Addressing Occupational Deprivation in Refugees: A Scoping Review

In 2015, over 21 million refugees were displaced worldwide. A significant issue faced by this population is occupational deprivation – being deprived of engagement in meaningful activities. Despite this being a global problem, information on interventions that address occupational deprivation has not been synthesized. To bridge this gap, we conducted a scoping review to examine interventions that can be used when working with refugees who face this issue. For our methods, we used a five-step framework and reviewed interventions using the following databases: PubMed, CINAHL, PsycINFO, and Google Scholar. Initial searches yielded 191 studies, 7 of which were retained. Community-based rehabilitation, familiar activities from native countries, projective techniques allowing for emotional expression, mastery of practical skills allowing for navigation in new environments

Resettlement is the transfer of refugees from an asylum country to another nation that has agreed to admit them and ultimately grant them permanent settlement (United Nations High Commissioner for Refugees, 2017). The resettlement process varies from country to country, but it often involves strict vetting and satisfying several legal criteria. After being resettled, refugees still encounter the need for adaptation to different social and environmental demands, while at the same time, attempting to retain cultural traditions of their native countries (Kolb, 2009). Although refugees physically relocate into new communities, many still face a variety of issues. One significant issue is occupational deprivation.
The concept of occupational deprivation involves disparities in the opportunity for people to participate in activities that hold personal, social and cultural meaning (Whiteford, 2000). The underlying premise is that people are inherently occupational, which implies that being deprived of occupation, or engagement in day-to-day, meaningful activities, is detrimental to their health (Law et al., 1998). Occupational therapy is one profession that can address this issue.
Occupational therapy is a global healthcare field that helps people across the lifespan participate in things that they want and need to do through the therapeutic use of everyday activities, or occupations (American Occupational Therapy Association, 2016). Practitioners play an important role in improving the health of individuals, groups, and populations through the development of occupational therapy interventions and through advocacy to address issues with participation and the multiple determinants of health (Braveman, 2016). Although it is within the scope of occupational therapy to address occupational deprivation, to our knowledge, no review has examined occupational deprivation in refugees. To bridge this gap in the literature, we conducted a scoping review to examine evidence on displaced populations and identify/map interventions that can be used when working with refugees who face occupational deprivation.

Methods
Scoping reviews aim to map key concepts underpinning a research area and the main types of evidence available on a topic (Arksey and O'Malley, 2005). They are appropriate to conduct as a stand-alone method of inquiry, especially when an area has not been reviewed comprehensively before (Mays et al., 2001). For our study, we adopted Arksey and O'Malley's framework (2005) to examine evidence on interventions for refugees. This framework includes the following five stages for conducting a scoping review: 1) identifying the research question, 2) identifying relevant studies, 3) study selection, 4) charting the data, and 5) collating, summarizing, and reporting the results.

Stage 1: Identifying the research question
In contrast to systematic reviews, which typically focus on a specific, well-defined question, scoping reviews tend to address broader questions, where many different study designs might be applicable to include in the review (Arksey and O'Malley, 2005). The question directing our scoping review was: Which interventions can be used when working with refugees who face occupational deprivation? "Interventions" was operationalized as therapeutic or rehabilitative techniques that could be used in healthcare practice across different settings. Occupational deprivation was our outcome measure. Understanding the nature and causes of occupational deprivation was also important to explore possible prevention strategies as well as to recognize the beginning signs of this issue.

Stage 2: Identifying relevant studies
To identify studies suitable for answering our research question, we applied a strategy that involved searching for evidence via electronic databases. A search for relevant articles published after 1995 was conducted using PubMed, CINAHL, PsycINFO, and Google Scholar. The search terms that we used were: occupational therapy, rehabilitation, refugee(s), refugee population, and occupational deprivation. These terms were carried out alone and in combinations using the Boolean operators "AND" and "OR." We aimed to locate studies that included/discussed interventions that could be used when working with refugees who face occupational deprivation.

