Challenges in supporting the struggle for sense of control : identifying rehabilitation needs of forced resettled women from the Middle East diaspora living with chronic pain

Women who are forced to resettle from the Middle East have experienced the cumulative trauma of war, threats, flight and adjusting to a new life in the host country. Many of these women develop musculoskeletal pain. Considering the ongoing conflicts worldwide, the high number of forced resettled people in Sweden will persist. Primary healthcare faces new challenges in addressing the needs of patients who live with the physical and mental consequences of war and resettlement.

The overall aim of this thesis was to illuminate the perceived causes of musculoskeletal pain and suggestions for rehabilitation measures to be able to support identification of needs of Middle East diaspora women.

In two initial studies, women from Iraq (study I) and professionals within primary healthcare (study II) were approached with interviews and questionnaires. The goals were to explore the perceived causes and suggested measures related to chronic pain in Middle East diaspora women. The results from these two studies, together with a review of existing research, formed the basis for the development of an interview guide, which was validated by cognitive interviews and a pilot test (study III). The guide was further evaluated by healthcare professionals in an intervention study (study IV).

The perception among both the women and the healthcare representatives was that the pain is complex and is related to experienced traumas and difficulties, but the women (study I), also considered the pain a physical symptom calling for a physical treatment. A physician could provide a trustworthy diagnosis and effective treatment with the main purpose of regaining a sense of control of the life situation, by controlling the consequences of pain in the body, for everyday life, and for future plans (study I). Meeting with Swedish healthcare was perceived as complicated from the perspectives of both the women (study I) and the healthcare professionals (study II). Although being able to identify the causes of pain related to traumas and difficulties, healthcare professionals found directing measures to identified causes of pain difficult (study II). The complexity of meeting patients who have experienced cumulative traumas in the form of chronic musculoskeletal pain indicates a need for increased support for healthcare professionals. For this purpose, an interview guide was developed (study III), from a person-centered point of departure, acknowledging physical, psychological, social, and spiritual components. An evaluation of the guide (study IV), indicated that the questions were perceived as useful and relevant but also associated with challenges, such as a perceived lack of competence to handle situations and reactions caused by asking about the women’s experienced traumas, as well as organizational factors such as time constraints and a lack of collaboration.

The results indicate a need for organizational changes with increased collaboration between healthcare and authorities within society. Such changes should be combined with increased knowledge and changes to routines within primary healthcare to avoid putting the patient at a disadvantage, but instead support her struggle for a sense of control over her situation. The results also indicate a need to include intersectionality and a person-centered approach in the education of healthcare professionals.

List of scientific papers

I. Zander V, Müllersdorf M, Christensson K, Eriksson H. Struggling for sense of control: Everyday life with chronic pain for women of the Iraqi diaspora in Sweden. Scand J Public Health. 2013;41(8):799-807.
https://doi.org/10.1177/1403494813492033

II. Zander V, Eriksson H, Christensson K, Müllersdorf M. Rehabilitation of women from the Middle East living with chronic pain: perceptions from health care professionals. Health Care Women Int. 2014.
https://doi.org/10.1080/07399332.2014.989439

III. Zander V, Eriksson H, Christensson K, Müllersdorf M. Development of an interview guide identifying the rehabilitation needs of women from the Middle East living with chronic pain. Int J Environ Res Public Health. 2015;12:12043-12056.
https://doi.org/10.3390/ijerph121012043

IV. Zander V. Identification of rehabilitation needs of women from the Middle East living with chronic pain : evaluation of an interview guide from the perspective of healthcare professionals. [Manuscript]