Original article

Problems faced by Syrian refugees and asylum seekers in Switzerland

DOI: https://doi.org/10.4414/smw.2020.20381
Publication Date: 26.10.2020
Swiss Med Wkly. 2020;150:w20381

Nikolai Kiselevade, Monique Pfaltzad, Matthis Schicka, Martha Birdc, Pernille Hansenc, Marit Sijbrandijb, Anne M. de Graaffb, Ulrich Schnyderd, Naser Morinaad

a Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich, Zurich, Switzerland

b Department of Clinical, Neuro- and Developmental Psychology, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam and Amsterdam Public Health Institute, The Netherlands

c International Federation of Red Cross and Red Crescent Societies, Denmark

d University of Zurich, Zurich, Switzerland

e PluSport, Umbrella Organization of Swiss Disabled Sports, Volketswil, Switzerland

Summary

BACKGROUND

Refugees and asylum seekers are susceptible to developing common mental disorders due to their exposure to stressful experiences before, during and after their flight. The Syrian Civil War, which started in 2011, has led to a massive number of Syrians seeking refuge and asylum in European countries, including Switzerland. Currently, Syrians are the second-largest refugee and asylum-seeking population in Switzerland. However, very little is known about the problems faced by this new population in Switzerland and their needs relating to mental health services. Identifying the problems faced by this community is crucial to providing adapted and tailored mental health services to Syrian refugees in Switzerland.

AIM OF THE STUDY

The current study aimed to identify problems that Syrian refugees and asylum seekers face daily while living in Switzerland in order to inform the adaptation of a brief psychological intervention.

METHODS

We used a cross-sectional, qualitative design and collected data according to The Manual for Design, Implementation, Monitoring and Evaluation of Mental Health and Psychosocial Assistance Programs for Trauma Survivors in order to identify problems perceived by the target population. Free-listing, open-ended interviews were conducted with 30 adult Syrian refugees and asylum seekers and analyzed using thematic analysis.

RESULTS

The results show that besides physical health problems, Syrians experience primarily two types of problems: practical and psychological (emotional) problems. These two types of problems are closely interrelated. The most common practical problems (problems with government and authorities, problems related to residence permits, problems with integration, cultural differences, language problems, problems related to education, problems related to employment, and problems with housing) were reported by almost half of all participants. Symptoms of mental disorders and feelings of uncertainty, frustration and injustice were the most common psychological problems and were mentioned by more than one third of the participants. The finding that almost half of the participants reported typical symptoms of mental health disorders suggests that a considerable number of Syrian refugees and asylum seekers might need mental healthcare.

CONCLUSIONS

Authorities, practitioners and researchers should recognize that Syrian refugees and asylum seekers are strongly affected by a broad range of problems. Besides practical problems, they suffer a multitude of psychological problems, and a significant number of them report, among other issues, symptoms of mental health disorders. Officials working with this population should be aware of this vulnerability and be prepared to refer clients in need of mental healthcare to mental healthcare providers. Moreover, the significant variety and number of problems experienced by this population should be taken into consideration when developing solutions tailored to their needs.

Keywords: mental healthcare services, refugee mental health, Syrian refugees and asylum seekers, psychological and practical problems, Switzerland, qualitative study

Abbreviations

AMHRG: Applied Mental Health Research Group

BASEC: Business Administration System for Ethics Committees

DIME: Design, Implementation, Monitoring and Evaluation

EU: European Union

PM+: Problem Management Plus

SEM: State Secretariat for Migration

SERI: Swiss State Secretariat for Education, Research and Innovation

STRENGTHS: Syrian REfuGees mental healTHcare Systems

UNHCR: United Nations High Commissioner for Refugees

WHO: World Health Organization

NK, NM, MB and PH: Acronyms for the authors’ names

Introduction

Syrians represent one of the largest refugee populations – around 6.7 million people – worldwide [1]. More than 5.6 million Syrian refugees and asylum seekers have settled in Turkey and other neighboring countries [2]. However, a considerable number have fled to Europe and have applied for asylum. During the past five years, Syria has been the most common country of citizenship of asylum seekers in European Union member states. Between 2015 and 2017, almost 800,000 asylum applications were registered within the European Union [35].

Switzerland has also been strongly affected by the increased influx of new applications. In 2015 alone, the number of applications reached almost 40,000, double the number in 2014 [6]. Furthermore, Syrians represent the second-largest population, after Eritreans, of asylum seekers or refugees in Switzerland, with more than 20,000 Syrian asylum seekers and refugees currently living in Switzerland [7, 8]. Although the number of new asylum applications in Switzerland has decreased in more recent years, the number of refugees and asylum seekers worldwide is increasing from year to year [1, 9, 10]. It can reasonably be assumed that the number of asylum applications in Switzerland will increase again in the coming years.

There is evidence that refugees and asylum seekers are susceptible to the development of common mental disorders due to their exposure to stressful experiences before, during and after their flight [11]. The prevalences of common mental disorders such as anxiety, depression and post-traumatic stress disorder in conflict-affected or displaced populations are between 20% and 30% [12, 13]. Especially after their arrival in host countries, refugees and asylum seekers encounter risk factors for mental disorders, termed “post-migration stressors” [1416]. Major post-migration risk factors include uncertainty about the asylum application, detention and reduced social integration [17].

