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Kouta C, Velonaki V S, Lazzarino R, Rousou E, Apostolara P, Dorou A, et al . Empowering the Migrant and Refugee Family's Parenting Skills: A Literature Review. JCHR 2022; 11 (4) :337-348
URL: http://jhr.ssu.ac.ir/article-1-747-en.html
Empowering the Migrant and Refugee Family's Parenting Skills: A Literature Review
Christiana Kouta * 1, Venetia Sofia Velonaki2 , Runa Lazzarino3 , Elena Rousou4 , Paraskevi Apostolara2 , AnaMaria Dorou5 , Victor Dudau6 , Athena Kalokairinou2 , Orazio Licciardello7 , Manuela Mauceri7 , Elena Nikolaidou8 , Alfonso Pezzella9 , Christina Samartzi10 , Andrea Kuckert-Wöstheinrich11 , Irena Papadopoulos12
1- Department of Nursing, Cyprus University of Technology, Limassol, Cyprus , christiana.kouta@cut.ac.cy
2- Department of Nursing, National and Kapodistrian University of Athens, Athens, Greece
3- Research Centre for Transcultural Studies in Health, Middlesex University School of Health and Education
4- Department of Nursing, Cyprus University of Technology, Limassol, Cyprus
5- Teacher, Edunet Nursing School Pictor Obedeanu 1, Craiova, Romania
6- Trainer, Edunet Organization Basarabia, Craiova, Romania
7- Scientific Director C&B Formazione Professionale, Catania, IT
8- Department Community Nursing Services, Cyprus Health Service Organisation, Limassol, Cyprus
9- Research Centre for Transcultural Studies in Health, Department of Mental Health and Social Work Middlesex University UK , London , UK
10- Doctors of the World-Greek Delegation Athens, Greece
11- Research and innovative project, St. Augustinus-Gruppe Neuss, Germany and Manager Bachelor of Science in Health Studies Fachhochschule Vorarlberg GmbH University of Applied Sciences, Dornbirn, Austria
12- Department of Transcultural Health and Nursing Head, Research Centre for Transcultural Studies in Health, School of Health and Education Middlesex University UK, London, UK
Keywords: Parenting, Migrants/Refugees, Cultural Competence
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Empowering the Migrant and Refugee Family's Parenting Skills: A Literature Review
Christiana Kouta 1* , Venetia Sofia Velonaki 2, Runa Lazzarino 3, Elena Rousou 4,
Paraskevi Apostolara 5, Anamaria Doru 6, Victor Dudau 7, Athena Kalokairinou 8,
Orazio Licciardello 9, Manuela Mauceri 10, Elena Nikolaidou 11, Alfonso Pezzella 12,
Christina Samartzi 13, Andrea Kuckert-Wöstheinrich 14, Irena Papadopoulos 15
  1. Department of Nursing, Cyprus University of Technology, Limassol, Cyprus
  2. Department of Nursing, National and Kapodistrian University of Athens, Athens, Greece
  3. Research Centre for Transcultural Studies in Health, Middlesex University, School of Health and Education, Middlesex University UK
  4. Department of Nursing, Cyprus University of Technology, Limassol, Cyprus
  5. Lecturer, Department of Nursing, Egaleo Park Campus, University of West Attica Scientific Collaborator, Department of Nursing, National and Kapodistrian University of Athens Ag. Spyridonos Str., Egaleo, 12243, Athens
  6. Teacher, Edunet Nursing School Pictor Obedeanu 1, Craiova, Romania
  7. Trainer, Edunet Organization Basarabia, Craiova, Romania
  8. Department of Nursing, National and Kapodistrian University of Athens, Athens, Greece
  9. Professor of Social Psychology Scientific Director C&B Formazione Professionale, Catania, IT
  10. Temporary Professor, Department of Medical and Surgical Sciences and Advanced Technologies, University of Catania; Piazza Università, Catania, IT
  11. Department Community Nursing Services, Cyprus Health Service Organisation, Limassol, Cyprus 
  12. Research Centre for Transcultural Studies in Health Department of Mental Health and Social Work Middlesex University UK
  13. Program Manager Doctors of the World-Greek Delegation Athens, Greece
  14. Research and innovative project, St. Augustinus-Gruppe Neuss, Germany and Manager Bachelor of Science in Health Studies Fachhochschule Vorarlberg GmbH University of Applied Sciences, Dornbirn, Austria
  15. Department of Transcultural Health and Nursing Head, Research Centre for Transcultural Studies in Health, School of Health and Education
ARTICLE INFO ABSTRACT
Original Article
Received: 07 March 2021
Accepted: 16 November 2022		 Bachground: Worldwide, more than 79.5 million people are forcibly displaced, including a significant number of migrant and refugee families with children. Migration and refugeedom affect these families in different dimensions, such as mental, physical and spiritual health. Identifying family needs and enhancing parenting skills can improve family cohesion and health, as well as smooth integration into the host country. This review is part of the Erasmus+ funded project- IENE 8 (Intercultural Education for Nurses in Europe) aiming at empowering migrant and refugee families regarding parenting skills.
