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Sudan, located in Northeast Africa, is a culturally diverse country with a population of over 44 million people and borders several countries including Egypt, Libya, and South Sudan (Sikainga et al., 2024). It has a rich history shaped by its ethnic diversity, and its capital, Khartoum, is notably where the Blue and White Nile rivers meet (Sikainga et al., 2024). Arabic and English are the most common languages spoken here (Sikainga et al., 2024).

Sikainga, A. A., Spaulding, J. L., Collins, R. O., Al-Shahi, A. S., Sabr, M. D., Economic Intelligence Unit. (2024). Sudan. Encyclopedia Britannica. https://www.britannica.com/place/Sudan

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In Sudan, dance is deeply influenced by traditional lifestyles, particularly among the Dinka people, who are primarily cattle herders. Men often create songs and perform dances centered around their oxen, reflecting their cultural connection to cattle and their role in daily life.

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Culture Corner: Dinka Tribal Dance In South Sudan

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Karar et al. (2017). Plant parts used to prepare traditional medicines

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Sudan's traditional medicine is a rich blend of Islamic, Arabic, and African practices, widely used in rural and poor communities as a primary healthcare resource (Karar et al, 2017). It relies heavily on medicinal plants to treat a variety of ailments, including microbial infections, gastrointestinal issues, malaria, diabetes, and respiratory disorders (Karar et al, 2017). Commonly used plant parts include leaves, roots, bark, seeds, and fruits (Karar et al, 2017). These parts are prepared in various forms, such as decoctions, infusions, powders, and poultices (Karar et al, 2017). Traditional medicine in Sudan is deeply rooted in cultural heritage and often aligns with modern pharmacological findings, though further research is needed to fully validate its efficacy and safety.

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Karar, M. G. E., & Kuhnert, N. (2017). Herbal Drugs from Sudan: Traditional Uses and Phytoconstituents. Pharmacogn Rev, 11(22), 83-103. https://doi: 10.4103/phrev.phrev_15_15

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In Sudan, the predominant religion is Islam, with the majority of the population adhering to Sunni Islam and participating in various religious brotherhoods, such as the Qādiriyyah, Khatmiyyah, and Mahdiyyah (Sikainga et al., 2024). Christianity has a historical presence but is now practiced by a small percentage of the population, primarily in the Nuba Mountains, with efforts from European missionaries contributing to its presence (Sikainga et al., 2024). Traditional animist religions are also practiced by a minority, particularly in the Nuba Mountains, where beliefs involve a supreme deity and spiritual intermediaries (Sikainga et al., 2024).

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Sikainga, A. A.,Spaulding, J. L., Collins, R. O., Al-Shahi, A. S., Sabr, M. D., Economic Intelligence Unit. (2024). Sudan. Encyclopedia Britannica. https://www.britannica.com/place/Sudan

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EFFECT OF SOCIAL DETERMINANTS ON SUDANESE REFUGEES 

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EFFECT OF SOCIAL DETERMINANTS ON SUDANESE REFUGEES 

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Social inclusion and non-discrimination are crucial determinants of health for Sudanese refugees resettling in Australia (WHO, nd). Murray's study (2010) shows that participants initially felt welcomed in Australia, benefiting from positive influences like social connections that helped their adaptation and acculturation process. However, they also faced challenges, such as issues with resettlement programs and experiences of discrimination (Murray, 2010). This can impact the psychological well-being and mental health of refugees (Murray,2010; Milner, 2010). The stress may manifest in various forms, such as anxiety, depression, or a sense of isolation (Milner, 2010).

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Milner K., & Khawaja NG. Sudanese Refugees in Australia: The Impact of Acculturation Stress. Journal of Pacific Rim Psychology. 2010;4(1):19-29. https://doi:10.1375/prp.4.1.19

Murray KE. Sudanese Perspectives on Resettlement in Australia. Journal of Pacific Rim Psychology. 2010;4(1):30-43. https://doi:10.1375/prp.4.1.30

World Health Organization. Social determinants of Health. https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1

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I initially believed that health care was a universal practice, equally applicable to all. However, I have since recognized that cultural considerations are essential, particularly when working with people from refugee backgrounds. Having analyzed the importance of recognizing the impact of refugee-like experiences on health from Domain 1, I now understand that traumatic events, post-traumatic stress disorder, and the unique challenges of resettlement significantly influence health outcomes and care needs. If I do not consider this consideration, there might be a chance that my patient will not receive the optimal treatment. I plan to apply this knowledge by providing trauma-informed care, incorporating person-centered communication, and ensuring a safe clinical environment. This approach will help me modify my care to meet the specific needs of refugees, ultimately improving their health outcomes.