Various barriers in the Swiss health system impede access to mental health care for Syrians [16, 18]. Therefore, the delay between refugees and asylums seekers entering Switzerland and their admittance to specialist mental health services may be considerable, often lasting years, and in some cases taking up to eight years [16]. It might, therefore, be expected that the number of patients with a Syrian background referred for specialist treatment for common mental health disorders will grow in the coming years. At the same time, very little is known about the mental health and mental health needs of this population in Switzerland (until now, only one study, one dissertation and one research protocol on the mental health (needs) of Syrian refugees and asylum seekers in Switzerland have been published [1921]. Findings from studies and reports on the challenges faced by Syrian refugees and asylum seekers in everyday life in Middle Eastern countries [2224] can be transferred to the situation in Switzerland, but only to a very limited extent (e.g., discrepancies in social life, prosperity, health and mental health supply, language, religion, etc.). To date, no studies exploring the problems faced by Syrian refugees and asylum seekers in Switzerland have been published. Moreover, no studies have investigated the problems faced by refugees and asylum seekers (either in general or in any particular population) from their point of view [20, 25]. However, knowledge about the specific problems and needs of Syrian refugees and asylum seekers in Switzerland is needed to provide adequate treatments. In this context, it is crucial to understand “problems” as a broader construct; that is, to consider not only psychological distress and symptoms of mental health disorders, but also other aspects, such as practical challenges in everyday life, issues related to family and relatives remaining in the host country, challenges experienced during the flight, and physical health problems. The relationships and interdependencies between these different problems and mental health conditions are well established [2629]. Moreover, approaches like, for example, the ecological model of distress in refugees and asylum seekers, suggest that several displacement-related factors, such as poverty, unemployment, family conflicts and violence, loss of possessions, discrimination, separation from family members, uncertainty regarding asylum status, detention in asylum seeker centers, and loss of social support networks, have a direct influence on individuals’ mental health [30]. For this reason, having a better understanding of the problems faced by a refugee and asylum seeker population in the context of the specific environment of a particular country may lead to substantial improvements in their situation, particularly regarding their mental health, through the creation and implementation of more tailored solutions.

Therefore, this study aimed to identify a broad range of problems faced by Syrian refugees and asylum seekers in Switzerland and to close the existing knowledge gap about the perceived problems of this population. Moreover, this knowledge is valuable in informing the adaptation of a brief psychological intervention, Problem Management Plus (PM+), in Switzerland [11, 31].

Materials and methods

This study was part of the STRENGTHS project (Syrian REfuGees mental healTHcare Systems) [11]. The STRENGTHS project is a multi-country study evaluating the adaptation, implementation and scaling up of PM+, a low-intensity psychological intervention developed by the World Health Organization, among Syrian refugees and asylum seekers [11, 31, 32].

Before the adaptation and implementation of PM+, a qualitative assessment was conducted to identify priority problems from the perspective of Syrian refugees and asylum seekers in Switzerland in order to explore their understanding of mental health and psychosocial problems (due to differences in culture and environment) and to evaluate the barriers to mental healthcare. For this qualitive assessment, data were collected according to Module 1 of The Manual for Design, Implementation, Monitoring and Evaluation (DIME) of Mental Health and Psychosocial Assistance Programs for Trauma Survivors [33]. Module 1 of the DIME manual describes procedures for a qualitative assessment to identify priority problems from a local perspective and to explore participants’ understanding of mental health and psychosocial problems. This module consists of three steps: free-listing interviews, key informant interviews and focus group discussion.

The current manuscript focuses on the first step of the qualitative assessment: the free-listing interviews. The free-list method is well suited to qualitative research which aims to identify as many potentially important problems as possible [34]. The selection of these relevant problems is crucial for identifying the interventions that are needed and that are likely to be acceptable to and feasible for the target population, and that would therefore be effective and sustainable.

Interviewers

For this project, the position of Syrian research assistant was announced by an e-mail advertisement at local Swiss Universities. The requirements were, among other things, Syrian-Arabic as mother tongue, proficiency in English or German, and being enrolled in or having a university degree. Six Syrian research assistants (four female and two male) were recruited to conduct interviews with the participants in Arabic. Four of them were regular students and the other two were guest students (at the time of the interviews) who had already qualified to continue their master’s studies as regular students from the next semester. None of the interviewers had studied psychology or related social sciences. The research assistants received one day of training (facilitated by NM & NK) on the following topics: an introduction to the study and how it fits into the wider program and research cycle; research principles: minimizing bias, ethics, human subject issues, confidentiality and privacy issues; working with vulnerable groups (sensitive interviewing), how to provide study information and how to obtain informed consent correctly; qualitative research methods and an overview of the methods to be used in this study; dealing with distress during interviews; data management; and training in free-list interviewing according to the study protocol and practice sessions/role plays.

Participants & recruitment

The participants were adult Syrian refugees and asylum seekers living in Switzerland since the outbreak of the Syrian Civil War in 2011. They were selected using maximum variation sampling, in accordance with the DIME manual [33, 35]. The purpose of this method is to include Syrian refugees and asylum seekers covering a broad range of the relevant variables (e.g., gender, age, ethnicity/cultural background, religion and educational level). Following previous research in the field and in accordance with both the DIME manual and Lincoln and Guba [35], we aimed to interview 30 participants [33, 3638]. Participants were recruited through word of mouth and snowball sampling (as recommended in the DIME manual) using the personal contacts of the study team across Switzerland (i.e., the Syrian interviewers informed their personal contacts about the study and encouraged them to contact the study coordinator about participation). The participants were interviewed by an interviewer they did not know. No participants were recruited through mental healthcare services.

