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    Construction of health among the Rohingya refugees in Bangladesh : a culture-centred approach : a thesis presented in partial fulfilment of the requirements for the degree of Doctor of Philosophy, Massey University, Manawatu, Palmerston North, New Zealand
    (Massey University, 2023-12-21) Rahman, Md Mahbubur
    Rohingyas, the majority of whom are Muslims (followers of the religion of Islam) are the ethnic minority group of the Rakhine state of Myanmar, where they have lived for centuries. However, Rohingyas lost their citizenship rights through a state sponsored apartheid-like system in 1982 and since then they have been stateless. As a result of organised state-led persecutions and even genocide for decades, Rohingyas are now the largest stateless community of the world. It is estimated that around 3.5 million Rohingyas are now scattered throughout the world. Among them, only an estimated 600,000 Rohingyas are still living in Myanmar. However, the exact figure of Rohingyas in Myanmar is difficult to confirm. The largest group, more than 1.6 million Rohingyas, is in Bangladesh. The majority of the Rohingyas once living in Rakhine state of Myanmar fled to Bangladesh after the latest genocide perpetrated against them by the Myanmar authorities from August 2017 onwards. Most of the Rohingyas who fled from Myanmar are now living in 33 makeshift camps at Cox’s Bazar, Bangladesh. The Rohingyas have been living in the camps of Bangladesh for years without any citizenship rights or refugee status. In this thesis, the Rohingyas are deliberately designated as refugees as they fulfil all the conditions of refugees by various international laws. According to the 1951 Refugee Convention, "a refugee is defined as a person who owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his nationality, and is unable to or, owing to such fear, is unwilling to avail himself of the protection of that country or to return there because there is a fear of persecution" [Article 1(a)(2), 1951 Refugee Convention]. Bangladesh is not a signatory to the 1951 Refugee Convention or its 1967 protocol and has avoided labelling the Rohingyas as “refugees.” Instead, Bangladeshi authorities refer to the Rohingyas as “Forcibly Displaced Myanmar Nationals” (FDMN) and do not afford them the right to work or freedom of movement. Rohingyas who fled persecution in Myanmar have reason to fear persecution if they return and so they have been staying in the camps for years. In the Bangladeshi camps, while the local authorities and international agencies barely manage to provide minimum basic needs, the Rohingya people suffer from a lack of provisions for long-term needs, such as adequate healthcare services and education. The current study explores various health issues concerning the Rohingya people living in 33 camps of Cox's Bazar, Bangladesh. To discover their health issues, the localised, lived experiences of Rohingyas have been studied to identify the current health policy approaches and interventions addressing their health needs. This research employs a Culture-Centred ethnographic data collection methodology, with 41 in-depth interviews including some Focused Group Discussions. Purposive and snowballing methods were used to identify and recruit the Rohingya participants. The researcher has applied the Culture-Centred Approach (CCA) to find out the Rohingya refugees’ health needs. The Culture-Centred Approach is a theory of health communication that works through centring culture along with structure and agency and believes the community should have a voice in defining their problems and finding solutions. This thesis argues that the construction of Rohingya healthcare services at the refugee camps of Bangladesh follow the top-down approach and the services are predetermined by the local authorities and international agencies. The Rohingyas are the passive users of all of their basic needs including the health needs. The voices of Rohingyas are not being heard and there is no attempt to hear them, even when critical decisions regarding their health and life are being made. From that point of view this thesis examines the lived experiences of Rohingyas living in the refugee camps of Cox’s Bazar, Bangladesh through dialogical exchanges between the researcher and the Rohingya refugees. The findings suggest a theory of “looking from below” through the lens of culture, structure and agency that enables a better understanding of Rohingya health issues in the ground-level micro-practices. The study demonstrates that, given proper opportunities to take part in the decision-making processes, the Rohingyas can improve their health utilising the existing health care facilities of the camps. This thesis also advocates the Rohingya refugees’ participation in any community engagement process so as to enable a better life for them in the refugee camps with the limited infrastructures and minimum opportunities. This study also argues for greater Rohingya involvement in medical care to provide facilities that may address the localised, culture-based health needs of the refugee community.
