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Introduction
Worldwide, the refugee population is at its highest since World War II (The U.N. Refugee Agency, 2019). More than two-thirds of refugees (67%) are from the Middle East, South America, and Africa (United Nations Higher Commissionaire for Refugees [UNHCR], 2020). Women reportedly constitute half of the world's refugee population (The U.N. Refugee Agency, 2019; UNHCR-women, 2021) and are regarded as one of the world’s most vulnerable groups and the world's biggest minority. They are predominantly from patriarchal societies (UNHCR, 2017).
Women are more likely to experience an array of unique gender directed traumatic events throughout their life span (Olff, 2017). In the case of refugee women, their experience of traumatic events throughout the migration journey have been found to impact their psychological wellbeing post-resettlement (Schweitzer et al., 2018).
1. Review of literature
In past decades, attempts to clarify what constitutes a potentially traumatic event and its impact on individuals have provided a lexicon of interpretations that often create confusion (Courtois et al., 2009; McCormack & Thomson, 2017). The American Psychiatric Association (2013) defines trauma as actual or threatened death, serious injury, or sexual violence. Many studies differentiate between single incidence trauma, cumulative non-interpersonal traumas, cumulative interpersonal traumas or complex traumas (Kira, 2001; McCormack et al., 2021). A variety of reactions have been reported following exposure to traumatic events indicating that individual experiences fall on a spectrum from none to severe (Briere, Agee & Dietrich, 2016; Weathers & Keane, 2007); and the adaptation process may either result in assimilation or accommodating negative and positive posttrauma changes (Joseph & Linley, 2005).
The psychopathological impacts of gender-based trauma in women refugees include but are not limited to posttraumatic stress disorder (Vallejo-Martín et al., 2021), depression and anxiety (Hossain et al., 2021). However, Joseph and Linley's (2005) organismic valuing process theory (OVP) defines positive changes after exposure to traumatic events as growth out of adversity. This is seen as changes in appreciation of self, relations with others, and changes in worldview. Perceived or real posttrauma psychological wellbeing encompasses self-acceptance, environmental mastery, personal growth, autonomy, positive relations with others, and a purpose in life (Ryff, 1989; Ryff & Singer, 1996). Therefore, an overview of literature assists in understanding refugee women's posttrauma psychological wellbeing.
A scoping review will better identify, map and synthesise the available evidence and pinpoint knowledge gaps while capturing the breadth of literature that reports on the journey of refugee women, potentially traumatic experiences, and their impact on the posttrauma psychological wellbeing of women refugees. The purpose of the review is to provide an overview of literature rather than informing clinical guidelines or practices (Peters et al., 2020) by answering the research question:
to synthesise the literature concerning gender-specific trauma and psychological wellbeing changes in refugee women in the aftermath of the refugee journey and provide an opportunity to identify key concepts, gaps in the research, and types and sources of evidence (Arksey & O'Malley 2005).
2. Methods
2.1 Study design
Grant and Booth (2009) define Scoping review as a "preliminary assessment of potential size and scope of available research literature. They aim to identify the nature and extent of research evidence (usually including ongoing research)." A scoping review seeks a more inclusive breadth of commentary than traditional systematic reviews with correspondingly a more expansive inclusion criteria to identify knowledge gaps, scope a body of literature, clarify concepts, or investigate research conduct. This scoping review intends to report the breadth of research and identify knowledge gaps to update research areas. Therefore, the authors will utilise the PRISMA extension for Scoping Reviews (PRISMA-ScR) tool and seek advice from The Joanna Briggs Institute Manual for Evidence Synthesis (Peters et al., 2020). The current scoping review intends to present a descriptive report of the reviewed material deprived of analytically assessing individual studies or integrating evidence from different research (Brien et al., 2010); therefore, no bias is involved. Therefore, the quality assessment and critical appraisal of the risk of biases are not required in the current scoping review (Peters et al., 2020).
2.2 Data collection instruments
The authors screened the electronic databases based on the topic, and the most applicable databases with the most coverage were underscored as PsycInfo, PubMed, Embase, SCOPUS, and CINAHL.
