Salutogenic Approach for People with Refugee Experience
Top Contributors - Naomi O'Reilly
Despite living in the 21st Century, armed conflicts, poverty and political or religious persecution are constant and widespread around the world, causing large populations to flee from their places of origin in the quest for safety, freedom and an income to be able to live. Adding together adult individuals, families, and unaccompanied minors, the numbers of asylum seekers and refugees have increased steadily in the past years. According to the United Nations High Commissioner for Refugees (UNHCR), at the end of 2014 almost 60 million people were displaced from their places of origin and by 2015, around half of the population of forced migrants were women and girls. 8 million people, more than half of them under 18 years old, have left their countries as a result of the wars in Syria, Afghanistan and Iraq between 2011 and 2016.  This has been described as the biggest migration crisis in Europe’s history since World War II.  After facing dangers, crossing rivers, and/or walking hundreds of kilometres over different terrains, one-fifth of the asylum seekers arrive at high-income European countries, while the remaining four-fifths stay in neighbouring countries such as Lebanon, Jordan, Turkey, Cyprus, Kurdistan and Greece, where they are crowded in mass refugee camps. 
As is expected, forced migration has a massive impact on the lives of refugees and asylum seekers including depression, anxiety, post-traumatic stress disorder, sleeping problems, respiratory and digestive infections, among others.  Furthermore, individuals have struggled with finding a sense of belonging or social recognition, with developing trust and confidence , with maintaining motivation to try to adapt to their new circumstances , with financial and social disadvantages , communication difficulties due to cultural and language differences, instability and a constant fear of being deported.  However, the salutogenic approach offers ways to give refugees the tools and opportunities to overcome a difficult past and have a better present and future. In fact, the strategies may take advantage of the point that “under certain circumstances, adversity may have the potential for positive outcomes, such as increased resilience and thriving”. It is a task that requires commitment on two sides: the refugees and asylum seekers on one; and the governments and the population of the territories that offer asylum on the other one.
A Finnish study  found that the integration of migrants in social affairs relied mainly on migrants themselves, and underlined the importance of society to put effort in building relationships with migrants to make the process reciprocal and successful. Similarly in their research on the meditational role of schools in supporting psychosocial transitions among unaccompanied young refugees, Pastoor  points out that “it is not only refugee students who have to adapt to the educational and sociocultural requirements of (Norwegian) schools, but these, including the local and national education authorities, need to actively support resettling refugee students ́ adaptation to life in a new society.” Some of the proposals are for schools to promote an easier transitional process and coping strategies for young refugees , including a salutogenic arena for:
- So they can acquire knowledge, skills and understand the norms needed for participation and inclusion in their new society.
- So they can receive support, a sense of someone caring about them and their future, and motivation to achieve their goals, either from a mentor, a teacher or classmates, and;
- To promote the process of mental recovery and restoration of meaning after their traumatic experiences.
In addition, teachers may need to be willing to step a bit outside of their role and be a significant person in their student ́s lives, to guide them by “means of advice and authority, praise for achievement, understanding their experience before and after flight, help in conflict resolution, further education and career advice.” 
In a similar way, it was found that safety, calm, efficacy, connectedness and hope are essential principles for promoting resilience in any disaster.  Based on this background, at the International School of Peace on Lesbos, Greece, and connectedness, and hope, are essential principles for promoting resilience in any disaster. The plan to help minors in their transition process to feel and express more hope has included “developing mutual help, giving opportunities for older children to help younger ones, practicing conflict resolution by means of dialogue and mediation, and creating social age groups that build joint activities together, which facilitate development of behavioural patterns in the spirit of tolerance and reciprocity.” 
A research study  on refugee women at risk of social exclusion conducted over a period of 6 months, where they were submitted to a health promotion program, evaluated the effectiveness of a salutogenic plan focused on the empowerment of these women, with the acknowledgement of the health inequities that migrants experience based on variables like gender, country of origin or socioeconomic status. The objectives of the interventions in this case were to improve self- knowledge, and to identify family and community roles (comprehensibility and manageability, linking to a Sense of Coherence) and personal capacities discussing future projects (manageability and meaningfulness). Based on the increase of self-esteem and the physical quality of life, as well as on the reduction of perceived stress of the migrant women, the authors suggest that the salutogenic model of health should be applied in health promotion programs and included in policies to reduce health inequity among migrant populations. 
Other studies have focused on pregnant women , refugees in their perinatal period and giving birth in the country where they have been given refuge. Many women in these studies felt socially unrecognised and found difficulties in trusting and accessing the same services as local citizens in the healthcare system and to communicate with professionals. However, this seems to be a two-way issue according to Varjonen , who found that building trust and confidence with and from migrants seems to be a challenge for health care providers in Finland. Thus, a key to successfully integrate migrants and make them feel acknowledged and confident in the system requires “conscious efforts from the healthcare providers to facilitate social recognition and reciprocal relationships”. Simple actions like greeting and answering patients’ questions, might help women to overcome difficult experiences related to pregnancy and childbirth.  However, it is also important to support healthcare professionals by allowing them access to interpreters or tools to be able to communicate more effectively with users. Balaam  suggests some prompts for health professionals to contemplate while interacting with asylum seeker and refugees, in particular women:
- Feeling safe and trusting the caregiver is vital. Use professional interpreters. Speak slowly. Using ‘safe’ open questions such as: ‘Tell me about yourself?’ and ‘How does this compare to back home?’ Listen if she wants to talk, if she doesn’t, reassure her that this is ok. Explain how confidentiality works within the maternity services.
- Consider the woman’s social situation. Has she got the resources to access maternity care? Is she receiving the financial support she is entitled to?
- Support the woman in challenges she faces such as lobbying to avoid dispersal and to access appropriate housing.
- To local refugee organizations, support groups, specialist services such as FGM support, peer/ doula support schemes.
- Explain the organization of healthcare services. Discuss woman’s expectations of childbirth and how any cultural requests can be met.
As has been mentioned above, there are many positive outcomes of salutogenic approaches that have been studied in refugees, and these include, among others: posttraumatic growth as appreciation of life, changes in priorities concerning what is important in life, personal strength, becoming resilient through struggle, compassion for others, a sense of responsibility and personal strength, self-knowledge, and the ability to make sense of experiences to project brighter futures. 
“While every refugee’s story is different, and their anguish personal, they all share a common thread of uncommon courage, the courage not only to survive, but to persevere and rebuild their shattered lives.” Antonio Guterres, UN High Commissioner for Refugees, 2005
Although more research needs to be conducted in respect of the salutogenic model, there is plenty of evidence that proves the model to be an effective health promotion resource that increases resilience and has an affirmative effect in the perceived physical and mental state, quality of life and wellbeing of people, including refugees and asylum seekers, as individuals and even within their society. Since it is a valid, reliable, multidimensional, and applicable instrument for measuring health in different situations and cultures  , more policies for health promotion through the model should be suggested and implemented at an international level, including migration programs. The interventions should continue to be focused not on disease but in salut.
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