Stage 3: Study selection
The study selection process is shown in Figure 1 using the Preferred Reported Items in Systematic Reviews and Metaanalysis (PRISMA) flowchart (Moher, 2009). This flow chart illustrates how studies were identified, screened, made eligible, and included in the review.
To answer the question of our scoping review and ensure consistency in selecting studies, we developed inclusion and exclusion criteria. Inclusion criteria were: 1) peer-reviewed research articles found in academic journals that were published between 1996 and 2016, 2) articles that were written in the English language, and 3) all articles (quantitative, qualitative, or mixed methods) that discussed interventions for refugee populations or people from refugee backgrounds across the lifespan. Exclusion criteria were: 1) articles that were not peer-reviewed or found in academic journals, 2) articles published before 1996, 3) articles published in languages other than English, and 4) articles that did not include/discuss an intervention or involve refugees/people from refugee backgrounds. A team of graduate students contributed to the review of titles, abstracts, and articles.
The electronic database search yielded 191 records, 121 of which were screened for eligibility. 114 of the 121 studies were excluded because they did not meet the inclusion criteria or were not relevant to the research question. A total of 7 studies were selected to be included in the final review.

Stage 4: Charting the data
Charting describes a technique for synthesizing data by sifting and sorting material according to key issues and themes (Ritchie and Spencer, 1994). The data we charted were entered into a table (See Table 1) and included information about each study. We recorded the following: author(s), year of publication, location of the study, research design, sample characteristics, type of intervention, and key findings.  Stage 5: Collating, summarizing, and reporting the results Scoping reviews seek to present an overview of all material reviewed. While this study requires an analytic framework or thematic construction, there is not an attempt to present a view regarding the 'weight' of evidence (Arksey and O'Malley, 2005). As a result, rather than determine which interventions are better than others at addressing occupational deprivation in refugees, our scoping review aimed to map out the evidence and present different interventions that can be used when working with displaced populations. To collate, summarize, and report the results, we performed a descriptive analysis and then analyzed the evidence by age group. The studies were organized this way to account for the fact that specific age groups may face qualitatively different challenges from each other, and to address these challenges, interventions used in pediatric or school settings, for example, may not be appropriate to use when working in settings with adults.

Descriptive analysis
Of the seven studies included in the review, one was a cohort study, five were qualitative case studies, and one was an exploratory study using qualitative methodology. The majority of studies (five out of seven) were from developed countries, including Australia, Norway, and the United Kingdom. Participants in the studies came from all over the globe, including the Middle East, North Africa, East Asia, Central Asia, South Asia, and Eastern Europe. Although one study was published in 2002, the other six were published within the last seven years, indicating relatively recent information on interventions that can be used when working with refugees who face occupational deprivation.

Analysis by age group: children (0-18 years)
One study in Kosovo examined a preventive occupational therapy program with children survivors of war (Simó-Algado et al., 2002). The program was based on a communitycentered approach, and its objective was to facilitate emotional expression of traumatic experiences, which could affect participation in meaningful occupations. The authors found that engaging in projective techniques that allow for emotional expression, such as painting and drawing with free themes, helped children express and process traumatic events. Through these techniques, children were able to express how they were feeling, learn the importance of expressing their emotions in a positive way, and continue engaging in activities that were meaningful to them.
A second study in Jordan examined a Palestinian refugee camp (Al-Heresh et al., 2013). The purpose of the study was to apply occupational and social justice theories to a community-based rehabilitation program. The occupational therapists at the camp used space to create a playground to meet the play-related goals of one eight-year-old participant with cerebral palsy. As more children in the community became interested in playing on the playground, it allowed for the development of new friendships and expression of positive emotions. This type of communitybased rehabilitation not only allowed children to participate socially with others, but it also created opportunities that gave them occupational fulfillment.
A third study in Australia examined an occupational therapy program that was designed to facilitate participation of high school students from refugee backgrounds (Copley et al., 2011). Three cycles of action research were used over 18 months. The program shifted focus from individual task mastery in the classroom to development of social competence through an activity-based group program. Using in-depth interviews with staff members (n=13), the researchers found that activities in the group program that provided opportunities to address social competence, such as cooking and engaging in science experiments, fostered better alignment between teachers and occupational therapists, as well as improved learning in new environments. Participating in such activities allowed for the development of social skills in refugee students to support participation and performance in the classroom.

