Introduction

Navigating healthcare systems and engaging in healthy behaviors can be difficult for those born in the countries they reside in; refugees however, contend with additional challenges and a myriad of factors affecting their health outcomes. In providing some context into what or who constitutes the refugee population, the United Nations High Commissioner for Refugees (UNHCR) describes a migrant as someone who left their home for a variety of reasons, including but not limited to, seeking better education, work, or reuniting with family; [1] while a refugee is someone who leaves due to “war, violence, conflict or persecution” [2]. Castañeda and Holmes, however, caution on the limitations of these definitions, as they argue “[w]hether a person is identified as a refugee or as some other socially constructed category… depends on historical, sociocultural, political, and economic contexts” [3]. There are nuances and implications for the use of the terms refugee versus migrants in regard to the choice to emigrate. These delineations are not necessarily rigid, [4] and the notion of choice is one that can be contested given the push and pull factors that cause people to emigrate, which for immigrants, are often economic, with important implications for health and well-being.

According to the UNHCR, the most recent data from 2018 indicated that there are over 25.9 million refugees worldwide, more than at any time in history [5]. As of 2015, the three countries that resettled the greatest number of refugees were, first, the U.S. who resettled 52,583 refugees, second, Canada who resettled 10,236 refugees, and third, Australia who resettled 5,211 refugees [6]. Following these three countries, there was Norway (fourth), Germany (fifth), Sweden (sixth), the United Kingdom (seventh), Finland (eighth), New Zealand (ninth), and France (tenth) [6]. The process of resettlement in another country is lengthy. In the U.S. for example, the process of resettlement takes at least two years and involves intensive medical and security screening by at least fifteen different agencies [7]. Over 3 million refugees have come to the U.S. since 1975 and resettled in all 50 states [7]. Once they arrive, refugee health screening, care, access, and clinical resources vary among states [8]. The official Domestic Medical Screening Guidelines Checklist by the Office of Refugee Resettlement (ORR) is strictly physical and assesses cholesterol, hepatitis, HIV/AIDS, and Tuberculosis (TB) status, but does not assess any psychosocial aspects of health [9]. The U.S. Centers for Disease Control and Prevention (CDC) has twelve additional recommended screening guidelines, including mental health, which are not mandatory [9]. Additionally, in Australia for example, from 2014 to 2015 there was an average waiting period of 14.5 months to receive a refugee visa [6]. Moreover, since 1977, Australia has been among the top three countries in the world for refugee resettlement [6]. Australia accepted the largest number of refugees from 1980 to 1981 with 20,795, and from 1975 to 1978, and then from 1984 to 2012 and 2013–2016, Australia accepted less than 10,000 refugees per year [6]. Resettlement in Australia also involves medical screening as well as character screening, which includes screening of “criminal conduct”[10], of the individual or family and family they may be reunifying with in the country of resettlement [10]. In countries of resettlement, health care and social service providers who work with refugees, particularly refugee women, need to be equipped to work in a culturally safe manner and to be sensitive to their unique needs.

The existing body of literature focused on aspects of refugee health, such as prenatal appointments or mental health among refugee women. While this research has been valuable for informing recommendations for best practices with this population, it lacked a holistic approach that includes other salient factors (e.g., social support, barriers in the healthcare system, and cultural realities) that impact women’s health, post-settlement. Literature on this topic tends to focus on one specific population and one specific health outcome among refugee women. For example, Marshall et al., focused solely on the mental health of Cambodian refugees ages 35–75 in their study [11]. In this article, we conduct a comprehensive synthesis of the literature on the topic through thematic review to identify social, cultural and environmental factors that affect refugee women’s health. While we examine the U.S.-specific context, the literature covers several different resettlement countries, including the U.S., such as Australia, Belgium, the Netherlands, South Korea, and the United Kingdom; thus, the findings have implications for other nations that resettle refugees. This is because, as we demonstrate in our review of the literature, many factors that influence refugee women’s health, such as patient-provider interactions and migration history, impact health regardless of the resettlement country. Furthermore, resettlement countries have different healthcare systems. For example, in Australia there is a mix of universal public and elective private health insurance, in the Netherlands the government provides most care through publicly financed health insurance, and in the U.S. while there are some programs for children and the elderly, most Americans have private health insurance and many are uninsured [12].

In our review we uncover how different ecological factors impact refugee women’s health post-settlement. Our key research questions were 1) what arenas, such as health care, social support, violence, and mental health, help or hinder refugee women’s health post resettlement, and 2) how can the Social-Ecological Model (SEM) (individual, interpersonal, organizational, and community levels) framework be adapted to inform implementation of programs targeting refugee women at various levels?

To address our research questions, we conducted a two-tier analysis of the literature. First, we conducted a deductive thematic analysis of the literature guided by a cultural safety lens. A cultural safety lens means that providers examine the power dynamic of their relationships with patients as well as participate in sensitive reflections of their interactions with patients.[13] Second, we created an adapted SEM model to provide clear framing and recommendations in our discussion section for improving the health of refugee women. This article presents information on the background of refugees as well as experiences with violence, mental health, health care and social support. Our methodology is fully explicated in the methods section.