Methods: This was a scoping review of literature. The IENE 8 partner countries (Cyprus, Germany, Greece, Italy, Romania, and United Kingdom) searched for peer reviewed papers, grey literature and mass media reports at international, European and national level. The time period for the search of scientific and grey literature was between2013-2018, and for mass media, it was between 2016 and 2018.
Results: 124 relevant sources were identified. They included 33 Peer reviewed papers, 47 Grey literature documents and 44 mass media reports. This revealed the importance of understanding the needs of migrant families with children.
Conclusion: It is evident from the literature that there is a need to support refugee parents to adjust their existing skill and to empower them to develop new ones. Healthcare and social services professionals have an essential role in improving the refugees' parenting skills. This can be done by developing and implementing family-centered and culturally-sensitive intervention programs.

Keywords: Parenting, Migrants/Refugees, Cultural Competence

 

Corresponding Author:
Christiana Kouta
christiana.kouta@cut.ac.cy

How to cite this paper:
Kouta Ch, Sofia Velonaki V, Lazzarino R, Rousou E, Apostolara P, Doru A, et al. Empowering the Migrant and Refugee Family's Parenting Skills: A Literature Review. J Community Health Research 2022; 11(4): 337-348.

Introduction
According to the UNHCR (1), by the end of 2019, there were about 79.5 million forcibly displaced people worldwide. 40% of them were children. This means that there are a significant number of families with children and youths in refugeedom. The challenges and threats to child health and wellbeing are related to the complex interaction of civil-political, social, economic, cultural and environmental factors (2).These refugee/migrant children-but particularly families as a whole- are affected by trauma due to their previous experiences, during and after migration (3). Vulnerable migration is commonly associated with Adverse Childhood Experiences (ACEs), such as emotional neglect, witnessing violence, loosing family members and so on (4,5). Further, children can be affected through parents or family members; parents' emotional and psychosocial condition influence children. These negative experiences are considered risk factors regarding poor mental and physical health outcomes and social and behavioral difficulties (6, 7, 8). There is little information about their specific needs (3). However, some supporting resources regarding family and parenting skills do exist. A prolonged disruption regarding the parent-child relationship may have a negative impact on both children’s and parents’ well-being. Thus, parenting during the migration process is of great importance.
Refugee and migrant families (particularly children) are exposed to many different factors affecting their needs, such as such as lack of adequate health care, education, difficulties in communication due to linguistic challenges, social exclusion and so on (9,10). While they have some common needs, they are not a homogenous group. Each family’s (with children) life narrative and personal resilience may determine their individual requirements in a unique way (11). Additionally, children’s needs are also affected by the parents’ history. For example, according to a recent systematic review (12), trauma of asylum-seeking and refugee parents indirectly affects child's well-being via mechanisms of insecure attachment, maladaptive parenting styles, limited parental and emotional availability, problematic family functioning, accumulation of family stressors, dysfunctional and intra-family communication styles, and severity of parental symptomology.
