A migrant is “a person who moves away from his or her place of usual residence” (United Nations, 1980). Almost half of the world’s international migrant population is female (Boyd, 2021). Female migrants are at a greater risk of diagnosable mental health-related illnesses compared to male migrants (e.g., Bermejo et al., 2012; Hacker et al., 2011). Such conditions include Post-Traumatic Stress Disorder (PTSD) and perinatal depression (Nyikavaranda et al., 2023). Despite this, most migration research has primarily focused on men (Llácer et al., 2007).
The current systematic review by Patrick Nyikavaranda et al. (2023) addresses a significant research gap by focusing on the experiences of female migrants in Europe, rather than the traditionally male-centric perspective. The study explores the barriers and facilitators that female migrants encounter when seeking mental health (MH) support, providing a much-needed feminist lens on the issue, highlighting the unique challenges and support mechanisms for female migrants.
Migration research has predominantly focused on male migrants’ experiences, overlooking the female experience, but nearly half of the world’s international migrant population is female.
Methods
The study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines (Page et al., 2020), and the review protocol was registered on PROSPERO (CRD42021235571). The review focused on studies that:
- Included female migrants, asylum seekers, or refugees, with data on female experiences.
- Addressed common mental health conditions (e.g., PTSD, depression, anxiety disorders).
- Examined barriers and facilitators to accessing formal (i.e., professional) and informal mental health support.
The SPIDER search tool (Sample, Phenomenon of Interest, Design, Evaluation, Research Type) was used to inform the search strategy and identify qualitative and mixed-method studies (Cooke et al., 2012) across six electronic databases. Keywords included female migrants, mental health, access, primary care, and community health services in Europe.
Titles and abstracts were independently screened by two reviewers (AT and PN), with full-text evaluations conducted for inclusion. The process involved further review by additional four team members (CDL, CJJ, PP, and MP) to ensure the suitability of studies for inclusion. The settings considered were primary care and community care, focusing on comprehensive services to meet the majority of health needs. In total, 17 studies were included in the current review.
The Mixed Methods Appraisal tool (MMAT) was used to appraise the reporting of included studies critically, and the Feminist Quality Appraisal Tool (Morgan et al., 2017) was employed to analyse gender-specific barriers and facilitators, incorporating transnational, intersectional, and decolonial perspectives. The two reviewers, AT and PN, independently assessed the MMAT and found no significant differences in their assessments. Regarding conflict resolution, the final inclusion of studies was determined after any disagreements or inconsistencies between the reviewers were discussed and resolved through consultation with additional team members (CDL, CJJ, PP, and MP). No papers were excluded due to study quality, and all the papers were assessed as having good study quality based on the study design.
Results
The study identified several barriers to accessing mental health support for female migrants, including lack of access to appropriate information, cultural barriers, stigma, structural obstacles, and gender-specific barriers. On the other hand, potential facilitators included gender-appropriate/sensitive services, culturally appropriate services, gender-specific support, and involvement of religious leaders.
Barriers
Access to Information: Many female migrants lack awareness about available mental health services and how to access them. This lack of information prevents them from seeking the help they need.
I don’t think they tell us like early enough, you know when you’ve found out then they tell you. I think there should be something where you find out before a little. (FG, Young female) (Kiselev et al., 2020)
Cultural and Spiritual Barriers: Cultural beliefs and spiritual practices can act as barriers to accessing mental health support due to differing understandings of mental health and stigma associated with help-seeking.
Stigma: The mental health stigma both within migrant communities and in the broader society discourages women from seeking support. Fear of being judged or misunderstood further exacerbates this problem.
my friend…never tells her mom anything [about her mental health problems] and she always bottles it up and she just…thinks of her mum getting upset (FG2, Girl 1) (Ali et al., 2017)
Structural Barriers: Legal and administrative hurdles, such as restrictive immigration policies and lack of legal status, further limit access to healthcare services. Economic constraints, such as lack of insurance and financial instability, also play a significant role.
Gender-Specific Issues: Gender-specific barriers include additional caregiving responsibilities, fear of discrimination, and experiences of gender-based violence, preventing women from prioritising their wellbeing.
Facilitators
Religiosity: For many female migrants, their faith and religious practices serve as sources of comfort and support. Religiosity can provide resilience and a sense of community, helping women cope with mental health challenges.
Community and Religious Leaders: Leaders within migrant communities and religious groups play a crucial role in facilitating access to mental health support. They can provide guidance, advocate for mental health awareness, and connect individuals with resources.
Gender-Sensitive Support: Services that are tailored to the specific needs of female migrants, such as those offering gender-sensitive support, help in addressing mental health issues effectively. These services consider cultural contexts and provide a safe space for women.
Education Settings as Facilitators: Educational institutions were seen as important facilitators by providing mental health education and support services. Schools and other educational settings can offer resources and create awareness among female migrants and their families.
Resilience and Adaptability: The resilience and adaptability of female migrants play a significant role in their mental health. Many women demonstrated strong coping mechanisms and the ability to adapt to new environments, which helps them navigate mental health challenges.
