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Syrian Refugees, Women, Mental Health, Qualitative Method

The forced migration caused by the civil war in Syria, which started in 2011 and continues to date, has been described as the ‘biggest migration event’ by the United Nations High Commissioner for Refugees. From a demographic perspective, the current population of Turkey rose with the Syrian migration (total estimated number of Syrians: 3,644,342) such that now 4 out of every 100 people in Turkey are Syrians. This figure makes Turkey the country that hosts the world’s largest refugee population (Adalı, et al. 2020).

It is well known fact that refugees often face more than one threat as loss of family, sexual and physical abuse and lack of shelter or food during war (Georgiadou, et al. 2018). Moreover, refugees face physical exclusion, social isolation, a lack of access to their fundamental rights, linguistic hurdles, racism, cultural marginalization, daily stressors, and discrimination at post-displacement (Kim, et al. 2016; Li, et al. 2016). Taken all these together, it is not surprising that the refugees prone to develop a variety of psychological disorders (Leiler, et al. 2019; Tay, et al. 2019).

A quantitative study of 27000 Syrian refugees resettled in refugee camps found that 19% of them have high levels of anxiety, and 9% have high levels of depression (Önen, et al. 2014). Furthermore, according to a study that looked at the prevalence of post-traumatic stress disorder among Syrian refugees, it was discovered that roughly one-third (33.5 percent) of Syrians had symptoms that met the criteria for the disorder (Alpak, et al. 2015). Furthermore, when Syrian refugees in Turkey are compared to refugees from Southeast Asia, the former Yugoslavia, and Central America in Western countries (e.g., the United States, Australia, or Canada), they have higher rates of mental disorders (Alpak, et al. 2015; Cantekin, et al. 2017) Refugees’ mental health issues are likely to persist even years after initial settlement (Bogic, et al. 2015).

It is known that half of Syrians have migrated to Turkey are women and girls of reproductive age and Syrians in Turkey have a much younger population. Being both a woman and a refugee means additional suffering that can affect women’s health at multiple levels, mainly due to trauma, accommodation problems, language, education, and income, as well as prevailing sociocultural and traditional norms and values regarding women (Yağmur, et al. 2018).

Syrian society is a patriarchal society and Syrian women are primarily responsible for housework and childcare in the division of labor, while men are responsible for providing for the household. In case the women work outside the home, they are monitored by the male relatives. These cultural practices, which are already difficult, become more complex for Syrian women refugees. Refugee women are at greater risk for mental health problems such as depression and anxiety due to lack of social support, violence, poverty, adverse health conditions and discrimination (Lee, et al. 2016). The uncertain living conditions in the refugee country, concerns about the safety of family and friends, uncertainty about the future and lack of control cause refugee women to experience fear, anxiety and hopelessness for the future (Anderson, et al. 2013; Buz, et al. 2008; Kirmayer, et al. 2011). In addition, due to their mother or wife roles, women feel obligated to carry extra burdens during the migration process to support family members’ adjustment to a new way of life, and they often take on the role of preserving and maintaining family values, culture and beliefs. In the process of struggling with all these difficulties, they show social interaction and wasting enjoyable time outside as the most important coping strategies (Anderson, et al. 2013). However, especially in Turkey, language barriers keep women away from accessing to education, employment opportunities, health services, social networking, and many other psychosocial and economic factors that can facilitate adjustment and adjustment in Turkey more often than men. The most important determinants to facilitate adjustment to refugee country are women’s access to education, employment opportunities, health services and creating a social network. According to the results of a systematic review on the health outcomes of Syrian women in Turkey (Çöl, et al. 2020), free health services are provided regarding women’s reproductive health, sexual health, gender-based violence, and psychosocial support; however, especially in Turkey, women seem to be more hindered than men in accessing these opportunities due to the language barrier (Syed, et al. 2006).

Finally, it should be emphasized that the Syrian refugee population in Turkey is a diverse one; however, one main limitation of the literature is that it homogenizes this diversity, neglecting how differences based on gender, class, ethnicity, place of origin, religion, and legal status contribute to shaping the everyday practices of Syrian refugeesm (Baban, et al 2019). Of the studies conducted in the last five years and the main findings presented, very few have focused on women and adolescent girls. Adolescent girls and young women’s unique needs, opportunities, access to services, and relationships with the host community remain less studied. Consequently, the overarching goal of this study aims is to describe and highlight adolescent girls and young women’s needs with specific focus on their mental health issues as well as psychological service needs based, using the qualitative research methodology.

