The Impact of Environmental Factors on Immigrant and Refugee Care and Intergenerational Trauma: A Multidimensional Analysis

Kashvi Jain1 & Abinaya Sridharan2, Tanish Patel3, Khushi Patel4, Allison Pham5, Angeleen6, Dishika Chandra6

I. INTRODUCTION

The plight of refugees is a matter of great concern, as they are often marginalized and vulnerable to numerous challenges that adversely affect their physical, psychological, and social well-being. Their migration journey is marked by both physical and psychological traumas, owing to the violence, war, and persecution that led them to leave their home countries in search of safety and a better future. Upon arrival in host countries, they have to contend with further difficulties such as finding work and housing, and dealing with stigmatization and health issues.

The mental health of refugees is a critical concern since they are exposed to numerous stressors and factors, before and after their migration and hence, they are at a higher risk of developing severe mental disorders such as PTSD, mood disorders, and anxiety disorders, which are often compounded by discrimination, racism, poverty, and limited access to appropriate healthcare and services. Therefore, addressing the multiple determinants of mental health and illnesses, impacting refugees at various levels including but not limited to individual, family, institutional, and societal factors is important.

II. SOCIOCULTURAL IMPACTS ON REFUGEES’ HEALTH

Sociocultural influences impact refugee’s health through challenges connecting to resources for healthcare and education, as well as the accompanying stress of adapting to a new cultural context. More than 65 million people are placed in different countries as refugees due to war or persecution. Social, cultural, and economic backgrounds impact refugees’ mental and physical health, especially those who are part of marginalized groups based on gender, race, socioeconomic status, and language. As a result, they struggle in their new surrounding environments through a lack of access to resources.

Factors including cultural norms, ethnicity, gender, socioeconomic status, and education each influence the mental and physical health of refugees. Some ethnicities may face issues in accessing resources and care, specifically for getting access to physicians that speak their native language or receiving translations. Without taking into context problems such as reproductive health, it becomes difficult to access and understand health care that attends to variances within cultures. Since “countries in West Asia […] and South Asia […] have policies that legally discriminate against women,” (Gray 2021) the lack of access to services becomes detrimental to their overall health.

Through experiencing cultural shifts, refugees must make informed decisions to properly prepare for their own arrival, in addition to adapting to their new surroundings. By the force of adjustment to change their own life to adhere to a new culture, along with its norms and standards, the health of refugees decreases and can become more at risk, especially if they do not understand the language of their environment. Especially in the United States, where “refugees who are more proficient in English also report stronger health literacy skills.” (Feinberg 2020) To adjust to their new surroundings, they are required to adapt to unfamiliar environments, dealing with stigma and potential lack of financial literacy. The stigma placed around refugees due to language barriers and appearances negatively impact their health. To add on, financial literacy plays a large role with refugees’ abilities to settle into their new environment. Without the proper access to the knowledge of how finance and the overall economy functions, finding a safeground within navigating a country starts to delve towards the more difficult side. Feelings of uncertainty take a toll on them, where 5 to 44% of refugees experience depression, 4 to 40% face anxiety, and 9 to 36% experience PTSD. Especially for Indigenous people, who, within the span of a month, experienced psychological distress 2.5 times the general population. Due. to the language barriers, refugees are unable to access proper health care and treatment which lowers their life expectancy and survival.

During the journey to a new environment, refugees may become lost or separated from their loved ones, causing trauma and depression. As of 2022, 43.3 million children became displaced due to either conflict or violence. Family separation significantly contributes to the wellbeing of many refugee children, causing them much distress during the transition (Shadid 2021). Alongside stress from relocating, lack of proper social connection with others and a sufficient amount of resources makes it difficult for migrants to gain access to healthcare services.

When arriving in a new country, refugees may experience communication barriers as a result of limited knowledge of the dominant language in the receiving country, making it difficult to voice any health-related concerns. Having limited access to healthcare, education, and housing can cause many rifts and create large disparities. According to one survey carried out by Feinberg, O’Connor, Owen-Smith, and Dube, 78% of participating refugees preferred a language besides English to complete the survey. Considering that the U.S.’s primary language is English and that other languages spoken are often shamed, the survey reflects the uncomfortableness of refugees living within the U.S. In 2015, 34% of Americans believed immigrants represent a threat to the United States’s customs and values (Szaflarski 2019). Prior to moving to another country, the original language many refugees speak is the one they find comfort within. Cultural differences and gaps can cause struggle with financial security and receiving assistance. Since many resources within the United States, especially those within education are often catered solely towards its citizens.