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    Refugee social services : an examination of institutional logics and value co-creation : a thesis presented in partial fulfilment of the requirements for the degree of Doctor of Philosophy in Marketing at Massey University, Manawatū, New Zealand
    (Massey University, 2024-11-14) Smith, Ro-Ann Patricia
    This thesis contributes to the much-understudied area of refugee services in the services marketing literature by using SDL as a theoretical lens to study refugee social services’ institutional arrangements and their impact on refugees’ and service providers’ value co-creation. This study sought to gain insight into the perspectives of the institutional logics of staff and clients of refugee social services. To investigate the dynamics of power and culture in relation to these perspectives, a government-funded and a non-government-funded refugee social services organisation was chosen. The study also looked at the impact of power, culture, and these perspectives of institutional logics on perceptions of value that the refugees gained in the service experience, and the value co-creation and co-destruction behaviours of staff and clients. To achieve this, a qualitative approach was taken, and interviews were conducted with the service providers and clients from both organisations. The data was analysed using thematic analysis. The results showed that power and culture had a significant impact on the perspectives of the institutional logics of the organisations, perceptions of clients, value gained, and value co-creation and co-destruction behaviours. Results showed incongruence in the staff and client perspectives on institutional logics for the government funded organisation based on the refugees’ lack of power and cultural understanding of the service experience, resulting in clients overestimating value gained and positive value-co-creation behaviours. The staff, though more powerful than the refugees, also lacked power in the organisation, resulting in value co-destruction behaviours. Conversely, the staff and clients of the non-government funded organisation, shared cultures and power and consequently shared perspectives of the institutional logics of the organisation. This resulted in mostly positive value co-creation behaviours. This study contributes to the much-needed marketing literature on refugee services and adds to the SDL and value co-creation literature, particularly as it relates to the impact of political economic factors. The managerial implications of the study stand to improve services for refugees in social services and other contexts by creating new ways to conduct research with them and educating refugees and stakeholders on how to better co-create value.
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    The United Nations (UN) Card, Identity, and Negotiations of Health among Rohingya Refugees
    (MDPI (Basel, Switzerland), 2023-02-15) Rahman MM; Dutta MJ; Plaza Del Pino FJ; Ugarte-Gurruxaga MI
    Being persecuted and expelled from Myanmar, Rohingya refugees are now distributed throughout the world. The Southeast Asian nation of Malaysia has been a preferred destination for Rohingyas fleeing Myanmar's state-sponsored genocide and more recently in a bid to change their fates from the refugee camps in Bangladesh. Refugees are one of the most vulnerable groups in Malaysia and often face dire circumstances, in which their health and wellbeing are compromised. Amidst a plethora of structural challenges, Rohingya refugees try to claim some of their rights with the aid of the UN card (UNHCR ID cards) in Malaysia. Guided by the culture-centered approach (CCA), this study examined the perspectives and experiences of healthcare among Rohingya refugees while living in Malaysia, now resettled in Aotearoa, New Zealand. The participants' narratives showed that the UN card not only materialized their refugee status in Malaysia but also offered them a way of living in a world where documents anchor the materiality of health.
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    Health Care Services Utilization and Health-Related Quality of Life of Syrian Refugees with Post-Traumatic Stress Symptoms in Germany (the Sanadak Trial)
    (MDPI (Basel, Switzerland), 2021-04-01) Grochtdreis T; Röhr S; Jung FU; Nagl M; Renner A; Kersting A; Riedel-Heller SG; König H-H; Dams J
    Refugees who have fled from the ongoing civil war in Syria that arrived in Germany often develop post-traumatic stress symptoms (PTSS). The aim of this study was to determine health care services utilization (HCSU), health care costs and health-related quality of life (HrQoL) of Syrian refugees with mild to moderate PTSS without current treatment in Germany. The study was based on the baseline sample of a randomized controlled trial of a self-help app for Syrian refugees with PTSS (n = 133). HCSU and HrQoL based on the EQ-5D-5L and its visual analogue scale (EQ-VAS) were assessed with standardized interviews. Annual health care costs were calculated using extrapolated four-month HCSU and standardized unit costs. Associations between health care costs, HrQoL and PTSS severity were examined using generalized linear models. Overall, 85.0% of the sample utilized health care services within four months. The mean total annual health care costs were EUR 1920 per person. PTSS severity was not associated with health care costs. The EQ-5D-5L index score and the EQ-VAS score was 0.82 and 73.6, respectively. For Syrian refugees with higher PTSS severity, the EQ-5D-5L index score was lower (−0.17; p < 0.001). The HCSU and the resulting health care costs of Syrian refugees with mild to moderate PTSS without current treatment are low and those with a higher PTSS severity had a lower HrQoL.