Procedure

The participants were informed about the study through the informed consent letter and received a written copy of this. Informed consent was obtained verbally to ensure the anonymity of the data. Since the present study does not fall within the scope of the Swiss Human Research Act, ethical approval was not required, but an ethical waiver was granted for the study by the Ethics Committee of the Canton of Zurich (Business Administration System for Ethics Committees number 2017-00404).

The participants were first asked demographic questions (age, religion, education and gender). Then, they were asked three questions. The first question, “What are the problems that affect Syrian refugees and asylum seekers living in Switzerland?”, and the variation of it, “Can you think of any other problems that affect Syrian refugees and asylum seekers in Switzerland?”, were asked repeatedly by the interviewers to obtain as many responses as possible (the other two questions are presented and explained in the “data analysis” section as they were not considered in the present study). Answers were recorded verbatim by the interviewer on structured answering sheets. The interviewers were instructed to use separate sections for each reported problem, if possible, and not to introduce their own language or to summarize the answers, as the data should accurately reflect the participants’ views, rather than those of the interviewer. Furthermore, the interviewers were instructed to let the participants speak in their own words in order to prevent discussion about the problems and to maintain the focus on the questions regarding problems. Audio recordings were not considered feasible as they could lead to alienation of the participants. The interviewers worked in pairs, with one person facilitating the interview and the other transcribing the participant’s statements. Each participant received a voucher worth CHF 20 (around USD 20) for a local retail chain after the interview. The participants did not know about the voucher before starting the interview.

After finishing the interview, the interviewing pair reviewed and jointly corroborated the statements. The texts were translated to English by professional (paid) interpreters and checked for accuracy by the interviewers.

Data analysis

This manuscript focuses on responses to the first interview question. The other two questions (“How does a Syrian refugee or asylum seeker spend her/his day?” and “Whom in the local community do Syrian refugees and asylum seekers consult when facing a problem?”) and their corresponding answers were not considered in the presented analysis as they relate to other components of the main project, STRENGTHS.

We used applied thematic analysis as described by Guest, MacQueen, and Namey [39]. Initially, MB and PH examined the dataset to identify central themes in the data and presented it within the STRENGTHS consortium. Thereafter, an MSc in Psychology student created the codes and integrated their groupings into the broader concept under the supervision of MB and PH. As a next step, the research team (the authors of the current manuscript) reviewed and mutually agreed on the coding framework. Finally, NK, who was not involved in the first step (to eliminate possible bias), coded the dataset according to the final coding framework. The final coding was cross-checked by the research team and ambiguous or uncertain cases were discussed by the research team again.

The coding was performed using NVivo 12 software (Version 12, QSR International). It is important to note that it was possible to allocate one statement to several codes since each statement could contain information relating to several themes.

Results

The interviews were conducted in May 2017. Each interview lasted between 30 and 45 minutes.

Demographics

Thirty Syrians (N = 30) from seven German-speaking cantons (mostly from Zurich) participated in the study. Their median age was 34 years (18-76 years). Table 1 provides further participant characteristics. All the interviews were conducted in Arabic.

Table 1

Participants’ demographics.

Variablen%N
Female1136.7
Religious affiliationMuslim2170
Christian723.3
Zoroastrian13.3
Without religious affiliation13.3
Started graduate education1343.3

General overview of reported problems

Although the participants were asked about the problems that affect the Syrian refugee and asylum seeker population in Switzerland, they mostly described their own problems, or the problems experienced by their family members and friends. In general, participants reported multiple problems that could be assigned to three main types: psychological problems (including mental health-related problems), practical problems and physical health problems. The majority of the statements were related to the first two types of problems. The aggregated codes for these problems are presented in Table 2. Physical health problems were mentioned by 13 participants.

Table 2

Psychological and practical problems faced by Syrian refugees and asylum seekers in Switzerland (the 10 most common problems from each type).

 Psychological problemsn (%N)Practical problemsn (%N)
   Structural problemsSocio-cultural problems 
ISymptoms of mental disorders14 (47)Residence permit 20 (67)
IIFeelings of uncertainty14 (47)Problems with government and authorities 20 (67)
IIIFrustration14 (47) Problems with integration18 (60)
IVFeelings of injustice10 (33) Cultural differences17 (57)
VFeelings of inferiority9 (30)Language problems 17 (57)
VIFeelings of isolation8 (27)Problems related to education 17 (57)
VIIDistrust in (governmental) system8 (27)Problems related to employment 17 (57)
VIIIFeelings of not being understood7 (23)Problems with housing 17 (57)
IXEmotional impact of the war6 (20)Problems with providers 14 (47)
XFeelings of marginalization4 (13) Problems within family14 (47)

On average, each participant mentioned more than 20 problems (mean = 20.9, standard deviation = 5.5). Therefore, there were strong collocations between the individual problems, as presented in Table 3 (co-occurrence between individual problems within one interview). No participant stated that they (the participant) or Syrians (in general) have no problems in Switzerland. Only one participant made a positive statement: “The Swiss state opened the door to Syrians and provided them with a lot of support, moral and financial aid. I really respect that.” [I14]

Table 3

The frequency of collocation between particular reported practical and psychological problems within one interview. Percentages are rounded off/down.