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Refugees from Sudan often arrive in Australia with a range of health issues due to prolonged exposure to conflict, displacement, and limited access to healthcare (Michael et al., 2013). These experiences can affect individuals' health, mental health, understanding of health issues, treatment adherence, and access to care (Migrant and Refugee Health Partnership, 2019). One common health concern is mental health disorders, particularly post-traumatic stress disorder (PTSD). According to the Australian Refugee Health Practice Guide, to manage persistent psychological and psychosomatic symptoms, it is recommended to build a trusting relationship and allow adequate time for patients to discuss their experiences, as well as offer both non-pharmacological and pharmacological treatments, including referrals to specialized services for survivors of trauma.

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Australian Refugee Health Practice Guide. (n.d). Management of psychological effects of torture or other traumatic events.

https://refugeehealthguide.org.au/psychological-effects-of-torture-trauma/

Michael, S., Anna, C. H., Mahmood, M. A., Moore, V. (2013). Separation from family and its impact on the mental health of Sudanese refugees in Australia: a qualitative study. Australian and New Zealand Journal of Public Health,37(4),

https://doi.org/10.1111/1753-6405.12088.

Migrant and Refugee Health Partnership. (2019). Culturally Responsive Clinical Practice: Working with People from Migrant and Refugee Backgrounds: Competency Standards Framework for Clinicians. Culture Diverse Health. https://culturaldiversityhealth.org.au/competency-standards/about-the-standards/

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Written by on . Posted in Approach to patient care

Overview

People from refugee backgrounds, including people seeking asylum, vary in their readiness to disclose previous trauma, and much depends on context, and the empathy, warmth and skill of the clinician. Talking about past experiences can may be psychologically beneficial in the right circumstances. However, the knowledge that the patient may have endured certain experiences due to their country of origin or transit is generally sufficient for you to orient your care.

Common psychological effects of torture or other traumatic events include a range of symptoms and behavioural effects. Some patients may suffer a mental health disorder, the most frequent being post-traumatic stress disorder, depressive disorder and anxiety disorders. ¹

Commonly occurring effects that may disrupt daily life include:

intrusive and recurrent memories of traumatic events, flashbacks, nightmares, avoidance of reminders of traumatic events, detachment from others, numbing, hypervigilance, exaggerated startle response

depression and grief

guilt and shame

distrust and anger, sensitivity to justice and injustice

difficulties with memory and concentration

interpersonal difficulties, including isolation

impact on physical health from factors such as poor appetite and sleep issues.

Children and adolescents experience similar psychological reactions to trauma as adults, however, the clinical presentation reflects their age and development. Presentations may include behavioural issues, sleep concerns, attention difficulties, low self-esteem, friendship difficulties, enuresis, and developmental/education concerns, as well as symptoms of anxiety, depression and post-traumatic stress disorder (PTSD). Parent mental illness affects child wellbeing, and addressing both parent and child mental health is important.

Approach to care

More detail of someone's experiences is often required to understand and manage the causes of persistent psychological and psychosomatic symptoms. Details of past traumatic experiences are best elicited if:

a trusting relationship has developed

there is adequate time for the patient to respond

the patient feels comfortable with the professional interpreter, and their confidentiality has been assured.

Some useful questions include:

'Some people have had bad things happen to themselves and their families. Has anything happened to you or your family that could be affecting your health or the way you are feeling now?'

'When did the problem start? You do not need to tell me all the details, but can you tell me something of what was happening at the time?'

'Do you have any other problems that we have not talked about that I can help you with today?'

Responding to a disclosure of torture or trauma

Validate your patient's reaction by acknowledging their experience (e.g. 'That's a terrible thing you have been through.').

Remind your patient that their reaction is a normal response to their circumstances, as often survivors blame themselves and see their reactions as abnormal or weak.

Avoid false assurances. Nevertheless, indicate that with time and appropriate support, improvement can be achieved.