Condon et al.’s study (13) highlighted awareness of parents regarding the difficulties of maintaining optimal health for their children as well as important cultural differences. For example, parents from more established communities in UK (e.g. Pakistani and Somali) focused on barriers to their children’s outside play, exercise, and nutrition; whereas parents from Eastern Europe focused on difficulties ensuring family's financial security. Cultural values, beliefs, and attitudes of families are of importance in understanding and expressing their needs.
The traumatic events and daily challenges that these children and families encounter leads to the need for provision of culturally sensitive care and support (4). According to the recent country reports of the Committee on the Rights of Children, professionals’ education must be broad enough to include the principles of children's rights (14). Health professionals could contribute to reduce health inequities by understanding the specific needs, culture and norms of both children and their families (15). Becoming better educated in this sense, healthcare and social workers can empower migrant and refugee families in relation to parenting.
Migrant parents seem to be open to and in need of interventions focusing on parental roles (16). Such interventions have yielded promising results, such as improvement in parenting efficacy (17), parents’ sense of responsibility and the general quality of intergenerational (parent-child) relationships (18). Interventions aiming to empower migrant parents should consider the cultural aspects of both the families' and the receiving countries (18, 19).
An orientation toward the culture of the hosting country concerns a stronger parenting efficacy, better parental psychological adjustment and improved parenting skills (18). Thus, parents who feel more efficient in their role are more persistent in overcoming family difficulties. This also has positive effects on the family’s health. Lack of confidence in their parenting skills may create more difficulties in family cohesion and social inclusion. Health and social professionals can help improve parenting skills while practicing cultural competence. Cultural competence focuses on cultural knowledge and cultural sensitivity.
This background evidence led to the development of the IENE 8 project. It is an umbrella for projects based on the Papadopoulos, Tilki and Taylor's model for transcultural nursing and cultural competence. (20). The IENE 8 project was funded by the Erasmus+ program of the European Commission (Grant ID: 2018-1-CY01-KA202-046848) with 6 participating countries (Cyprus, Greece, Germany, Italy, Romania, and the United Kingdom) (21).
The IENE 8 consortium developed and pilot tested a curriculum to train health and social care workers to provide evidence-based support, knowledge and skills on parenting to refugee and migrant families.
The aim of this paper is to present the review of the literature the authors conducted to identify the migrant and refugee families’ parental support needs and.It further focused on factors for the development of a program to train health and social care workers to improve their knowledge about parenting skills the refugee families
need.
Methods
A scoping literature review was applied. The review was based on the research question: What are the most predominant areas of interest at national, European and international level concerning the issues encountered by migrant and refugee families with children related to support for parenting skills?
Selection criteria and search strategy
In order to define the keywords to be used, the consortium decided unanimously to be guided by the Papadopoulos, Tilki and Taylor (PTT) model for cultural competence (22, 23). The model is based on four key constructs: a) cultural awareness, b) cultural knowledge, c) cultural sensitivity, and d) cultural competence. It provides the values, philosophy, and educational principles, as well as a conceptual map regarding potential content and educational tools for healthcare professionals working with refugees or migrants (24). This model was enhanced with the use of some sub-categories as to focus more on refugee and migrant parenting (Table 1).
To ensure a broad scope for this review, the IENE 8 researchers searched for peer reviewed papers, grey literature and mass media reports. All these sources were scoped by each participating country with regard to the following categories: international, European and national literature. The time periods for the search were: scientific and grey literature from 2013 to 2018, while for mass media it was 2016-2018.
International literature was done in the following data bases: EBSCO (CINAHL, MEDLINE, PubMed) Google scholar, Cochrane, PsycINFO, ScienceDirect.
Grey literature was based on: A) International and European: government reports, policy statements/papers, theses. B) National: Government reports, policy statements/papers, theses/ project/white papers and evaluations/ conference proceedings/ bulletins/fact sheets.
Mass media sources were based on: A) International and European: International organizations doing media coverage (such as CNN, BBC). B) National: Local media organizations (such as newspapers, TV, national press releases from relevant organizations including national NGOs).