Through being affected by war and environmental crises, mental health problems arise affecting refugees’’ ability to integrate into society. By facing issues in terms of economic disparity and stigma, it makes it difficult for refugees to rebuild their lives and overall well being. As a result of the exposure and experience of trauma and healthcare costs, refugees experience a limitation within the economy.

Culture is another post-migration factor that can prevent one from seeking mental health sources and even worsen the condition of immigrants. Kirmayer et al. argue that cultural beliefs and attitudes create a stigma toward mental health issues which shape individuals’’ perceptions and experiences of psychological distress (Kirmayer et al. 2011). The intersection of the stigma towards mental health, alongside the mindset towards the refugees creates a unique experience towards them. Language barriers and financial situations also create obstacles to receiving mental health services, exacerbating mental health disparities. A study by Abe-Kim et al. highlights the importance of culturally appropriate interventions in addressing mental health disparities among immigrant populations as many cultures, such as South Asia countries, draw from traditional frameworks that overlook mental health issues (Abe-Kim et al. 2002). Nadeem et al. emphasize the importance of increasing linguistically and culturally appropriate services to fulfill the needs of the differing immigrant populations for their health (Nadeem et al. 2008).

When migrants arrive in their new geographic location, they frequently face a slew of new challenges resulting in acculturation stress, stress that stems from the process of adapting to a new culture and can profoundly impact immigrants’ mental health (Ren & Jiang 2021; Choy et al. 2021). A study by Birman et al. concluded that the levels of acculturation stress were correlated with increased symptoms of depression and anxiety (Birman et al. 2002).

In line with such findings, Berry has proposed a stress and coping model of acculturation which suggests that the level of acculturation stress an immigrant encounters is dependent on multiple factors, like language proficiency, social integration, and discrimination (Berry 2005). Social and environmental factors also impact the degree to which mental health negative outcomes are lessened. For example, older, females, more educated, and refugees with better pre-displacement social status experienced worse mental health in the new contexts. Mental health problems were also more prevalent for refugees living in institutional housing, undergoing restricted economic freedom, or those who were deported or displaced in their home nation.

III. BIOLOGICAL ASPECTS OF REFUGEE HEALTH

Causes of Mental Health Problems in Refugees

In accordance with the long-running dispute about the influence of nature versus nurture on biology and psychology, mental health of adult refugees is affected by the interaction of both psychological and environmental factors (Kashyap et al. 2021).

Refugees and asylum seekers have been identified as some of the most vulnerable populations to mental health and psychological damage, due to a plethora of stressors, traumatic events, and pre and post-displacement challenges. Environmental factors can be characterized as adversity faced before, during, and after migration, while psychological factors are utilized by refugees to cope with those adversities (Kashyap et al. 2021). Although a probable correlation, the explanation behind the interaction of environmental and psychological factors influencing mental health needs further longitudinal and experimental research.

The influx of immigration and forced migration has led to drastic effects on the mental stability of refugees due to the lack of accessibility. Pre-migration stressors can be a result of exposure to political violence and trauma faced in countries of origin such as mass genocide and assault (Steel et al. 2009). Post-migration and asylum-related stressors are linked to PTSD symptoms and emotional distress in asylum seekers and refugees (Carswell et al. 2009).

Post-Migration Stressors

Post-migration stressors such as long migration journeys and language barriers can trigger a variety of traumatic psychological stress responses in refugees and immigrants. The experience of migrants in immigration detention centers is a specific post-migration stressor that facilitates the loss of liberty and the threat of deportation. A 2011 study underscores the environment of the detention centers, which is associated with high levels of anxiety, depression, and PTSD symptoms (Robjant et al. 2011).

Talking about past stressful memories can awaken negative thoughts and influence refugees’ state of mind negatively. Furthermore, though intergroup contact can aid refugee integration, it may also exacerbate their trauma (Porter & Haslam 2005) and highlight their experiences with integrating into a new environment. The trauma arises as a result of prejudice, stereotyping, and pressure to assimilate.

Biological Aspects of PTSD and Depression — Brain Activity — PTSD

Posttraumatic stress disorder (PTSD) is a mental disorder where patients encounter flashbacks or memories triggered by a previously experienced traumatic event. In order to uncover the biological manifestations of PTSD in the brain, the amygdala (a mass of gray matter in the brain involved in the function of experiencing emotions) must be examined.The amygdala plays a critical role in the fear and learning linked with PTSD symptoms and extinction learning linked with PTSD treatment (Martin et al. 2009). A multitude of studies of PTSD patients reveals a spike in amygdala activity especially in response to fearful stimuli, the magnitude of amygdala hyperactivity corresponds to the level of severity of the patient’s PTSD.