The way I see Somali women is, is that they are really strong… Most of them are single mothers, and the way they cope is unbelievable, it’s unbelievable. I mean, they try their best, yeah? And most of them don’t have any families around at all, it’s only them. (Aisha, Group 2) (Whittaker et al., 2005)
Gender-sensitive care provision is essential to effectively address mental health difficulties experienced by female migrants.
Conclusions
The study underscores the necessity for culturally and gender-sensitive approaches to mental health support, emphasising the role of community networks and education in bridging the gap. By focusing on female migrants’ unique experiences, this systematic review provides valuable insights for policymakers and healthcare providers to develop more effective, inclusive mental health services.
The findings advocate for a multi-faceted strategy to address the complex interplay of factors influencing mental health support access for female migrants.
Strengths and limitations
The current review provides a comprehensive and inclusive analysis of the barriers and facilitators to mental health support among female migrants in Europe, addressing a critical gap in traditionally male-centric migration research. The strengths of the review lie in its adherence to PRISMA guidelines, the use of a feminist lens, and the broad inclusion of studies from multiple European countries, which together ensure a thorough understanding of the unique challenges faced by female migrants.
The review is both clinically relevant and timely, particularly in the context of ongoing global migration trends and the increasing diversity within European populations. The mental health of migrants is a critical public health issue, with female migrants often facing unique challenges that exacerbate their risk of MH conditions (Nyikavaranda et al., 2023). The relevance of this research is underscored by the fact that mental health support systems in Europe are often ill-equipped to meet the specific needs of these populations, leading to disparities in access to care and outcomes (Ingleby, 2012).
However, the review also has limitations that need to be acknowledged. The study may be subject to language and publication bias, primarily including studies published in English and accessible through specific databases, potentially excluding relevant research in other languages or less accessible sources. The cross-sectional nature of most studies limits the ability to draw conclusions about long-term trends and impacts, highlighting the need for more longitudinal research. Furthermore, the focus on Europe means the findings may not be directly applicable to female migrants in other regions with different healthcare systems and sociopolitical contexts.
The use of tools like the Mixed Methods Appraisal Tool (MMAT) and the Feminist Quality Appraisal Tool ensured rigorous quality assessment, but the lack of discussion on potential biases such as publication bias weakens the overall reliability of the results. Moreover, while the review’s authors combined the results reasonably well, the implications of high heterogeneity among studies could have been explored more thoroughly.
The lack of longitudinal data limits the findings generalisability over time, while the focus on European settings might restrict the applicability of these results to other social contexts.
Implications for practice
The review emphasises the importance of providing culturally sensitive mental health services and training healthcare providers to become more culturally competent and address the unique needs of female migrants. Services need to provide interpretation services but also raise awareness on mental health-related cultural beliefs and practices within minoritised immigrant communities (Nyikavaranda et al., 2023). Considering the importance of stigma, community and religious leaders can also play a crucial role in promoting mental health awareness, encouraging support-seeking behaviours within their communities and building bridges with local services. Training leaders to provide initial support and referrals can enhance trust and acceptance of mental health services (Nyikavaranda et al., 2023; Boyd, 2021).
Services tailored specifically to address gender-specific issues, such as experiences of gender-based violence and caregiving responsibilities, are essential. Creating safe spaces for women and offering services that consider these factors can improve mental health outcomes. Integrating mental health support with other services, such as maternal and child health, can provide a holistic approach to care (Llácer et al., 2007; Nyikavaranda et al., 2023).
Service development initiatives to creating easily accessible information in multiple languages are needed to bridge access gaps. This can go beyond localised resources to information campaigns targeting female migrant communities to raise awareness (Nyikavaranda et al., 2023; Llácer et al., 2007). Policymakers should consider reforms on immigration policies that simplify the process for female migrants to access healthcare services, regardless of their legal status. Collaboration between healthcare providers and legal aid organisations can also provide comprehensive support to navigate these barriers (Hacker et al., 2011; Bermejo et al., 2012).
On an individual level, clinicians can further support female migrants in accessing mental health care by adopting culturally sensitive practices and fostering trust. Building strong therapeutic relationships through active listening and demonstrating cultural competence can help alleviate fears and mistrust that many female migrants may have towards healthcare systems. Clinicians should also be proactive in offering translation services and ensuring that all communications are accessible to non-native speakers, thus removing language barriers at the point of care (Llácer et al., 2007).
Empowering female migrants through culturally sensitive mental health services and community engagement leads to better integration and well-being.
Statement of interests
No conflicts of interest to declare.
Links
Primary paper
Nyikavaranda, P., Pantelic, M., Jones, C. J., Paudyal, P., Tunks, A., & Llewellyn, C. D. (2023). Barriers and facilitators to seeking and accessing mental health support in primary care and the community among female migrants in Europe: a “feminisms” systematic review. International Journal for Equity in Health, 22(1), 196.
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