 Practical problems
Problem numberI
[%]
II
[%]
III
[%]
IV
[%]
V
[%]
VI
[%]
VII
[%]
VIII
[%]
IX
[%]
X
[%]
I (%)8
[40]/(57)
8
[40]/(57)
10
[55]/(71)
9
[53]/(64)
5
[29]/(36)
8
[47]/(57)
7
[41]/(50)
8
[47]/(57)
9
[64]/(64)
8
[57]/(57)
II (%)12
[60]/(86)
10
[50]/(71)
10
[55]/(71)
9
[53]/(64)
7
[41]/(50)
8
[47]/(57)
6
[35]/(43)
10
[59]/(71)
10
[71]/(71)
6
[43]/(43)
III (%)9
[45]/(64)
11
[55]/(79)
11
[61]/(79)
11
[65]/(79)
6
[35]/(43)
9
[53]/(64)
8
[47]/(57)
9
[53]/(64)
8
[57]/(57)
9
[64]/(64)
IV (%)10
[50]/(100)
6
[30]/(60)
5
[27]/(50)
5
[29]/(50)
5
[29]/(50)
7
[41]/(70)
4
[24]/(40)
8
[47]/(80)
6
[43]/(60)
4
[29]/(40)
V (%)6
[30]/(67)
7
[35]/(78)
8
[44]/(89)
7
[41]/(78)
5
[29]/(56)
8
[47]/(89)
7
[41]/(78)
7
[41]/(78)
6
[43]/(67)
5
[36]/(56)
VI (%)6
[30]/(75)
2
[10]/(25)
5
[27]/(63)
4
[24]/(50)
6
[35]/(75)
5
[29]/(63)
3
[18]/(38)
4
[24]/(50)
4
[29]/(50)
3
[21]/(38)
VII (%)7
[35]/(88)
5
[25]/(63)
5
[27]/(63)
4
[24]/(50)
6
[35]/(75)
7
[41]/(88)
5
[29]/(63)
6
[35]/(75)
5
[36]/(63)
4
[29]/(50)
VIII (%)6
[30]/(86)
4
[20]/(57)
5
[27]/(71)
5
[29]/(71)
3
[18]/(43)
4
[24]/(57)
3
[18]/(43)
4
[24]/(57)
5
[36]/(71)
2
[14]/(29)
IV (%)3
[15]/(50)
4
[20]/(67)
2
[11]/(34)
3
[18]/(50)
0
[0]/(0)
2
[12]/(34)
2
[12]/(34)
4
[24]/(67)
4
[29]/(67)
2
[14]/(34)
X (%)3
[15]/(75)
1
[5]/(25)
2
[11]/(50)
1
[6]/(25)
3
[18]/(75)
2
[12]/50)
1
[6]/(25)
3
[18]/(75)
2
[14]/(50)
2
[14]/(50)

The three types of problems are presented in detail in the relevant chapters below. The order in which the reported problems within each type or subtype of problems are presented is based on how frequently the problems were mentioned. Finally, each problem is assigned a numeral based on its position (I-X) in Table 2.

Practical problems

Ten participants reported practical problems, which were divided into two subtypes: socio-cultural problems and structural problems. Structural problems are usually aspects of the external environment, whereas socio-cultural problems correspond to internal customs, attitudes or (cultural) practices [40]. Therefore, problems with integration, cultural differences and problems within the family are socio-cultural, and the other seven problems mentioned are structural problems.

Structural problems (I, II, V-IX):

The reported structural problems were strongly focused on a particular practical problem. However, the most frequently mentioned problems of this type were “residence permit” and “problems with the government and authorities”.

Residence Permit (I): In most cases, the residence permit was the first problem mentioned. The majority of participants (n = 20, 67%) mentioned the long waiting time to receive the permit: “I’ve been in Switzerland for one and a half years and I still don’t have a residence permit” [I7] or “The waiting period for a refugee to obtain a residence permit for Switzerland may last for years […]” [I22]. An additional point regarding permits was the various types of residence permits: “Constant fear of getting an F residence permit” [I19]. [Note: various residence permits exist for refugees in Switzerland. There is a “B” permit for legally recognized refugees, which carries more advantages than an “F” permit, which is granted to temporarily admitted refugees. Theoretically, F permit holders could be expelled to their home country if it is considered to be safe (again) by the Swiss government.] Moreover, participants frequently linked the permit to other restrictions in everyday life, such as not being allowed to travel abroad: “We’re holding F residence permits, which means that we are not allowed to leave Switzerland despite having family members in neighboring European countries” [I18], or lack of access to language courses: “My four kids attend school, but my wife and I are not allowed to learn the language because we don’t have a residence permit” [I4].