PARTICIPANTS & PROCEDURE: This qualitative study conducted in was part of a multicenter research project aimed to develop and evaluate a psychosocial- sexual and reproductive health integrated intervention package for adolescent girls and young refugee women. The qualitative component aimed to inform the development of this intervention. A total of nine focus groups with Syrian women (4), men (3), and relevant stakeholders (2) were carried out in Ankara. The group was formed based on maximum variation sampling. In determining the participants, assistance was obtained from key people known to Syrians living in Ankara. The demographic information was listed in Table 1.

Table 1 The sociodemographic variables of participants in FGDs

Focus groups with Syrian women and men were held in Arabic and with the stakeholders in Turkish. All focus group discussions (FGDs) were led and moderated by a facilitator and assisted by a transcriber who ensured that the notes were being captured. Informed consent was obtained from the participants. The study was approved by X (ref: 01.03.2018–04/12) as well as X Ethical Review Committee (ERC) approval (ref: A659340043300) (Table 1).

STUDY DESIGN: The overall study design was guided by the ecological framework and the health belief model. Thematic analysis was used to examine and analyze the data. Focus group meetings mainly concentrated on two subjects: (i) psychological and mental health and (ii) suggestions about solving the problems. The former topic was queried with the following question as “What types of psychosocial issues/problems could Syrian refugees, adolescent girls, and young women face in your community?”. The other topic was questioned with the question of “Do you think women seek help in order to solve any psychological problems they could be facing?”

According to the observed results, many factors impacted Syrian women’s psychological health and well-being, as expressed by women, men, service providers, and stakeholders. Psychological health was assessed by taking into account five main attributes (Table 2).

Table 2 Sub-themes and codes addressed in the assessment of psychological and mental health

GENDER DYNAMICS: Syrian women reported in the FGDs that they were under pressure from their husbands and other family members about appearing in public. The homebound status of Syrian women was cited to be negatively impacting their psychological health in particular:

“In general, women are under more pressure than males; it may be because of family or husband. For example, she cannot go out of the home even when she wants to. And there is this language problem again. She cannot speak and understand the language spoken around her and is not given training in the language; she finds it difficult to be outside of the home.” (Man)

STIGMA IN SEEKING PSYCHOLOGICAL SERVICES: Seeking support and services for psychosocial problems is often perceived as weak and tends to be stigmatized. In many circumstances, it is difficult to decide to seek out psychological support, and they tend to conceal it due to the fear of being stigmatized as “having gone insane”:

“Nobody goes since people who go to a psychologist are regarded as nuts in Syria. We know this is not the case, but this is how it goes.” (Woman)

DIFFICULT LIVING CONDITIONS: Another issue was attributed to the nature of their men’s working life. Trying to adapt to working under harsh conditions (e.g. long and intense working hours) that are often perceived as unfair can present psychological challenges. The fact that their husbands work so as to help maintain the family order, looking for a job, working hard, and earning little, pushes women to be “understanding”:

“In Syria, we used to have our own house, and we did not pay rent. It is not the case here, and we have to pay. We try to speak silently and understandably mitigate the responsibility of the male.” (Woman)

GROUP SOLIDARITY AMONG SYRIAN WOMEN: Service providers expressed how Syrian families tend to live close to each other, building strong community networks and enhancing solidarity among women. The internet is another medium of communication in this regard. All the women indicated that they have smartphones, participate in Facebook groups, and communicate with other Syrians through virtual channels:

“I see there is strong solidarity among women. Women come in as a group. A man is leading them, but he waits outside without intervening. A single woman rarely comes by herself. They act as a group, and group members support each other. If you can find somebody in the group that you can act in rapport with, she can easily lead others.” (Gynecologist, female)

POLITICAL CLIMATE: It has been observed that Syrian women are directly affected by the discourse and policies concerning refugees. This further aggravates their psychosocial problems:

