Leave no one behind: how nurses are building capacity within health systems to respond to global forced migration : JBI Evidence Synthesis

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Leave no one behind: how nurses are building capacity within health systems to respond to global forced migration

Kassam, Shahin1,2; Marcellus, Lenora1,2; Butcher, Diane2,3

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doi: 10.11124/JBIES-22-00384
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Inclusion is a core value driving the 2030 agenda for addressing the global Sustainable Development Goals (SDGs).1 This global commitment calls the world to act on inequities faced by populations affected by structural marginalization, exclusion, and discrimination. However, only recently have populations facing forced migration been recognized within the SDGs as a cross-cutting issue relevant across most, if not all, 17 SDGs.2 Even more recent is the World Health Organization's (WHO) first report addressing the health of populations affected by forced migration.3 While this report recommends integrating migration as a key social determinant of health, there is a need to take a deeper look at the meaning of forced migration as a distinct experience of being a migrant with unique health implications.

Forced migration has historically been attributed to war and conflict; however, reasons for being forced to move from a person's home are increasingly complex. As we have done in our systematic review, “Experiences of nurses caring for involuntary migrant maternal women,”4 exploring such reasons can expand understanding of migration as a social determinant of health. As briefly described within our review, 3 core explanations of forced migration have been further examined: climate change, political fragility, and the consequences of colonialism.

First, understanding the effects of climate change on forced migration is long overdue. It has been forecast that over 1 billion people will be forced to migrate due to global issues, including environmental instability and climate disasters, by the year 2050.5 Facing the largest climate change threats are Sub-Saharan Africa, South Asia, the Middle East, and northern Africa.5 Such threats have been linked to increased economic and social insecurity, leading to higher rates of conflict and violence.6 Civil war within Sudan has been cited as among the first climate change–induced conflicts, where fragile governance and socioeconomic contexts have exacerbated tensions and developed new stressors.7

Second, we focus on political tensions as a reason for forced migration. The most recent political conflicts have affected Afghanistan, Syria, Ethiopia, and Ukraine. It will soon be 1 year since the full-scale war affecting Ukraine and Russia first began. At the 6-month mark in August 2022, over 6 million Ukrainians had been forced to escape their war-torn region, and they now face new challenges of navigating convoluted pathways toward accessing health services.8

Although not explicitly mentioned in our systematic review, the consequences of colonialism is a third reason for forced migration that is often overlooked.9 Many countries have been impacted by colonial regimes; however, countries located within regions such as the Middle East, South-East Asia, and Africa, continue to experience legacies of colonial oppression that drive populations to migrate under duress. Such legacies include disproportionate experiences of racism, ongoing civil unrest, and continued Indigenous knowledge suppression.10

In our systematic review,4 we applied intersectionality with the intention of highlighting social variables and addressing complexities experienced by nurses working with involuntary migrant maternal women. In doing so, we examined the interplay of sex and gender with race within the experience of forced migration, which revealed that women are disproportionately marginalized and facing additional barriers in accessing health and social services. With over 50% of all forced migrant populations being women,11 sex, gender, and race are critical social variables to consider. The WHO report3 addresses these variables and outlines how maternal child health is a global health priority, as women who migrate face numerous barriers to accessing antenatal and postnatal care. As a result, these women have higher rates of poor outcomes, including limited social support and gender-based violence sequelae. As noted in the WHO report, improving access to maternal health care within the host country can help to improve the SDG of reducing global maternal mortality and the preventable deaths of newborns and children. Exploring the potential for reaching this goal entails focusing on experiences of care provision and determining whether equitable health services are being delivered.

Harnessing knowledge of people's experiences can lead to the generation and enhancement of supportive interventions. Such interventions can target populations receiving care, the providers delivering care, and the structures that support and/or delimit health care services. In our systematic review,4 we identified studies that explored experiences of nurses caring for involuntary migrant maternal women. Nursing practice is informed by national and international associations, including the International Council of Nurses, and policies that guide practice. Recognized as critical contributors among interdisciplinary and community-based health teams, nurses are well-situated within health systems to provide effective and equitable care to populations forced to migrate.12 Nurses’ experiences are grounded in the complexities faced by women forced to migrate. Our review identified what nurses know and what they need to further develop through structural commitments aimed at addressing impacts of forced migration on women's health, as well as sustainably supporting trauma- and violence-informed practice.

Our review responds to the WHO recommendations of strengthening systems and ensuring inclusion. It contributes to the knowledge of how health systems should leverage nursing knowledge and build capacity among nurses, who are one of the largest forces in health care. If we have learned anything in the past few years of the global pandemic, it is that nurses have the capacity to lead, collaborate, and advocate for addressing issues faced by under-served populations. However, we also recognize the need to structurally support nurses and involve them in this process of building capacity. Doing so holds the promise of providing nurses with time and resources to support populations marginalized by global crises, such as forced migration, and to ensure no one is left behind.

References

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3. World Health Organization. World report on the health of refugees and migrants [internet]. WHO; 2022 [cited 2022 Oct 18]. Available from: https://www.who.int/publications/i/item/9789240054462.
4. Kassam S, Butcher D, Marcellus L. Experiences of nurses caring for involuntary migrant maternal women: a qualitative systematic review. JBI Evid Synth 2022;20 (11):2609–2655.
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7. United Nations Climate Change. Conflict and climate [internet]. UNCC; 2022 [cited 2022 Oct 18]. Available from: https://unfccc.int/blog/conflict-and-climate.
8. International Organization for Migration. Ukraine crisis 2022: 6 months of response [internet]. IOM; 2022 [cited 2022 Oct 18]. Available from: https://www.iom.int/sites/g/files/tmzbdl486/files/situation_reports/file/IOM-Ukraine-Regional-Response2022-6-Month-Special-Report.pdf.
9. Fonkem A. The Refugee and migrant crisis: human tragedies as an extension of colonialism. Round Table 2020;109 (1):52–70.
10. Carpi E, Owusu P. Slavery, lived realities, and the decolonization of forced migration histories: an interview with Dr. Portia Owusu. Migr Stud 2022;10 (1):87–93.
11. United Nations High Commissioner for Refugees. Safeguarding individuals: women [internet]. UNHCR; 2018 [cited 2022 Oct 18]. Available from: http://www.unhcr.org/women.html.
12. Kassam S, Marcellus L. Creating safe relational space: public health nurses work with mothering refugee women. Public Health Nurs 2022; [Epub ahead of print.].
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