Problems with government and authorities and problems with providers (II): Participants seemed to differentiate between “problems with government and authorities” (n=20, 67%) and “problems with providers” (n=14, 47%). Statements that clearly referred to a single person or general staff as a specific group (e.g., refugee coordinators, advisors, welfare employees, etc.) were assigned to the category “problems with providers” (e.g., “Yelling in the refugee’s face, not giving him/her enough time to explain his/her problem or point of view and providing him/her with no support” [I16]). In contrast, statements regarding dissatisfaction with the legal framework in Switzerland or the state in general were categorized as “problems with government and authorities” (e.g., “Facing difficulties with government and cantons in facilitating the transfer of residence” [I24]). However, many participants reported that both problems are somewhat intertwined: “But for my problems with the state, I find great difficulties in solving them because the municipality is not responding and respecting me, although I work 100%.” [I20] Some participant responses regarding problems with providers showed that these problems might be contradictory from the participants’ perspective. The following two examples regarding education and work illustrate this: “Every time I talk to the social worker so he can help me with pursuing my higher education, he refuses and tells me that I should work first […]” [I6] / “I completed a German language course and enrolled for school four months later, but I did not study all the subjects, only some specific ones. Now that I want to work, they do not agree and tell me that I still need to take courses like physics, chemistry, science, history and geography.” [I16]

Language problems (V): Since none of the participants were native speakers of any of the official Swiss languages, language problems were among the most common problems (n=17, 57%). Nevertheless, statements regarding language did not focus on language alone. They were always related to other problems, for example to the residence permit (“Changing the residency because of the N [residence permit], which causes a lack of stability and a difficulty in learning the language” [I28]), or to lacking the personal resources needed to learn the language (“I went to a language school but couldn’t learn because it was hard for me. I left it after some time because my head started hurting and I was not benefitting at all. I cannot communicate with people here due to the language barrier” [I10]), or to the inability to carry out routine daily activities, for instance supporting children with their homework (“I cannot help my kids with their studies due to the language” [I4]).

Problems related to a single problem (problems VI-IX): All the participants except one mentioned at least one of the following three challenges: problems with education (n=17, 57%), employment (n=17, 57%) or housing (n=17, 57%). The problems regarding education were mostly related to the residence permit and restrictions on accessing language courses or professional education (e.g., “Because I still haven’t got a residence permit, I can neither learn the language nor get a decent education to start a new life” [I3]). However, several interviewees traced their problems with education to difficulties getting education obtained in Syria officially approved in Switzerland: “The educated person suffers from the significant difficulty, or the impossibility, of obtaining the certificate equivalency [...]. The state is working on destroying your ambition” [I20]. The reported problems with employment were similar. Labor market restrictions exist, depending on the residence permit: “[…] but I was not allowed to work because I still did not get a residence permit” [I1]. Furthermore, existing or permitted job opportunities are often not related to the individual’s education or professional experience (“Force people to work in a field that has no relation with what they have studied or what they have learned in their lives” [27]). Some of the statements more broadly described the difficulties in finding a job (“Difficulties in finding a job” [I30]). Finally, housing problems were strongly related to accommodation in asylum or refugee camps with adverse or crowded conditions (“Our family consists of a father, a mother and three children, sharing a house with other people. We also share the toilet. We suffer from many diseases due to poor hygiene, and there are constant nuisances and constant fuss due to a large number of residents in the same house” [I1]). Notably, the lack of space was reported to be a reason for psychological distress: “The tininess of the space and sharing a room cause much psychological distress and hardship, as a boy or a girl needs his/her own room to study, practice hobbies or even be isolated and have some time for oneself, especially due to the psychological stress due to the novelty of the situation” [I15].

Socio-cultural problems (III, IV, X)

Problems with integration (III): More than half (n=18, 60%) of the interviewees reported problems with integration. These problems can be divided into three subtypes. First, integrational problems were connected to language problems (e.g., “The problem is that the language Swiss people use is very different from the German language I am learning […]” [I2]). Second, integrational problems were referred to as the interaction between Syrians and the Swiss (e.g., “[…] some Syrians refuse to integrate with the Swiss and prefer to hang out with Syrians only” [I29]). This type of problem was perceived by respondents to be primarily attributable to the Swiss: “Swiss are not interested in the refugee, integrating him/her into the society and allowing him/her to work according to his diploma and abilities” [I14]. Finally, some of the respondents reported feeling insulted and discriminated against by the Swiss population: “In addition, I am a hijabi and people here do not welcome it, many attempt to convince me to take off my hijab, which I believe in and consider a part of my identity.” [I2] / “Although I am Christian, I was subject to humiliation by my atheist professor, who told me that I came from a third world country, a less developed country.” [I16]

Cultural differences (IV): Problems caused by cultural differences are mostly attributable to differences between the way of life in Syria and in Switzerland: “For example, ‘shaking hands’ isn’t permitted between men and women[…]” [I22] and to the fear regarding new behavior patterns: “[…] the young Syrians get exposed to and tempted by the lifestyle, girls and alcohol” [I19]. Seventeen participants (57%) reported such problems. One participant summarized the issue as follows: “These customs and traditions are not ours and we are unable to integrate/internalize them.” [I18]