Analysis by age group: adults (18 years and over)
One study in the United Kingdom explored the value of an allotment group for refugees and the role of horticulture on health, well-being, and social inclusion (Bishop and Purcell, 2013). The participants were recruited from members attending a weekly group set up for refugees. Researchers observed the participants during four consecutive weekly sessions and then conducted semi-structured interviews (n=5) to collect data. The authors found that gardening/horticulture was identified as a meaningful activity due to its therapeutic nature and social inclusion. This activity also allowed the participants to grow crops from their native countries, allowing them to reminisce on past occupations and maintain a connection to their culture.
A second study in Australia outlined two separate refugee programs in Australia and Bhutan for practitioners who wanted to work/volunteer in those areas (Boyle, 2014). The aim of these programs was to foster autonomy and social integration into new communities while retaining traditions that the refugees held dearly. Although the focus of this study was on the role of occupational therapy practitioners, descriptions of the community-based programs suggested that social participation, such as playing sports and participating in choirs, allowed for refugees' social integration into new communities. These types of programs addressed occupational deprivation by providing refugees with social outlets and supporting them to become a part of larger communities.
A third study in Norway examined adult refugee students (n=11) resettled from various parts of the world (Werge-Olsen and Vik, 2012). The study aimed to identify how participation in everyday activities could serve as tools for language training and job acquisition. Researchers conducted interviews with the participants through the help of interpreters. They found that during language training, students' prior engagement in meaningful activities received little attention. A thorough understanding of an individual's activity history could make it easier to apply skills and expertise from native countries. Furthermore, familiar and meaningful activities from refugees' native countries could enable communication when language skills are limited. Engaging refugees in activities that they are accustomed to could not only help maintain prior values, but it could also link these values to activities in new countries.
A fourth study in Australia explored how occupations could be used to understand transitions involved in the resettlement process for refugees (Suleman and Whiteford, 2013). The participants included newly arrived refugees at a resettlement service in Brisbane. The intervention was a community-based, life skills program that aimed to restore independence by meeting basic needs and building skills required for successful resettlement. The researchers suggested that community-based rehabilitation that focused on practical skills, such as community mobility and money management, enabled refugees' ability to engage in new environments. Since living in a new country can be challenging, teaching practical skills could build confidence in refugees who wish to acclimate to new societies.

Discussion
Scoping reviews are appropriate to conduct when the evidence is limited and aligns well to the objective of the study, which was to identify and map existing knowledge (Arksey and O'Malley, 2005). While there is a need for more research on interventions for refugees who face occupational deprivation, we did gain some insight on different interventions and what information is missing in the literature. Although scoping reviews do not 'weight' evidence, it is worth noting that none of the studies included in our review contained quantitative analyses, and some studies did not include information on their sample sizes.
These observations indicate a need for more systematic trials when studying the effects of interventions on refugees. More information is needed to conduct other types of studies (e.g., systematic reviews) to determine which interventions are the most effective at addressing occupational deprivation in this population.
Although the aim of our study was not to evaluate the relative effectiveness of different interventions, we still gained valuable insight on our original research question: Which interventions can be used when working with refugees who face occupational deprivation? According to the literature, community-based rehabilitation, meaningful activities that refugees are familiar with, projective techniques that allow for positive emotional expression (e.g., collective artwork), mastery of practical skills that allow for navigation in a new environment (e.g., money management), and activities that promote social competence, inclusion, and participation, (e.g., cooking) can be used when working with refugees who face occupational deprivation. Healthcare professionals can consider and use these intervention options when working with refugee populations. Because of the varied nature of displaced people, their cultures, new environments, and prior occupations, more research is needed on interventions for refugees who face occupational deprivation. Furthermore, with multiple refugee crises continuing to develop throughout the world, the need for occupational therapy continues to grow.

Limitations
Our study has limitations, particularly with our data collection strategy. Since we exclusively searched for peer-reviewed studies through electronic databases, it is possible that we may have overlooked pertinent information that was not archived electronically or published in peer-reviewed journals. Additionally, since our search focused on literature available in English, we could have missed relevant information on interventions for refugees that was published in other languages and not translated into English. Our scoping review, however, still followed Arksey and O'Malley's framework (2005) and provided useful information on our area of inquiry.

Conclusions
Occupational deprivation remains an important issue for refugee populations. To our knowledge, this is the first study to map interventions that can be used when working with refugees who face this global problem. According to the evidence, community-based rehabilitation, familiar activities from native countries, projective techniques that allow for positive emotional expression, mastery of practical skills that allow for navigation in a new environment, and activities that promote social competence, inclusion, and participation can be used when working with refugees who face occupational deprivation. It is important for healthcare practitioners, researchers, and stakeholders around the globe who work with refugees to understand the impact that displacement can have on this population and be aware of these intervention options. Addressing occupational deprivation and helping refugees engage in meaningful activities are all goals that can be achieved. To get to that point, however, it will take further research, a better understanding of the nature of deprivation, and the dedication to help others help themselves.