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    Predictors of psychological distress in Syrian refugees with posttraumatic stress in Germany
    (Public Library of Science (PLoS), 2021-08-04) Renner A; Jäckle D; Nagl M; Hoffmann R; Röhr S; Jung F; Grochtdreis T; Dams J; König H-H; Riedel-Heller S; Kersting A
    Syria has been the main country of citizenship of refugees in Germany since 2013. Syrians face numerous human rights violations in their country that can be accompanied by the experience of potentially traumatic events, loss and displacement. Along the migration process, refugees are exposed to various factors that can have an impact on mental health. The aim of this study is to investigate sociodemographic, war- and flight-related as well as post-migration factors as predictors of posttraumatic stress, depression, somatization and anxiety in Syrian refugees with posttraumatic stress symptoms based in Germany. Data were based on the baseline sample of the “Sanadak” randomized-controlled trial. A total of 133 adult Syrian refugees participated in the study. A questionnaire covered sociodemographic and flight-related questions as well as standardized instruments for symptoms of PTSD (PDS-5), depression (PHQ-9), somatization (PHQ-15), anxiety (GAD-7), generalized self-efficacy (GSE), religiousness (Z-Scale), social support (ESSI) and mental health stigma (SSMIS-SF). Linear regression models were executed to predict mental health outcomes. Sociodemographic predictors (i.e., female sex, higher education) and flight-related predicting factors (i.e., variability of traumatic events) have a negative impact on mental health in Syrian refugees with posttraumatic stress symptoms in Germany. Mental health stigma predicts worse mental health outcomes. Post-migration factors have a major impact on mental health, such as low income, lack of social support, low life satisfaction or a strongly felt connection to Syria. Somatization is an important manifestation of mental distress in Syrian refugees with posttraumatic stress symptoms. Our study showed a range of factors predicting the mental health of Syrian refugees with posttraumatic stress symptoms. Measures to foster mental health could be securing financial security, promoting gender equality and tailored psychosocial programs addressing mental health stigma, loss and social support networks.
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    HELP@APP: development and evaluation of a self-help app for traumatized Syrian refugees in Germany – a study protocol of a randomized controlled trial
    (BioMed Central Ltd, 2019-04-30) Golchert J; Roehr S; Berg F; Grochtdreis T; Hoffmann R; Jung F; Nagl M; Plexnies A; Renner A; König H-H; Kersting A; Riedel-Heller SG
    Background Syrians represent the largest group among refugees in Germany. Many of them were exposed to sequential traumatizing events including war, escape and post-migration stressors, which significantly increase the risk to develop symptoms of posttraumatic stress and other mental disorders. However, there is a lack of adequate treatment options for traumatized refugees in Germany. Moreover, their access to psychosocial care is often restricted due to legal regulation, language barriers, and unclear cost coverage. We therefore aim to develop a low-threshold supportive self-help app for Syrian refugees with posttraumatic stress symptoms. By conducting a randomized controlled trial, we further aim to evaluate the apps’ efficacy, usability, acceptance, and economic health benefit/cost-effectiveness. Methods We will develop a modular, interactive self-help app in Arabic, which will be grounded on cognitive-behavioral models for the treatment of posttraumatic stress. Subsequently, screened positive (i.e., Syrian refugees, 18–65 years old, mild to moderate posttraumatic stress symptomatology as quantified by the Posttraumatic Stress Diagnostic Scale for DSM-5/PDS-5) participants (ideally up to n = 234) will be randomly allocated to an intervention (IG) and control group (CG), respectively. Participants in the IG will gain access to the self-help app for one month, while participants in the CG will receive psychoeducational reading material in form of a comprehensive brochure on traumatization and posttraumatic stress. Measurements are scheduled before the intervention (T0), directly after the intervention (T1, one month later) and three months after the intervention (T2). Using linear mixed effect models, we will investigate change in posttraumatic symptomatology. We will also test for changes in secondary outcomes such as depression, anxiety, and quality of life. Moreover, we will inspect the usability and user acceptance of the app. To evaluate the app in terms of its economic health benefit, the incremental cost-effectiveness ratio will be calculated. Discussion We plan to make the app freely available to the general public after evaluation. Thus, the app can help to add-on to routine care, which currently lacks sufficient and appropriate treatment options for Syrian refugees. Trial registration German Clinical Trials Register/Deutsches Register Klinischer Studien (DRKS). Registration ID: DRKS00013782. Registered: 06th of July 2018.
