28 were excluded, including eight that discussed on internally displaced people (IDPs), 14 that were not related to nursing and health, and six duplicate articles. Of the remaining thirty-four articles, 9 met the eligibility criteria as they focused on women's health and family support, and were considered for the review. A thematic analysis was undertaken to identify major themes relating to women's health and family support issues, and nursing interventions that were implemented.

Results
From the contents of the remaining nine articles that were reviewed, ten themes were extracted: family planning, sexual health, nursing education, family support, mental care, nursing care, social support, women's health, community services, and gender-based violence. To better grasp issues faced by women refugees and necessary nursing interventions to be implemented, those categories and related studies are presented in the following lines. Table 1 shows health issues encountered by women refugees at their resettlement place. Three main themes related to those issues were found, including `Culture sensitivity`, `Seeking life balance`, and `Gender-based violence (GBV).`   Table 2 presents problems faced by women refugees that required family support care. In total, nine themes were identified, including `Family reunion`, `Changing family roles`, `Unsatisfactory family life`, `Discrimination`, `Child health problems`, `Mental health in the family`, `Adaptation of life`, `Family togetherness`, and `Forgetting homeland`. From these issues, we extracted 30 categories that health care professionals should consider when providing family support care to refugee families ( Table 2). Table 3 presents a list of health interventions implemented by nurses caring for women refugees and their families. They include `Culture care diversity and universality`, `Antenatal care (ANC) and counseling`, `Communication skill`, `Health education promotion`, `Family assessment`, `Interventions for parents and children`, `Preventive care`, `Transnational families support`, `Construction of family strengths`, `Health and safety`, and `Togetherness`. From these interventions, 35 categories were extracted, comprising actions that might contribute to providing adequate health and supportive care for women refugees and their families (Table 3).

Discussion
This review describes the primary health and family support issues encountered by women refugees in resettlement. It was found that cultural factors directly affected women refugees in terms of their expectations on preventive health services and health care, which influenced their health care choices. Women refugees studied were from various countries, with differing sociocultural backgrounds and had varying perspectives on reproductive health care.
Two studies [7,8] reported on genital mutilation (FGM) and early or forced marriage in adult refugee populations, and this issue is also considered one of the growing health problems among refugee girls. Of the communities that practice FGM, supporters of this tradition think that FGM preserves family honor and makes a girl fits for early or forced marriage. However, it has been reported that early or forced marriage exposes girls to high risk of first pregnancy, resulting in maternal morbidity and mortality [16]. On the other hand, women refugees as well as refugee families from societies that valued traditional herbal remedies sometimes have negative perspectives on modern health care and seem reluctant when offered western medical care in their host countries [7,8].
A study conducted by Catolico [9] illustrated the situation of Cambodian women refugees who escaped political conflicts in their home country and were separated from family members when moving to their new settlement sites in the United States. Patterns of knowing, caring for self and seeking life balance were their main health challenges, and the latter emerged as the core perspective of the study.
During resettlement, women refugees often face isolation in their new environment; and mothers have to care for family members and undertake multiple tasks to keep the household functioning. They may face marginalization in their modern society and may suffer psychological or life trauma [10,11,13]. Furthermore, those of women refugees living in camps may encounter security issues. In overcrowded camps, for example, discrimination, safety, and security issues are among stressors that exacerbate anxiety in refugees [11,12,15].
Protection and promotion of human rights, particularly women's rights, are one of the recommendation sins the 'global agreements' of the United Nations Conference of NGOs, in its Agenda 21 on Protecting and Promoting Human Health and which addresses the primary health needs of the world's populations [17]. The provision of culturally sensitive health services with a holistic approach to meet the needs is crucial for the life transitions of women refugees and their families in resettlement. This includes motherchild health care, family planning counseling, preventive health services, health education, and promotion as well as the construction of the family strengths in the adaptation process in a new environment.

Limitation
The main limitation of this review is that identified articles were only considering topics related to the health and family support issues encountered by women refugees and related nursing interventions implemented to promote human security. Moreover, the identified articles were limited to qualitative studies conducted and published in English. Therefore, there might be other interesting studies published in languages other than English that could provide more knowledge regarding our study topic.

Conclusion
This review showed that culture sensitivity was as one of the main issues faced by women refugees. When leaving their home countries, refugee families expect to have a new life in a secure environment in their resettlement places. However, they may face anxiety and disappointment. It is of utmost importance that disaster nurses and other health professionals caring for refugees and working in refugee settings understand the cultural background (country of origin, traditions, beliefs, religion, values, etc.), and health needs of women refugees in order to implement interventions that can solve a wide range of problems and help them lead a secured life and have their human identity protected.  Weine et al. [10] Understand the complexity of the family system and tie together the family narrative Family-oriented knowledge Sweden