The authorities have recently grown quite suspicious about and strict toward us. What would I do if they suddenly decided to send us back? No home, no means, no safety?” (Woman)

Some discriminatory attitudes, failure to engage in harmonious relationships with the host community, and exclusion were stressed upon as often causing profound psychological impacts, making the women feel alone:

“For example, we cannot mesh with the local community here. For example, when we try to rent a house, they tell us no house for Syrians, saying they don’t like Syrians. We Syrians can adapt to the local conditions/ people if they are open to us, but actually, they are afraid of us. They behave like we are a weird, strange community.” (Woman)

COPING MECHANISMS: FORMAL AND NONFORMAL STRATEGIES: It is observed that trying to solve the problem within the family and through personal individual efforts to cope without telling anybody else were the main methods they used. Crying alone and letting no one learn about their problems was regarded as an indicator of psychological strength.

“I lost two brothers in the war. My mother died of cancer a month ago, and it was because of chemical weapons used in the war. My son and my cousin were taken to intensive care after having been wounded in an airstrike. All these events passed before my eyes. However, I still cannot accept seeing a psychologist. It seems as if that is a place where only insane people should go. It gives you bad thoughts, and I keep crying all the time.” (Woman)

PERCEIVED BARRIERS: THE TRUST ISSUE: An essential reason behind women’s reluctance to seek psychosocial help was the “trust” issue. The women need to discuss their problems among trusted others in a safe place. When these opportunities are perceived as available, the women do seek out help and find it helpful:

“It is a matter of trust. Some Syrian women came in and were silent. They asked these women if they needed psychological support. They were hesitant at the beginning, but some of them said yes. The women who received psychological support visited their psychologist after two months and thanked her. So they want to speak out, and they want to speak with someone they feel they can trust.” (Doctor)

LANGUAGE: One of the most commonly reported difficulties in seeking access to psychosocial services was noted to be language:

“Language is a problem in psychological support sessions. Although translators are often used, psychological support requires much longer and better quality communication than other healthcare services. Transferring emotions is interrupted when a third party interferes. Psychological support must be a process involving only two parties, and this barrier is one of the important problems.” (Turkish Female Expert, Women’s Services, Ministry of Family and Social Policies)

However, others noted the quality of services is also problematic, highlighting that private healthcare provides better care, better treatment, and shorter periods of waiting, but many cannot afford this.

CHILDREN HAVE TOO MANY PROBLEMS: It was indicated that Syrian women tend to prioritize seeking health services for their children’s problems over solutions for their own psychological and psychosocial issues.

“Given our population, most families coming in for counseling services do so for their children. Their complaints include bedwetting, including its form as ‘post-traumatic stress disorder,’ peer bullying at school, insomnia, and nightmares. These suggest that families are concerned about their children and do rush around for help.” (Social worker, female, Migrant Health Centre)

SEXUAL AND REPRODUCTIVE HEALTH: The women agreed that issues related to sexual reproductive health and psychosocial problems are interrelated. Traditions support early child marriage and having numerous children. All these are too tiring for women, and feeling psychologically tired and unwell badly affects sexual life as well:

“For example, when I feel psychologically tired, I don’t want to have sex. Maybe I recalled something from the past, or a story has come to my mind … My husband has no respect for such situations. He does not care about my psychology; all he cares about is what he wants at that moment. It makes me feel bad, and I want to stay away.” (Woman)

Two important findings can be highlighted based our assessment. First, refugee women have significant difficulties associated with being a woman. Women continue to face important challenges related to their psychosocial wellbeing. This was perceived to be predominantly attributed to the patriarchal ideology and the problems experienced before the forced migration. These patriarchal norms continue to exist in Turkey, often closely linked with the prevailing social norms and the status of women in Syrian society. The second finding pertained to being, specifically, a refugee woman. Refugee experiences, generally, often make women more vulnerable than men. Being a woman and a refugee means additional suffering that can affect women’s health at multiple levels, mainly due to trauma, language, education, income, and sociocultural and traditional norms and values about women.