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    Traumatized Syrian Refugees with Ambiguous Loss: Predictors of Mental Distress
    (MDPI (Basel, Switzerland), 2021-04) Renner A; Jäckle D; Nagl M; Plexnies A; Röhr S; Löbner M; Grochtdreis T; Dams J; König H-H; Riedel-Heller S; Kersting A
    Refugees from war zones often have missing significant others. A loss without confirmation is described as an ambiguous loss. This physical absence with simultaneous mental persistence can be accompanied by economic, social or legal problems, boundary ambiguity (i.e., uncertainty about who belongs to the family system), and can have a negative impact on mental health. The aim of this study was to identify sociodemographic and loss-related predictors for prolonged grief, anxiety, depression, post-traumatic stress disorder (PTSD) and somatization in treatment-seeking Syrian refugees with post-traumatic stress symptoms in Germany experiencing ambiguous loss. For the present study, data were based on the treatment-seeking baseline sample of the “Sanadak” randomized-controlled trial, analyzing a subsample of 47 Syrian refugees with post-traumatic stress symptoms in Germany experiencing ambiguous loss. Sociodemographic and loss-related questions were applied, along with standardized instruments for symptoms of prolonged grief (ICG), anxiety (GAD-7), depression (PHQ-9), PTSD (PDS-5) and somatization (PHQ-15). Linear regression models were used to predict mental health outcomes. Having lost a close family member and higher boundary ambiguity showed a statistically significant association with higher severity in prolonged grief. The overall model for somatization reached statistical significance, while no predictor independently did. Boundary ambiguity showed a statistically significant positive association with depression, while the overall model showed no statistically significant associations. Boundary ambiguity and missing family members seemed to be important predictors for prolonged grief. These findings support the importance of reunification programs and suggest an inclusion of the topic into psychosocial support structures, e.g., including psychoeducational elements on boundary ambiguity in support groups for traumatized individuals and families experiencing ambiguous loss. Further research is needed for a more detailed understanding of the impact of ambiguous loss on refugee populations.
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    Recruitment and Baseline Characteristics of Participants in the “Sanadak” Trial: A Self-Help App for Syrian Refugees with Post-traumatic Stress
    (MDPI (Basel, Switzerland), 2020-10) Röhr S; Jung FU; Renner A; Plexnies A; Hoffmann R; Dams J; Grochtdreis T; König H-H; Kersting A; Riedel-Heller SG
    Many Syrian refugees residing in Germany have been exposed to traumatizing events, while treatment options are scarce. Therefore, the self-help app “Sanadak” was developed to target post-traumatic stress in Syrian refugees. We aimed to inspect the recruitment and baseline characteristics of the participants in the trial, which is conducted to evaluate the app. Analyses were based on the recruitment sample (n = 170) and the trial sample (n = 133). Data were collected during structured face-to-face interviews in the Arabic language. Targeted outcomes included post-traumatic stress (primary; Post-traumatic Diagnostic Scale for DSM-5/PDS-5) and depressive symptoms, anxiety, resilience, among others (secondary). Recruited individuals were M = 32.8 (SD = 11.2, range = 18–65) years old; 38.8% were women. The average PDS-5 score was 23.6 (SD = 13.2) regarding trauma exposure, which was most frequently related to experiencing military- or combat-related events (32.9%). Moreover, 46.5% had major depression and 51.8% showed low resilience. Anxiety was present in 40.6% of the trial participants. Psychological distress was high in Syrian refugees residing in Germany, enrolled in a trial targeting post-traumatic stress. This underlines the need for intervention. Our results provide important figures on the mental health of a not well-studied population group in Germany.