Problems within the family (X): Fourteen participants (47%) reported problems within their family. Often, problems within a family were caused by the restrictions or difficulties in daily life related to refugee status. This was, for example, the case for problems related to employment (“The difficulty of getting a job causes bad family relationships” [I25] or “Unemployment leads the couple to spend more time with each other; therefore, a lot of problems occur” [I28]), lack of money (“There isn’t enough money for shopping or other activities and thus a lacking social life, and this causes psychological distress and sometimes insanity and imbalance in life, which leads to developing disorders and problems and disintegration in the family” [I16]) or unsuitable housing (“Many families live in one flat, which causes big problems among them that sometimes escalate to a physical fight” [I22]). Other problems were connected to alcohol and substance abuse (“My husband used to hit me. He still drinks a lot and sometimes he gets too drunk and hits me in front of the kids. […] and we fight over money because he spends a lot on drinks (alcohol) and tobacco […]” [I9]). Participants frequently stated that the transition from the value system in their home country to the one in Switzerland was exacerbating family problems: “Transition from a dictatorial society to a democratic one. This transition is hard and it takes a long time to adapt to it. During this time, people are suffering from problems inside the house.” [I25] “The difficulty of Syrians’ integration among themselves, as there are many religiously intolerant families, and the two-faced life, that is, outside the house showing that he adapts well and accepts the Europeans, whereas inside the house he is a dictator with his daughters and his wife.” [I14] On the one hand, this transition [to the European value system] results in a change of gender-related attitudes regarding men trying to oppress their wives: “Integration is allowed only to the Syrian man in Switzerland. Concerning women, though, his view of her is bad, and he does not accept her integration or for her to get her rights.” [I23] “Some Syrian men force their wives to be housewives and refuse to let them study.” [I24] On the other hand, the transition to the European value system leads to women understanding and using their rights: “The state support of the woman and her freedom makes the Syrian woman dominate over the man and retaliate against him, which generates many, many family problems, unlike in Syria.” [I11] “There is a great number of divorces due to giving women equal rights to men, and the woman’s control of the family’s fate.” [I18]

Psychological problems

With the exception of three participants, all participants reported psychological or emotional problems.

Symptoms of mental disorders (I): Almost half of respondents (n=14, 47%) described typical symptoms of common mental health disorders such as fear, anxiety or sleeping problems: “Unexplained fears with heart palpitations and inability to breathe.” [I22]. − “I still have very scary dreams, I can’t sleep, neither at night nor during the day, and I started smoking.” [I6]

Feelings of distress (I, III, and VI): In addition to the reported symptoms of mental disorders, participants reported several single feelings that might be summarized as feelings of distress. These feelings included feelings of uncertainty (n=14, 47%) (“I’m always anxious and concerned because my future is very uncertain” [I2]), frustration (n=14, 47%) (“The difficulty of traveling to Lebanon and neighboring countries, especially for those coming by the agency of the UN. Many family members are still in Lebanon, and the longing for my family is killing me” [I11]), and feelings of isolation (n=8, 27%) (“Because I’m living on my own and my kids never ask about me, and I have no company/friends here, I get bored a lot […]” [I10]).

Feelings of perceived marginal position in society (IV, V, VIII, X): Participants also described feelings related to their perceived position in society. The feelings that were mentioned most frequently were feelings of injustice (n=10, 33%) (“[…] there is a huge difference in salaries, there’s no justice” [I20]), feelings of inferiority (n=9, 30%) (“A Syrian feels that he is treated as if he is coming from a backward country, although he knows that he is acculturated and educated” [I19]), feelings of not being understood (n=7, 23%) (“The ‘Social’ officials control the Syrian refugee’s life, without taking into consideration or respecting his/her viewpoint” [I19]), and feelings of marginalization (n=4, 13%) (“The government should give more attention to older people” [I24]).

Distrust in the (governmental) system (VII): Eight participants (27%) reported problems that can be summarized as distrust in the (governmental) system. Some of the statements referred more broadly to distrust in governmental institutions (“The person will be afraid to complain to the police as it is a bad place” [I24] or “I have no trust in the government institutions due to the lack of trust in the staff” [I28]). However, after participants further explained their problems, it became clear that this distrust was caused by the mismatch between their expectations and their actual experience in Switzerland: “We had heard that Switzerland is the most humane country in the world, but we have never felt it at all” [I15]. Sometimes, these unfulfilled expectations arose due to promises made by representatives of a refugee organization, such as one participant who was recognized as a refugee in the context of a resettlement program: “I was promised before coming here that my situation will get a lot better, but I was shocked after I got here. […] I keep begging them to implant artificial limbs so I can become independent and find a job, but they kept telling me that the insurance does not cover it. I also asked them to provide me with an electric or a power wheelchair, but I haven’t received anything.” [I5]

Emotional impact of the war (IX): The emotional impact of the war or negative experiences in Syria were mentioned by six individuals (20%). These statements frequently indicated that participants had trouble letting go of their memories: “[…] but I’m not forgetting what I’ve been through in Syria in terms of detention and injustice […]” [I11] or “I’m psychologically tired when I think of the many things that happened, yet they [Swiss authorities] don’t take this state of mind into consideration” [I17].

Physical health problems

Physical health problems were mentioned by 13 (43%) participants. However, the problems varied widely and were seldom mentioned more than once (e.g., thrombosis, dialysis, loss of weight, chronic blood infections, etc.), or only mentioned in a general way, such as in interview number 9: “I have health problems”. Dental problems and cardiac problems were each noted three times (10%). One participant explicitly related his problems to stress: “All this stress affects my teeth and generates abscess in the mouth and pain” [I13].

Discussion

In the present study, we explored the problems confronting Syrian refugees and asylum seekers in Switzerland. To our knowledge, this is the first attempt to gain insights into the self-identified problems of refugees and asylum seekers in Switzerland. The results highlight that Syrians experience a multitude of practical, psychological (emotional) and physical problems. The majority of the sample reported practical and psychological problems. These problems seem to be closely interrelated for most respondents. Moreover, the findings allow for further conclusions.