Negative emotions such as fear and sadness are linked to the amygdala. When the amygdala is hyperactive it can enhance these emotions contributing to PTSD and its symptoms. Symptoms of PTSD include intrusive thoughts and traumatic flashbacks. These have been theorized to be due to an imbalance between higher cognitive functions and negative emotional memories in which higher cognitive structures fail to suppress these memories. When PTSD patients are exposed to emotional stimuli, activation is detected in their brains’ ventral frontolimbic regions and ventral emotional systems, the magnitude of which is positively correlated with symptom severity. Other changes in brain activity are also correlated with PTSD symptom severity, such as a decrease in dorsal executive network activation.

Neurotransmitter & Neuroendocrine Signaling — PTSD Causes Nightmares

PTSD can lead to the development of sleep disorders, which are prevalent in refugees, and even more significant in those with PTSD. A study of 100 Cambodian refugees found that 67% who had sleep paralysis had PTSD and among 22.4% among participants without PTSD, statistical differences between these numbers are significant. Study suggests that panic disorder, PTSD, and stress in general greatly increase the rate of sleep paralysis (Richter et al.).

There are biochemical roots in how sleep disorders and nightmares work due to PTSD. Studies have shown that glutamate, a neurotransmitter linked to emotional processing, can become dysregulated in individuals with PTSD, leading to distorted memory processing. There are targeting glutamate-related mechanisms, such as using the anticonvulsant drug topiramate, that may offer therapeutic potential by reducing symptoms like nightmares and flashbacks in PTSD (Martin et al., 2009).

Another biological indicator of PTSD is the hypothalamic-pituitary-adrenal (HPA) axis, which has been shown to be disrupted in PTSD patients. Cortisol levels have diminished in patients’ urine, saliva, and plasma as well, as a result of the changes to the HPA. Lower cortisol levels have therefore been linked to PTSD as a biological effect of the disorder. A recent study shows that individuals with PTSD have lower cortisol concentrations which have been linked with greater symptom severity (Martin et al. 2009).

Brain Activity & Biological Aspects — Depression (Focus on Epigenetics )

Trauma-induced changes in brain structure and function also carry immense importance. Lanius et al. (2006) employed neuroimaging techniques to investigate the effects of trauma on emotional control and memory regions. The study found alterations in the aforementioned brain regions, pointing towards a neurological foundation for the emotional and cognitive issues encountered by refugees with depression.

Epigenetic mechanisms play a critical role in refugee populations, as revealed by genetic studies. Provençal et al. (2012) examined epigenetic modifications as factors in gene expression changes triggered by trauma; they might influence the risk of depression in refugees by modifying the expression of genes linked to stress response and neural flexibility. with the different types of trauma that is being faced, it can guide

Forced displacement and traumatic events can cause profound neurobiological responses contributing to depression. Miller and Rasmussen (2017) published a seminal study that highlighted biological changes in stress response systems among refugees.

IV. CASE STUDY ANALYSIS

Refugees are particularly vulnerable to mental health disorders due to their history of fleeing violence and conflict, which necessitates a focus on their mental well-being. Primary care physicians play a vital role in this situation by offering comprehensive care and addressing mental health needs through immediate referral for severe cases and recognizing refugees’ resilience.

Scholarship highlights the crucial role of primary care physicians in addressing the mental health needs of refugees, offering comprehensive care based on a patient-centered approach. The Centers for Disease Control and Prevention (CDC) outlines three action plans for addressing refugees’ mental health needs: immediate referral for acute or life-threatening mental health disorders, primary care follow-up for less serious conditions with specialist referral as necessary, and recognizing the emotional resilience of most refugees who may not require clinical mental health services. Notably, the research also sheds light on the impact of post-resettlement experiences like language barriers, housing, and poverty that exacerbate pre-existing mental health conditions.

Article №1: Refugee Mental Health: A Primary Care Approach

This study investigated the lived experiences of Afghan refugees in Iran following the upheaval caused by the Taliban’s invasion of Afghanistan. Challenges posed by the COVID-19 pandemic further exacerbated their difficulties. The study involving ten male Afghan refugees, averaging 26 years in age, residing in Iran since mid-2021 used thematic analysis to identify four central themes that encompass struggles of the refugees. These include enduring a ‘Tsunami of suffering,’ feeling ‘Lost in space,’ grappling with ‘experiences after reaching Iran,’ and confronting the ‘Challenges of the COVID-19.’