Expect that the patient who has disclosed a traumatic event may be unwilling to talk about it in subsequent consultations. Rather than pushing them to do so, talk about other things that may be currently troubling them.

Expect inconsistencies and/or fragmented accounts in the patient's retelling of their trauma history.

Explain to the patient how you are able to assist them.

Management

There is a consensus among practitioners experienced in caring for people from refugee backgrounds that optimum treatment of psychological problems involves non-pharmacological approaches either in addition to medication or as the primary treatment modality. ²

Medication may be required to manage symptoms that are sufficiently severe that they interfere with the patient's functioning.

When a patient presents with persistent symptoms believed to be related to trauma, consider referral to a psychiatrist, psychologist or the specialist service for survivors of trauma and torture in your state or territory

Each state and territory has a specialised torture and trauma counselling service for people from refugee backgrounds. These free and confidential services are non-denominational, politically neutral and non-aligned. For more information regarding specialist services for survivors of torture and trauma see Forum of Australian Services for Survivors of Torture and Trauma (FASSTT).

In some areas, counselling services through community health centres or mental health nurses may be available to assist the client and facilitate other referrals. See State and territory referrals.

Explain to the patient your diagnosis or opinion of their condition, and the likely causes of the condition. The patient's explanation for their problem is useful to enquire about.

Be aware of the stigma attached to psychological conditions.

Outline treatment options so that the patient is able to make a choice. Be specific about what the alternatives are.

Arrange emergency psychiatric management in the usual way for patients at risk of serious mental health deterioration, suicide, and violence to others or self-harm.

Ensure that professional interpreting services are available if required.

Considerations

Somatic complaints

It is not uncommon for patients from refugee backgrounds to somatise their psychological stress. Consider the following:

Take presenting concerns seriously, and conduct appropriate examinations and investigations as needed. People from refugee backgrounds may have received inadequate health care and usually need explanations of investigations. See Approach to consultation and management.

It may be helpful to discuss the relationship between the body and mind.

If somatic symptoms persist and a link between such symptoms and emotional distress is made, consider a referral for counselling and support.

Consider the trauma basis for symptoms and refer accordingly. Specialist services for survivors of trauma and torture are located in each state and territory. See State and territory referrals or .

Mental health of people seeking asylum
The psychological implications of uncertain migration status
People seeking asylum face particular stresses owing to their uncertain migration status, limitations on their access to benefits and, in some cases, their experiences in immigration detention centres. ³ Research indicates that people seeking asylum are vulnerable to being retraumatised and have particularly poor physical and mental health. ⁴

Issues faced by people seeking asylum include:

a limited capacity to plan for their future and develop stable social connections

detention centre experiences that may compound a sense of injustice and loss of control, and serve as reminders of persecutory practices in countries of origin

perceptions that they are not being believed by the Australian Government, or that they are being treated in a discriminatory fashion

feelings of powerlessness resulting from the limited control over their lives

exposure to unsympathetic or hostile attitudes in the media and the wider community

no or uncertain access to family reunion provisions. See Asylum seekers.

anxiety about the safety of loved ones still in dangerous circumstances overseas

limitations on their access to the resources required for positive mental health (e.g. English language tuition, secure housing)

stressors on families, including concern for wellbeing of children

the need to overcome barriers to participation in the Protection Visa application process, such as poor mental health and effects of torture or other traumatic events.

See Asylum seekers, State and territory referrals.

Other resources

References

1. Turrini G, Purgato M, Ballette F, Nosè M, Ostuzzi G, Barbui C. Common mental disorders in asylum seekers and refugees: umbrella review of prevalence and intervention studies. International journal of mental health systems. 2017;11(1):51.

2. Coffey GJ, Kaplan I, Sampson RC, Tucci MM. The meaning and mental health consequences of long-term immigration detention for people seeking asylum. Social science & medicine. 2010;70(12):2070-2079.

3. Silove D, Steel Z, Mollica RF. Detention of asylum seekers: assault on health, human rights, and social development. The Lancet. 2001;357(9266):1436-1437.

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Management of psychological effects of torture or other traumatic events

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Written by on . Posted in Approach to patient care People from refugee backgrounds, including people seeking asylum, vary in their readiness to disclose previous trauma, and much depends on context, and the empathy, warmth and skill of the clinician. Talking about past experiences can may be psychologically beneficial in the right circumstances.