Substance (mis)use among refugees as a matter of social ecology: insights into a multi-site rapid assessment in Germany

Abstract

Background Previous research concluded that substance (mis)use is increasing among forcibly displaced populations. Nevertheless, little research has been conducted within a social ecological framework aimed at identifying and understanding the factors affecting substance (mis)use embedded in the post-migration context in high-income countries. The present study aims to develop an understanding of the links and underlying mechanisms between refugees’ social ecological determinants and substance (mis)using behavior. Methods Rapid assessments (RAs), including 108 semi-structured interviews and 10 focus group discussions with key persons from various professional, and personal backgrounds, were carried out in German urban and rural areas. The RA approach of interviewing key persons and not solely refugees that (mis)use substances allowed us to gather multi-perspective knowledge on this sensitive topic. Qualitative content analysis was applied, aiming at identifying determinants of substance (mis)use embedded in the post-migration context of refugees and understanding the underlying mechanisms. Results One main result of the data suggests that the link between refugees’ countries of origin and their post-migration substance (mis)use is not as direct as often assumed. It is observed that refugees’ prospects and opportunities in receiving countries (e.g., work permits) undermine this commonly reproduced link. Further determinants are related to living conditions in German refugee shelters and social relations with peers and families. The influence of refugees’ living conditions can be summarized as potentially increasing substance availability and distress, whereas family separation produces a loss of control and responsibility, increasing the risk for substance (mis)use. Peers’ influence on substance (mis)use was reported to reflect a search for a sense of belonging. Conclusions Given that refugees who (mis)use substances have limited to no control over the factors identified in our study to be associated with substance (mis)use, common treatment and prevention approaches are challenged. Furthermore, we recommend aiming for a holistic comprehension of refugees’ substance (mis)use by expanding the focus beyond individuals to the social ecological context in any attempt, including prevention, treatment, research, and policy.

Good practice in reaching and treating refugees in addiction care in Germany – a Delphi study

“…Since modifying socio-political structures that contribute to addiction require political change and commitment at a higher level, it remains to be seen how individual addiction care facilities can make an impact. Nevertheless, building on previous studies [ 10 , 48 ] our current study contributes to wider policymaking by not only addressing the importance of the socio-ecological model of prevention which is beyond the conventional model of prevention focused on individual behavior, but also by identifying it as one of concrete good practice strategies to be implemented.…”

“…social welfare benefits or support provided by refugee aid organizations). Nevertheless, refugees in the post-migration setting are still subject to various socio-economic risk factors for substance (mis)use and addiction ranging from unemployment and poverty, marginalization and discrimination [ 8 , 9 ], poor living conditions, lack of entitlement to work and family status [ 10 ], to coping with traumatic experiences both in the country of origin, as well as the host country [ 11 , 12 ].…”

Good Practice in Reaching and Treating Refugees in Addiction Care in Germany – A Delphi Study

“…Post-migration stressors, especially in the context of the living situation of refugees, but also legal status concerning prospects and possibilities of e.g. work and meaningful activities, facilitate addiction [10,47] . To enable successful treatment, structural factors embedded in refugees' social ecology, such as formal access to the job market, family reuni cation, and residence prospects, have to be addressed [10,48] .…”

“…work and meaningful activities, facilitate addiction [10,47] . To enable successful treatment, structural factors embedded in refugees' social ecology, such as formal access to the job market, family reuni cation, and residence prospects, have to be addressed [10,48] . Socio-political solutions to combat marginalisation are needed.…”

“…Salas-Wright & Vaughn [7] found evidence that refugees in the US are less likely to meet substance use disorder criteria than non-refugees. However, refugees are subject to risk factors for substance (mis)use and addiction ranging from socio-economic issues such as unemployment and poverty, marginalization and discrimination [8,9], poor living conditions, lack of entitlement to work and family status [10] , to coping with traumatic experiences both in the country of origin, as well as the host country [11,12].…”