A broad list of synonyms related to each of the three constructs (gender-specific traumatic events, psychological wellbeing, women refugees) was prepared based on titles, abstracts, and index terms of relevant studies (see Table 1).
A Boolean search with truncations and wildcards will be used for the scoping review as follows:
Population (Women Refugees): (Female or Girl or Wom?n or Spouse* or Wife or Wives or Widow* or Mother*) AND (Refug* or Forced migrat* or Humanitarian migrat*) AND Concept (Gender-specific traumatic events): (Trauma* or Psychological distress or Mental ill* or Mental disorder* or Mental disease* or Posttraumatic stress disorder or Genocide or Ethnic cleansing or Ethnic minority or Racism or Exile or Tortur* or Abus* or Violen* or Combat Experience* or War* or Armed conflict or Surviv* or Victim* or Assault or Harassment or Rap* or Human trafficking or Negl* or Natural disaster* or Forced marriage or Persecut* or Loss or Death or Betray*) AND Context (Psychological wellbeing): (Psychological wellbeing or Autonomy or Environmental mastery or Personal growth or Relation* with other* or Positive relation* or Purpose in life or Self-acceptance or Posttrauma* growth or Growth out of adversity or Adversarial growth or Thriving or Meaning-mak*) - Limiters: Years 1992 -2022; human studies only
According to the PRISMA flow diagram, the additional hand-searched and suggested studies will be screened for inclusion. Therefore, the first Author will perform the final manual reference screening on the included full-text papers to identify any probable missing articles. Likewise, the Author will search Open Grey and Google Scholar for acceptable grey literature. Lastly, in case of requiring more information, the Author will seek the professional recommendations of experts and associations.
2.3 Requirements (inclusion and exclusion criteria)
2.3.1 Inclusion
2.3.1.1 Participants
This scoping review will include studies inclusive to refugees with the background of forced or involuntary displacement from the unique perspective of women refugees.
2.3.1.2 Concept
Refugees' trauma narratives often describe horrific events directed at stateless individuals in vulnerable situations (McCormack & Tapp, 2019; McCormack & Strezov, 2020), often reported as cumulative and complex traumas. In addition, gender often plays a part in the type of traumatic threat (Olff, 2017). Women endure and report more frequent interpersonal incidents and sexual assaults than men (Gavranidou & Rosner, 2003, p.132), and different types of traumas experienced by women generate different reactions and are most likely to give rise to ongoing psychological complications (Bowers, 2009, p.14). Gender-specific traumatic events refer to gender-specific types of distressing events. As a result, the current scoping review seeks the type and severity of traumatic events experienced by women refugees pre, during and post-migration.
2.3.1.3 Context
Diverse cultures refer to psychological wellbeing differently. Refugee women's studies need to be considered from within their cultural context to understand the impact of the migration journey, including gender-based traumatic events, and how women respond psychologically to these events. For many refugee women, there is no personal choice as many come from minority groups and patriarchal systems (United Nations High Commissioner for Refugees [UNHCR], 2017). Therefore, they are likely to be exposed to potentially traumatic events from a position of powerlessness and vulnerability (United Nations High Commissioner for Refugees [UNHCR], 2017). However, Hutchinson and Dorsett (2012) note that refugee women demonstrate resilience through adapting and coping post-resettlement despite facing tremendous challenges. Resiliency is the ability to resist negative change and return to the level of the psychological functioning present before traumatic events (Bonanno, 2004) rather than posttrauma thriving inclusive of behaviours and thought patterns not necessarily present prior to exposure to trauma (Turner & Cox, 2004).
This scoping review will include studies on posttrauma psychological wellbeing, as opposed to subjective wellbeing, involving changes in self-acceptance, environmental mastery, personal growth, autonomy, positive relations with others, and a purpose in life, during the post-resettlement stage. This scoping review will include studies that holistically refer to growth or positive posttrauma changes rather than resilience and psychopathology from a non-Western perspective.