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    A Self-Help App for Syrian Refugees With Posttraumatic Stress (Sanadak): Randomized Controlled Trial
    (JMIR Publications, 2021-01) Röhr S; Jung FU; Pabst A; Grochtdreis T; Dams J; Nagl M; Renner A; Hoffmann R; König H-H; Kersting A; Riedel-Heller SG
    Background: Syrian refugees residing in Germany often develop posttraumatic stress as a result of the Syrian civil war, their escape, and postmigration stressors. At the same time, there is a lack of adequate treatment options. The smartphone-based app Sanadak was developed to provide cognitive behavioral therapy–based self-help in the Arabic language for Syrian refugees with posttraumatic stress. Objective: The aim of this study was to evaluate the effectiveness and cost-effectiveness of the app. Methods: In a randomized controlled trial, eligible individuals were randomly allocated to the intervention group (IG; app use) or control group (CG; psychoeducational reading material). Data were collected during structured face-to-face interviews at 3 assessments (preintervention/baseline, postintervention/after 4 weeks, follow-up/after 4 months). Using adjusted mixed-effects linear regression models, changes in posttraumatic stress and secondary outcomes were investigated as intention-to-treat (ITT) and per-protocol (PP) analysis. Cost-effectiveness was evaluated based on adjusted mean total costs, quality-adjusted life years (QALYs), and cost-effectiveness acceptability curves using the net benefit approach. Results: Of 170 screened individuals (aged 18 to 65 years), 133 were eligible and randomized to the IG (n=65) and CG (n=68). Although there was a pre-post reduction in posttraumatic stress, ITT showed no significant differences between the IG and CG after 4 weeks (Posttraumatic Diagnostic Scale for DSM-5, Diff –0.90, 95% CI –0.24 to 0.47; P=.52) and after 4 months (Diff –0.39, 95% CI –3.24 to 2.46; P=.79). The same was true for PP. Regarding secondary outcomes, ITT indicated a treatment effect for self-stigma: after 4 weeks (Self-Stigma of Mental Illness Scale/SSMIS–stereotype agreement: d=0.86, 95% CI 0.46 to 1.25; stereotype application: d=0.60, 95% CI 0.22 to 0.99) and after 4 months (d=0.52, 95% CI 0.12 to 0.92; d=0.50, 95% CI 0.10 to 0.90), the IG showed significantly lower values in self-stigma than the CG. ITT showed no significant group differences in total costs and QALYs. The probability of cost-effectiveness was 81% for a willingness-to-pay of €0 per additional QALY but decreased with increasing willingness-to-pay. Conclusions: Sanadak was not more effective in reducing mild to moderate posttraumatic stress in Syrian refugees than the control condition nor was it likely to be cost-effective. Therefore, Sanadak is not suitable as a standalone treatment. However, as the app usability was very good, no harms detected, and stigma significantly reduced, Sanadak has potential as a bridging aid within a stepped and collaborative care approach. Trial Registration: German Clinical Trials Register DRKS00013782; https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00013782 International Registered Report Identifier (IRRID): RR2-10.1186/s12888-019-2110-y
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    ‘Look, wait, I’ll translate’: refugee women’s experiences with interpreters in healthcare in Aotearoa New Zealand
    (CSIRO Publishing on behalf of La Trobe University, 2022-05-09) Cassim S; Kidd J; Ali M; Abdul Hamid N; Jameel D; Keenan R; Begum F; Lawrenson R
    This study aimed to explore refugee women's experiences of interpreters in healthcare in Aotearoa, New Zealand (NZ). Semi-structured interviews were conducted with nine women who arrived in NZ as refugees. Analysis involved a ‘text in context’ approach. An iterative and interpretive process was employed by engaging with participant accounts and field notes. The various meanings behind participants' experiences were unpacked in relation to the literature and the broader socio-cultural contexts in which these experiences occurred. Findings highlighted issues with professional and informal interpreters. These issues included cost, discrepancies in dialect, translation outside appointments, and privacy. Findings indicate ethical and practical implications of using interpreters in healthcare for refugee women. A step to achieving equitable healthcare for refugee women in New Zealand entails putting in place accessible and robust communicative infrastructure.