Each IENE 8 partner country collected and selected its national resources in their national language (EL, EN, DE, IT, RO). Then, all literature results were presented to all partners in English. The title, summary and link to the source were provided on a formulated common template. The final selection was done with the consensus of all partners (25). Ethical approval was not necessary as all the material reported was publicly available.
Results
The significance of this scoping literature was that it provided a wide range of literature and resources on parenting skills of migrant and refugee families. This is a matter of great importance in sustaining a healthy, empowered, and integrated family within a host country. It is of added value that the IENE 8 project literature review is based on the PTT theoretical model (22, 23).
Results of the scoping literature search included 124 literature items: 33 Peer reviewed papers (international: 5, European: 8, national: CY-0, DE-5, EL-1, IT-4, RO-5, UK-5); 47 Grey literature sources (international: 7, European: 12, national: CY-3, DE-7, EL-5, IT-5, RO-5, UK-3); 44 Mass media reports (international: 7, European: 8, national: CY-3, DE-1, EL-9, IT-4, RO-5, UK-7) (25) (Table 2).
International
Peer review
The international peer reviewed studies mainly focused on interventions aiming to enhance refugee and/or migrant parents’ and children’s well-being, parenting and family functioning (17, 26, 27, 28). Several studies (17, 26, 27, 29) described the challenges parents face due to their displacement, raising children in a foreign country, and their impact on children’s wellbeing. It is highlighted that social and financial support in combination with family-focused interventions could enhance refugee families’ well-being and constitute protective factors for maintaining positive parenting (17, 26, 27, 28).
Grey literature
International grey literature focused on innovative approaches to support parenting in contexts of displacement and chronic adversity. There were interventions aiming to improve parenting skills, caregiver-child relationships and family functioning and decrease the possibility of child abuse or neglect. Positive parenting, nutrition, child development, dental hygiene, injury prevention, discipline versus punishment and resettlement are some of the areas in need of enrichment. National services are important for financial support, legal assistance, health services, housing, and education for both children and parents (30, 31, 32).
Mass media
Similarly, mass media at international level highlighted the need of social and emotional support for migrant and refugee families and presented some initiatives to provide such support (33, 34). The link between parents’ mental health and harshness in parenting due to migration on the one hand, and children’s emotional difficulties and disengagement on the other hand, were also underlined (35).
European
Peer review
Peer review for European papers underlined strategies which could contribute to meeting refugee and migrant families’ needs such as health, education, protection/prevention (e.g. sexual exploitation) and reducing health inequalities (36, 37, 38). Such strategies may be either specific for this population or incorporated within a wider population plan of action. Emotional and behavioral health, cultural and linguistic issues (39, 40), economic vulnerability and malnutrition are particularly important when working with such families (37, 41).
Grey literature
Protection of children throughout the migration chain has been a priority by the European Commission. In European grey literature the, difficulties of refugee and migrant families are discussed. Migrant and refugee children may face persistent violations of their rights. The European Program for Human Rights Education for Legal Professionals (HELP), jointly with the Office of the Special Representative of the Council of Europe Secretary General on Migration and Refugees, Tomáš Boček, developed a course which explains how critical issues are addressed in the international and European legal framework. Moreover, it provides an overview of the relevant case law of the European Court of Human Rights (37). Refugee families’ social integration in Europe, access to education, healthcare and protection services and transition to adulthood are also issues of importance as presented within the European grey literature (36, 37, 41).
Mass media
The link between parenting support, family cohesion, and children’s mental wellbeing was also covered by mass media in Europe (36, 37). Some media references underlined programs or other innovative ways to reach displaced families and identify their needs (including parenting skills) (36, 37, 41). Facilitating family re:union: (8) and more investment in education were also emphasized (40).
National
Peer review
Several German studies investigated migrant and refugee families’ special difficulties mainly related to childhood illness, vaccination, mental health, housing, financial situation, learning local language and education (9, 42, 43). Abdallah-Steinkopff (9), discussed a training program on strengthening family skills, such as communication and self-care of parents.