These themes encapsulate a cascade of traumatic events involving loss, insecurity, violence, and the persistent struggle for survival. (Missing subject to the sentence) underscore the necessity for tailored social and healthcare support to address the deep-seated repercussions of war, migration, and the pandemic on the mental health and overall well-being of Afghan refugees in Iran.
This paper delves into the realities of Afghan refugees in Iran in the aftermath of the Taliban’s invasion of Afghanistan. It underlines how pre- and post-migratory traumatic experiences significantly affect their physical, psychological, social, and economic well-being. The additional challenges stemming from the COVID-19 pandemic further compound their existing difficulties. The research identifies four overarching themes: the ‘Tsunami of suffering,’ ‘Lost in space,’ ‘experiences after reaching Iran,’ and the ‘Challenges of the COVID-19.’ These themes collectively depict a sequence of traumatic events involving loss, insecurity, violence, and the relentless struggle for survival. The study, involving ten male Afghan refugees residing in Iran, highlights their journey, encounters with death, life-threatening situations, and the profound impact of the pandemic through thematic analysis. The findings emphasize the profound implications of war, migration, and the pandemic on the mental health and overall well-being of Afghan refugees in Iran.

Article №2: Physical and mental health status of Iraqi refugees resettled in the United States

The study delves into the challenges faced by Iraqi refugees, highlighting their psychosocial trauma and displacement caused by prolonged war. It emphasizes the need for targeted healthcare interventions to address their specific health concerns, given the high prevalence of chronic conditions and mental health symptoms. The research takes into account the context of the Iraqi conflict since 2003, which has led to a substantial refugee crisis and explores the healthcare experiences of Iraqi refugees resettled in the United States.
The findings of the study underscore the considerable psychosocial trauma experienced by Iraqi refugees due to prolonged conflict, leading to displacement and a range of challenges. Despite relatively accessible healthcare, many participants reported delays in seeking medical care, attributed to factors like financial constraints, lack of transportation, and inadequate familiarity with available resources. The study draws attention to the significant prevalence of chronic conditions and mental health symptoms among Iraqi refugees, including anxiety, depression, emotional distress, and PTSD. This prevalence of mental health issues highlights the importance of addressing the distinct health concerns of Iraqi refugees through culturally appropriate approaches, comprehensive healthcare support, mental health screening, and interventions.

Article №3: A scoping review of mental health issues and concerns among immigrant and refugee youth in Canada: Looking back, moving forward.
This study critically examines the determinants of mental illness among immigrant and refugee youth in Canada, highlighting factors such as pre-migration experiences, discrimination, limited healthcare access, and in-and-out group dynamics. The research underscores the variability of mental health outcomes based on gender and immigration status, with a focus on the greater mental health challenges faced by female youth. The study delves into the nuanced prevalence of emotional and behavioral problems among refugee youth, emphasizing the role of pre-migration experiences and trauma in shaping their mental well-being. It recognizes the importance of family involvement and school environments in providing essential care and services to immigrant and refugee youth, with an emphasis on targeted interventions tailored to their unique needs during their initial year of settlement in Canada. The study draws insights from a comprehensive literature review of 17 Canadian studies conducted between 1990 and 2013, aiming to shed light on the mental health complexities faced by this population.

The research findings underscore the multifaceted challenges confronting immigrant and refugee youth in Canada concerning their mental health. These challenges stem from a convergence of factors including pre- and post-migration circumstances, gender dynamics, and accessibility to healthcare resources. The study highlights the necessity for collaborative efforts across different sectors, encompassing health, social, and settlement domains, to effectively address the determinants that influence the mental health outcomes of these youth. Crucially, interventions should prioritize family engagement, create supportive school environments, and be strategically timed during the early phases of resettlement to foster favorable mental health results. The research not only illuminates the complexity of these challenges but also emphasizes the potential for positive outcomes when tailored interventions are applied, facilitating the well-being of immigrant and refugee youth in Canada.