2.3.1.4 Evidence sources/types of studies
Quantitative, qualitative, and mixed methods studies published in peer-reviewed journals about gender-specific traumatic events experienced by women refugees will be counted for inclusion. This scoping review will include primary studies in the past three decades, as posttrauma growth or positive changes after adversities began appearing in the trauma literature during the early-1990s; however, other systematic and literature reviews may conceivably be utilised to explore reference lists manually. Furthermore, the Author will search Open Grey and Google Scholar for acceptable grey literature. As it investigates the context of women refugees, this scoping review will include the government and NGO's statements, annual reports, fact sheets (e.g., Health and welfare department; U.N. Women), conference proceedings, theses, and dissertations with relevant data in various forms (e.g., pdf and presentation slides). Lastly, the reviewers will not apply any initial filters except limited to 'human studies' and 'years 1992 -2022' in the searching strategy, but as a note, the reviewers will exclude any studies without accessible English translation because of limited resources for translation.
2.3.2 Exclusion
In the current scoping review, the reviewers will exclude studies if they solely focus on voluntary migration or refugee-like status inclusive of asylum seekers, stateless people, and displaced individuals, even though the study includes traumatic events and posttrauma psychological wellbeing. Moreover, the reviewers will exclude studies if they do not singly report on the impacts of gender-specific traumatic events on posttrauma psychological wellbeing and its dimensions. Ultimately, the reviewers will exclude studies if they do not separately analyse and report findings about women refugees.
2.4 Procedures
2.4.1 Screening process/ study selection
The Authors use Covidence to export articles from searching databases, checking references, and the recommendations. After duplicates are removed automatically, the studies will move to the titles and abstracts screening section in Covidence. In this level, two reviewers will screen the title and abstract of each study separately. As a pilot screening, the reviewers will screen 25 randomly chosen studies for quality and consistency in screening to discuss conflicts and clarify any inclusion or exclusion criteria accordingly. The research team will develop a title and abstract relevance screening table (see Table 2) to provide a clear screening outline.
It assists in preventing the waste of resources in acquiring studies that will not take on the minimum inclusion criteria (e.g., the reviewers will include the presented potential studies without available abstract for subsequent review of the full-text screening). The actual title and abstract reviewing process will begin after the reviewers' agreement is greater than 75% over the screening process criteria. In the next level, the included title and abstracts will move to the full-text screening section in Covidence.
The reviewers will do the full-text screening, and another author will randomly select articles undergoing review to confirm revision based on the utilised inclusion and exclusion criteria. While the accepted studies will be extracted from Covidence for the scoping review analysis, a comprehensive table will be documented to justify the excluded articles after the full-text screening process in Covidence. The reviewers will contact each other to resolve any raised conflicts through the screening process, and this process is vital to ensure consistency between the reviewers with the research question and purpose. As a final note, two professional reviewers will be accessible to evaluate and revise any unresolved conflicts in the screening process.
2.4.2 Data extraction
The quality assurance will occur while the authors will individually conduct a pilot data extraction from 5 studies based on the customised template (see Table 3).
After total agreement over the template and potentially revised template based on the pilot data extraction, each reviewer will separately extract the final data from the included studies in Covidence. The authors will stay in contact to deem any inconsistencies to attain a consensus throughout the process.
The authors will extract data based on the subsequent factors:
author, year, title
study type
country of origin
country of study
study aims, objectives or purpose
population (including age and sample size)
method
measures
gender-specific traumatic events- trauma (including trauma types and period)
outcome(s)- posttrauma psychological wellbeing
results- quantitative or qualitative or mixed-methods
Recommendations for future studies
3. Results and discussion
The current scoping review aims to synthesise the literature concerning gender-specific trauma and posttrauma psychological wellbeing in refugee women to identify key concepts, gaps in the research, and types and sources of evidence to inform practice using NVivo version 11. NVivo, in a mixed-method review, provides an organised and structured approach to offer thematical analysis. Therefore, relevant qualitative, quantitative, and mixed methods data around the topic will be extracted, thematically coded, and reported in the full scoping review as a descriptive narrative. The report includes gender-specific traumatic events pre-, during-, and post-migration and their impact on women refugees' posttrauma psychological wellbeing post-resettlement. Findings might be reported in tables, figures, and diagrams.