Romanian studies underlined the evolution of migrant children in the host country, the effects of migration on children left behind, and the need to take care of them (10, 44, 45). Furthermore, Italian literature studied refugee families’ commitment, social inclusion and the impact of parenting on immigrant child’s education (46, 47, 48).
The impact of parenting on children’s mental health was also described in UK scientific papers. A prolonged disruption to the parent-child relationship may have a negative impact on both children’s and parents’ mental well-being. Thus, parenting during the migration process is of great importance (49). Parents need support during the transition of their children to a new country and educational system. The school environment may play a crucial role in the development of refugee children. This is because peers recognized the school environment as an important element linked to refugees’ social networking, seeking for psychological support and focusing on studying (50, 51).
Greek and Cypriot peer review literature on relevant issues is limited or nonexistent. According to Terzoudis et al. (52) the weaknesses of the National Health System, in combination with the increased influx of migrants and economic recession, have necessitated the involvement of non-profit organizations. In cooperation with the public health services, they contributed to more effective provision of primary health care. They aimed at providing quality health services, psychological support and social integration for migrant families as well as protecting public health.
Grey literature
Grey literature in the partner countries is in line with European and international literature. Cyprus grey literature refers to programs regarding parents’ empowerment, giving emphasis to children’s education and psychological support (53, 54). The Romanian grey literature provided an indication of the magnitude of children's issues in migration in Romania and the effects of parental migration on them (55). Similarly, Italian grey literature presented the Italian migrants' phenomenon and the efforts done in order to support their social integration (56). In addition, German grey literature discussed programs and strategies for empowering families (referring to education, health, cultural adaptation etc.) (57). English (UK) grey literature described the obstacles in parenting practices such as social isolation, powerlessness and adaptation to a new culture. Supporting parents and family cohesion can act as protective factors against mental health problems of children (58, 59). Moreover, Greek grey literature presented family needs, such as food, housing, language learning and access to health services, education, and social inclusion (60). It emphasized the importance of parental participation in child’s education and psychological support of the family, particularly children (61, 62).
Mass media
Mass media in Cyprus presented the language barriers of migrant students. Some NGO programs provide language classes and help children with homework, and support their social networking and sense of community belonging. They also help in community engagement; and resilience and active participation regarding the social, economic and cultural life (63). Mass media in Romania focused on migrant children (64), while German mass media presented basic life issues such as housing (65). Furthermore, mass media in Italy highlighted how inequities affect children and their families (66). Problematic access to health care, particularly for refugee women and children, is a core issue for Greek mass media (67, 68). Despite the progress made in addressing the health needs of babies and pregnant women, the problematic access to maternal health care has an impact on mortality rates of mothers and babies (67, 68). The UK’s media also emphasized the effectiveness of parenting in relation to children’s health; however, often psychological and/or parent’s support are often unmet (69).
Discussion
The scoping literature was based on scientific papers, grey literature and media reports at international, European and national IENE 8-partner countries.
Results indicated great heterogeneity concerning the content of international, European and national literature on issues related to migrant and refugee's parenting needs and skills. Most of the literature (grey literature and peer reviewed) referred to the support needed for parents and families while in host countries. This realization is of much importance as relevant national services (such as social, health and migration services) need to become easily accessible and user friendly. It is to help migrants to appropriately do what is needed to be done according to national policies of each country, taking into consideration refugees’ human rights. The smooth integration will eased and promote healthy interactions within their ‘new’ community. Additionally, the most commonly mentioned areas of needing support included- social, financial, health, legal assistance, education and parents’ empowerment (39, 40). However, national peer reviewed papers in this area are limited. Research and/or local reports need to be encouraged as to identify a country's specific needs which will help implement more targeted actions. They effectively support not only migrant families, but also the local community.
It is worth noting that this scoping literature reveals the impact of the family's difficulties related to children’s wellbeing, such as health and educational guidance. Accordingly, interventions and policies aiming to support parenting and family cohesion are considered of great importance, and should be a priority.