V. STRESS DISORDERS/CARDIOVASCULAR DISEASE

The “Healthy Migrant Theory” argues that migrants have a better health status at immigration than they do at home, as well as to some extent better health status than the host country’s population (Hamilton, 2015). However, subsequent research has challenged this theory where the line between health and refugees shows a negative correlation. Refugees have the highest incidence of Post Traumatic Stress Disorder (PTSD), as in refugee populations post-migration, PTSD prevalence has been estimated at 31% [13] and about three times greater than in the host population, however there are variations between countries of origin (Eiset et.al, & 2022).The prevalence of PTSD in refugees is not a new topic regarding refugees’ health, however the rise of declining cardiovascular health manifested by PTSD is a topic of concern. A cross sectional study done in Spain showed that “higher age relates to higher hypertension and higher resilience relates negatively to hypertension” (Mendez, Jacinto, Mendieta, Garin, Rodriguez 2022), meaning stress related events are responsible for cardiovascular health issues. Overall, burnout and chronic stress negatively contribute to the health of refugees as they accumulate over time.

An essential question revolves around whether PTSD plays a role in the onset of cardiovascular disease, if there are shared underlying mechanisms between PTSD and CVD, or if CVD can trigger the emergence of PTSD. Cumulative research across all disciplines indicates that prolonged or chronic stress does influence the development of CVD (Kubzansky & Koenen, 2009).

Throughout our literature review, three factors were prevalent in how chronic stress can affect CVD: sympathoadrenal axis hyperactivity, hair cortisol concentration, and substance abuse.

Human bodies have an innate response to stress or perceived threat, however a repeated exposure to stress makes sympathoadrenal axis hyperactive, with its excessive release of stress hormones, can significantly contribute to the development and heart disease by increasing heart rate, blood pressure, and the risk of arrhythmias (Bedi & Arora, 2007). However, there are limited studies on the mechanism of how this axis increases the development of CHD.

Hair cortisol concentration (HCC) on the other hand has been found elevated in refugees in asylums (citation?). HCC is a measure of the level of the stress hormone cortisol that has been deposited in a person’s hair over a period of time. It is used as a biomarker to assess chronic psychological disease. German researchers conducted a study referenceing specifically recently fled asylum seekers to permanently settled Turkish immigrants, and non-immigrant Germans. The turkish immigrants were categorized into two groups one with PTSD and and without PTSD. Asylum seekers had a 42% higher HCC compared to the reference group HCC was 23% lower in permanently settled immigrants than in the reference group (Mewes et al., 2017). This indicates a state of relative hypercortisolism in recently fled asylum seekers, irrespective of whether they had PTSD. Refugees are consistently exposed to high levels of stress, regardless of whether they receive a clinical diagnosis of PTSD (Citation?). Subsequent studies have showcased the underlying connection between elevated HCC and cardiovascular disease, where the odds of ratio for cardiovascular risk is 2.7 (Mazgelytė et al., 2019). However, HCC also increases through traditional cardiovascular risk factors, such as substance abuse and smoking.

Displaced populations, including refugees, are more vulnerable to substance use and substance use disorders (SUD) due to the stress and trauma associated with forced migration and displacement. Furthermore, a study was conducted and found that the prevalence of hazardous/harmful alcohol use ranged from 4%-36%, alcohol dependence less than 1% to 42%, and unspecified drug dependence from 1% to 20% ( Horyniak et al, Year?). However, these numbers vary widely among the displaced population. The Acculturative Stress Model (ASM) suggests the process of adjusting to a new country is stressful. Furthermore, when individuals lack coping resources it can contribute to the development of substance use problems.(Jermy et.al, Year?) However, there is little literature review concerning substance abuse disorder/substance abuse in the refugee population but it’s a factor to take in consideration when evaluating how the development of CVD among refugees is primarily due to multiple different stressors.

VI. CONCLUSION

In culmination, this research paper delves into the intricate and challenging landscape of refugee mental health, shedding light on the multifaceted struggles that define the experiences of this vulnerable demographic. Through a comprehensive exploration of various studies, a compelling narrative emerges that underscores the profound impact of migration, conflict, and socio-economic stressors on the mental well-being of refugees. While the literature presents inconsistencies and contradictory findings, the overarching themes of trauma, displacement, and the pivotal role of both pre- and post-migratory experiences in shaping mental health outcomes are resoundingly evident.

These themes carry profound implications for the way societies approach mental health care within refugee communities. The collective findings advocate for a holistic and culturally sensitive approach that extends beyond individual well-being to the broader fabric of community and societal health. Such an approach necessitates collaborative efforts, where healthcare providers, community organizations, policymakers, and the refugees themselves converge to create a supportive environment. Through validating the lived experiences of refugees, offering tailored interventions, and combating the stigma surrounding mental health, societies can pave the way for a resilient, inclusive, and empathetic community. This vision transcends borders, cultures, and backgrounds, embodying a shared humanity that recognizes the intrinsic value of each individual and their right to mental well-being.

VII. REFERENCES

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