Firstly, a variety of practical problems were mentioned by almost every participant. In the current study, participants reported both typical practical problems, such as structural problems, which are usually aspects of the external environment (e.g., socio-economic status, institutional conditions, language problems, financial difficulties, etc.), and socio-cultural problems, which are related primarily to the dissonance between the internal customs, attitudes or (cultural) practices of the country of origin and those of the host country [40]. It is essential to understand this distinction in the context of Switzerland because the socio-cultural problems faced would probably differ or be less prominent in countries with a socio-cultural background more similar to that of Syrian refugees and asylum seekers.

Moreover, practical problems are consistent with the so-called post-migration stressors described in the ecological model by Miller and Rasmussen [30]. Post-migration stressors such as residency status [29], uncertainty about the recognition of asylum applications [17], language problems and associated communication difficulties [16, 41, 42], unemployment [16, 41], family conflicts [42], economic restrictions and low socio-economic status [41, 43], discrimination, and integration problems [16, 17, 42, 44] have been identified and described in earlier studies and were also reported extensively by our interviewees.

However, other typical post-migration stressors, such as lack of social support [41, 44], isolation [16, 42] and poverty [42, 45], were mentioned rarely in the present study. While Hassan et al. [3] link the lack of social support with the limited social support networks of elderly refugees and asylum seekers, our sample was relatively young (median = 34). Moreover, isolation was reported by only 20% of participants in Tinghog et al.’s sample [42]. Finally, Switzerland is one of the wealthiest countries in the world, with a well-developed social security system [46]. Switzerland’s well-developed social security system protects individuals from traditional poverty. This may explain why poverty was rarely mentioned by the participants.

Secondly, the psychological and emotional problems indicate that Syrians experience a wide range of distressing emotional states, as well as dysfunctional psychological symptoms. These problems are consistent with previous findings, as outlined by a systematic literature review based on studies conducted outside Switzerland [44]. The authors summarized various emotional, cognitive and social symptoms among Syrian refugees across studies. Their findings correspond directly and indirectly to the abstracted subcodes of symptoms of mental disorders and particular feelings such as feelings of uncertainty, frustration, injustice, etc. However, other symptoms described by Hassan et al. [44], such as sadness, grief, worry, rumination and hopelessness, were only sporadically mentioned in our interviews. This may be attributable to the small sample size in our study, or possibly to the fact that the participants did not sufficiently trust our interviewers and were thus reluctant to disclose difficult, more internalized emotions. Although we attempted to allocate participants to interviewers they did not know, some participants might have suspected that their interviewers would talk to other Syrians about the participants and their problems despite their duty of confidentiality, thereby creating distrust.

Thirdly, the results regarding statements about physical health were very ambiguous. It is somewhat surprising that even though almost half of the participants reported physical health problems, they merely mentioned them without giving an in-depth explanation, detailed complaints or any further explanation at all. This contrasts with the more detailed answers they provided about practical and psychological problems. A possible explanation for this might be the assumption that the topic of physical health problems was not a priority for the participants or that they perceived themselves as relatively healthy, despite some physical health problems. At the same time, it cannot be ruled out that the participants or the interviewers felt uncomfortable talking about personal physical health problems, and they did not probe for in-depth answers or ask further questions.

An important recurrent issue noted during the interviews was that 20 participants reported cultural differences and problems with integration or related problems such as feelings of not being understood and distrust in the (governmental) system. These issues have previously been investigated as forms of acculturative stress [47, 48]. It was not the objective of our study to investigate the general situation regarding integration, but the data suggest that acculturative stress must also be addressed in this target population.

Lastly, examination of the data revealed many double-coded statements and relationships between emotional and practical problems, which suggests possible associations between these two types of problems. For example, the residence permit was frequently mentioned together with other problems such as uncertainty, frustration or practical challenges. As the old saying goes, “the whole is greater than the sum of its parts,” and the problems faced by Syrian refugees and asylum seekers should be considered as a whole, therefore requiring systemic instead of solitary approaches.

Besides these study-related conclusions, it is important to note that the results of the study seem to be exemplary for refugee and asylum seeker populations in Switzerland in general and not specific to Syrians only. Moreover, the heterogeneity of the sample regarding, for example, age, sex, family status and religion, extends the validity of the results to the broader refugee population. Therefore, it could be assumed that these results can be extended to other refugee and asylum seeker populations in Switzerland.

Limitations

A number of limitations of this study must be addressed. Its external validity is challenged by the fact that the Syrian refugees and asylum seekers answered the questions based on their personal experiences. However, even without aiming to generalize the findings to the wider population of Syrian refugees and asylum seekers in Switzerland, it should be noted that our respondents showed high variation in terms of the relevant variables that adaequately describe Syrian refugees and asylum seekers in Switzerland [7, 8, 12]. Furthermore, the recruitment method might have created a sampling bias as the participants were recruited via the personal contacts of the study team across Switzerland. Also, the inclusion of participants from only the German-speaking part of Switzerland prevented us from gaining the perspective of the entire Syrian refugee and asylum seeker population in Switzerland.

Another limitation is the fact that the interviews were not audiotaped. Even though the interviewers were properly trained and worked in pairs (interviewer and transcriber), it is possible that the transcriber did not write down a statement precisely as it was reported by the interviewee.