To improve parenting outcomes and reduce the impact of migration-related stressors, parenting interventions (such as hygiene, immunization, psychological support) health and social care professional and policymakers need to take into consideration the contextual and cultural challenges experienced by these families and strengthen their protective factors (70). Health professionals are often those with whom migrant and refugee children and their families have contact.Thus, they have a unique opportunity to provide relevant interventions, such as mental health first aid, training in basic child/family health promotion (e.g. personal hygiene) as well as in more complicated issues, such as sexual health for adolescents. (71).
There is no doubt that migration is a difficult challenge for these families and the hosting countries. Many hosting countries share the same political and socioeconomic context of rising anti-migration sentiment and social discontent in the time of austerity and public service cuts (11). Migration policies and the way that different countries treat migrants and refugees vary. There are, however, several similarities (8). For example, based on Romanian literature, Romania considers itself not only as a host country, but also as a country where there are several “left behind” children due to parental migration (10,43). This is a very traumatic experience for children, who may be at risk without the support of their parents during their childhood and teennage years. This is not the case for other countries. Yet, in the literature of all countries included and at the European and international level, there is a clear concern that migrant and refugee families have unmet needs and need support (35, 36, 37).
The implications for health and social care professionals and volunteers speak to the need for improving their knowledge and skills. It concerns training migrant and refugee families with parenting skills, developing programs on most needed skills (such as social, educational and health matters), advocating for culturally appropriate policies and strategies, providing easy access, and appropriate use of health services, and culturally sensitive care. As a result, a culturally safe and competent social and health care would be ensured. Despite the fact that this review includes international and European relevant literature, the main limitation of this review is that specific national literature only came from the partner countries. The relevant decision was made unanimously from IENE 8 consortium for realistic reasons. Including more literature from other countries would have been useful, but it would have required more time and access to other resources.
Conclusion
This scoping review provides an important range of literature and resources on parenting skills of migrant and refugee families. This is significant in sustaining a healthy, empowered family and local community in general. Furthermore, this review provided the evidence and content for development of the IENE8 project’s training program for migrant and refugee families.
Parents' psychological adjustment in the host country is associated with improved parenting skills. Parents, who feel more efficient in their role, are more likely to effectively deal with family's difficulties, which results in having a positive effect of family’s health. Health and social care professionals, while practicing cultural competence, can undoubtedly have a vital role in improving parenting skills. They can also develop and implement intervention programs related to parenting skills and empowerment.
Table 1. Themes and Subcategories Used in the Search Process
  1. Cultural Awareness
    1. Cultural identity
  2. Cultural Knowledge
    1. Education
    2. Beliefs and values
    3. Health needs
    4. Protective factors
  3. Cultural Sensitivity
    1. Psychological support/trauma
    2. Compassion
    3. Resilience
    4. Communication
  4. Cultural Competence
    1. Cultural assessment
    2. Parenting needs
    3. Parenting practices
    4. Equality

All the themes and sub-categories were only focused on refugee or migrant parenting.
Table 2. Results of Scoping Review
Peer-Reviewed Papers Grey Literature Sources Mass Media Reports
International/European/national
5                     8		 International/European/national
       7                      12		 International/European/national
       7                   8
CY                                             0                                              3                                               3
DE                                             5                                              7                                               1
EL                                             1                                              5                                               9
IT                                             4                                              5                                               4
RO                                             5                                              5                                               5
UK                                             5                                              3                                               7
TOTAL 33 47 44 124
Acknowledgements
Authors would like to thank funders of the project. This is part of the Erasmus+ funded project IENE 8 (Grant ID: 2018-1-CY01-KA202-046848). They also thank Mrs. Ourania Sakellaraki who helped the IENE 8 project with her experience and knowledge on migrant and refugee families.
Conflict declaration
This is part of the Erasmus+ funded project IENE 8 (Grant ID: 2018-1-CY01-KA202-046848). Authors declare no conflict of interest.
Author's contribution
All authors contributed to the review of literature nationally. Authors Kouta, Rousou, Nikolaidou contributed to the review of the literature nationally, internationally, European.



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Review: Review | Subject: General
Received: 2021/03/7 | Accepted: 2022/11/16 | Published: 2022/12/19
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