Syrian refugees face a slew of challenges that could jeopardize their physical and mental health in their daily lives. Various public studies have revealed that Syrian refugees face social marginalization and frequently feel compelled to return to their home countries. Syrians are burdened by these feelings, which cause trauma and psychological suffering, stigmatize them, and prevent them from assimilating into the society they live (Ekinci, et al. 2015; Saleh, et al. 2018). Syrians are psychologically distressed and considering suicide as a result of challenges in both their own country and the nations to which they travel. However, they cannot communicate their views due to cultural and religious restrictions and the risk of stigma and exclusion (Saleh, et al. 2018). Similarly, in this study, it was emphasized that inability to enter into harmonious relations with the host community and exclusion cause deep psychological effects.

Current studies on Syrian adolescent girls and young women appear to be limited. Results show that young women face significant challenges, including access to general reproductive healthcare services, antenatal coverage, obstetric and gynecological care, psychological and mental health services, access to modern contraceptives, access to STIs and HIV prevention efforts, and support against domestic and intimate partner violence (Samari, et al. 2017). Cost, language, cultural understanding, limited availability and quality of services, poor quality of services, insufficient knowledge of mental disorder symptoms, and lack of awareness of mental health and psychosocial support and stigma have all been identified as significant barriers in studies with other conflict-affected populations. The experience of forced migration and life experiences in Turkey negatively affect their psychological well-being. Language difficulties also further aggravate this situation, as language proficiency is a significant issue when accessing services and care.

The Turkish government and non-governmental organizations have worked hard to meet the refugees’ basic needs, such as food and shelter. Nevertheless, Syrian men and women participating in this study talk about difficult working conditions and that men have to work longer hours in order to live in better conditions. It has been stated that these difficult conditions affect the mental health of women and may cause psychological difficulties. Furthermore, while efforts are being made to meet the mental health and social service needs of those who have been forcibly displaced, counseling services remain insufficient (Karaman, et al. 2016).

According to a study (Fuhr, et al. 2020), investigating the prevalence of mental illness among Syrians living in Istanbul and their ability to access mental health services, findings showed that post-traumatic stress disorder, anxiety, and depression symptoms were prevalent among Syrian refugees. However, only a tiny part of the population in need asked for psychosocial support. According to the authors, giving access to the national health system is not enough to overcome the mental health-related problems of refugees. Improving access to the needed care in this area calls for addressing shame, fear of social stigmatization and reprisals, and concern about lack of confidentiality. For example, sexual and gender based violence survivors are often reluctant to report instances of sexual violence or harassment or seek treatment (Thomas, et al. 2019).

In sum, available research on the problems faced by Syrian refugee women is also very limited in Turkey. More research is related to general issues facing Syrian refugees and children than to women-related problems. Living at home, the lack of paid work opportunities, difficult living conditions, economic difficulties, and lack of acceptability to seek and receive professional psychological support predisposes women to compromised physical and mental wellbeing. Embarrassment to seek psychological help, fear of social stigma, and anxiety about privacy hinder the seeking out the needed psychological support services. When language difficulties are further added to the difficulties produced by the leading social structure, the problems become even more significant.

To get the most out of the services available, refugees must first learn about them. The government and humanitarian organizations must adopt terminology that Syrians understand. Organizations should clarify available mental health and counseling services, define counselors, and explain their benefits in brochures, handbooks, reports, and nameplates. Most Turkish counselors who work with Syrians were educated in Turkish counseling programs fashioned after those in the United States and contained Western-based therapy ideas (Mocan-Aydin, et al. 2000). Because Syrians come from an Eastern culture, this Western-based education and practices may reduce the effectiveness of counseling and pose challenges to counselors. In this regard, a group of Syrian mental health facilitators who have been trained through the NBCC MHF program could help work with this community (Hinkle, et al. 2014).

As a conclusion, the young women and adolescent girls in this study are yearning to be proactive and to address their needs and challenges. Safe spaces that women and girls can seek out for their unmet psychological services that privately and confidentially accessible will encourage the Syrian migrant women to seek the needed services and take on a proactive role in managing their day to day problems. Also, it is strongly believed that additional research is needed to help address gender inequality in order to tailor better responsive interventions and programs, grounded by the realistic expectations that patriarchal values are inherit, less amenable to change, and were brought along with the Syrian refugee communities in with migration.

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