Moreover, since the interviewers encouraged the participants to cite additional problems by asking them open questions regarding any other problems, it is possible that the interviewees were stimulated to think and report about problems that are not critical to the target population. The order of the answers in each interview could be used to assess their importance on the assumption that the most relevant problems (from the individual’s point of view) were mentioned first. However, since the interviews were only written down rather than audiotaped, it cannot be ruled out that the original order of the reported problems was not the same as that listed in the transcription sheets.

Furthermore, in this paper we focused on the problems as perceived by the community in order to inform intervention planning, and we did not include the free-listing interview questions focusing on the ways Syrians cope with their problems. This may have led to the unconfirmed impression that Syrian refugees and asylum seekers only face problems in Switzerland.

Finally, the participants’ asylum status was not collected. However, being at different stages in the asylum procedure could have a significant impact on the problems reported. This might affect the participants’ perceptions of the situation and the attribution of their problems greatly. For instance, problems such as feelings of uncertainty and with residence permits might be less relevant to recognized refugees than to asylum seekers.

Practical implications

The findings of the present study suggest several courses of action for authorities and refugee and asylum seeker coordinators in Switzerland. First, it is important to take into account that a considerable proportion of the target population suffer from a broad range of practical and psychological problems that are inextricably interlinked. Second, given that a sufficient proportion of the participants reported typical symptoms of common mental health disorders, it is crucial to identify affected individuals before their condition gets worse. A reasonable approach to tackling this issue could be the implementation of short, standardized screenings for mental health problems in the refugees’ mother tongues. Finally, psychological assessments and support need to be provided to those screening positive. These steps are crucial because recent research indicates that the risk of having a common mental health disorder remains high in the years following resettlement [41, 49].

To prevent the chronification of common mental health disorders, continued efforts to make psychological support more accessible for refugees and asylum seekers are needed because, as reported in previous studies [21, 50, 51], several barriers to accessing mental healthcare infrastructure exist for refugees and asylum seekers in Switzerland. For this purpose, the findings were integrated while adapting the PM+ manual for the STRENGTHS project.

Although the aim of this study was to identify the problems faced by Syrians in order to inform mental health interventions, the results could also be used to inform refugee support programs in other areas, including language courses and integration programs. It would be useful to evaluate the reasons for the existing problems and to propose possible practical solutions. For example, the delays in the decision-making of the government when recognizing asylum applications might be caused by an overload of applications, and this might decrease the integration of refugees and asylum seekers [52]. However, the dependency of access to language courses on residency status is counterproductive if applicants need to stay in the host country for years until a decision regarding recognition or denial of the application is made. At the same time, any other possible options, such as language courses by non-profit or non-governmental organizations, digital language courses for smartphone users, or language learning and work experience through interest organizations (e.g., associations for sports, music, environment, etc.), should be explored while ensuring that refugees and asylum seekers have sufficient information about these options.

Conclusions

This study is an important first step to identifying and exploring the problems faced by Syrian refugees and asylum seekers in Switzerland from their perspective. However, it should not be suggested that the target population perceives only these problems as existing in Switzerland. Also, the focus of the study was on perceived problems and not, for example, positive aspects of their current situation.

Our study has shown that multiple practical, psychological and physical problems exist, and that the absolute majority of participants suffer from a multitude of these problems. From the point of view of mental health professionals, it is obvious that this concentrated load of problems results in stress, and regardless of personal predispositions for developing a mental health disorder, this stress might increase the probability of the target population developing common mental health disorders. Officials working with this population should be aware of this vulnerability and be prepared to refer clients in need of mental healthcare to the respective professionals or to supplementary low-intensity mental health programs (e.g., PM+) that are adapted to the needs of refugees and asylum seekers.

Additionally, the influence of practical problems on psychological problems and vice versa was not analyzed, but the data suggest a reciprocal relationship between these problems. This relationship raises the question of whether the elimination of one problem might influence other problems, or even reduce their severity.

At the same time, from the point of view of mental health professionals, the high number of perceived problems and their interdependence might boost the negative influence of particular problems on refugees’ mental health. Authorities, practitioners and researchers should take this knowledge into account and implement solutions tailored to the needs of the target population (social, educational, legal and family support).

Finally, the findings of the current study provide essential information for the development and preparation of the low-intensity intervention PM+ in Switzerland. In the future, this intervention might be an appropriate choice for the provision of mental health support to vulnerable refugee and asylum seeker populations that are highly affected by stress, as confirmed by the current study, and currently face multiple barriers to accessing regular mental health care [20, 21]. Access to low-intensity psychological programs might protect vulnerable populations from developing common mental health disorders and decrease the distress of their participants.

Acknowledgments

This study was conducted on behalf of the STRENGTHS consortium. We are grateful to Eliane Kunz for her support in working on the coding framework.

Statement on funding sources and conflicts of interest

This study was supported by the Swiss State Secretariat for Education, Research and Innovation under contract number 16.0205. The opinions expressed and arguments employed herein do not necessarily reflect the official views of the Swiss Government.

Credits

Header image: © Stevanovicigor | Dreamstime.com

Correspondence

Correspondence, Dr. phil. Naser Morina, University Hospital Zurich, Department of Consultation-Liaison Psychiatry and Psychosomatics, Culmannstrasse 8, CH-8091 Zurich, naser.morina[at]usz.ch

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