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The experience of Eritrean refugee women in addressing their mental health needs

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The experience of Eritrean refugee women in addressing their mental health needs

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Content The Experience of Eritrean Refugee Women in Addressing their Mental Health Needs
by
Madehania Baheta
Rossier School of Education
University of Southern California
A dissertation submitted to the faculty
in partial fulfillment of the requirements for the degree of
Doctor of Education
December 2022

© Copyright by Madehania Baheta 2022
All Rights Reserved

The Committee for Madehania Baheta certifies the approval of this Dissertation

Mary Andres
Alison Muraszewski, Co-Chair
Kimberly Hirabayashi, Committee Chair

Rossier School of Education
University of Southern California
2022

iv
Abstract
Mental health in the Eritrean community has long been seen as a stigma or taboo, which has kept
many Eritrean women from coming forward and receiving proper mental health support. This
has been especially true for Eritrean refugee women who experienced rape, torture, war, and
other forms of abuse while fleeing Eritrea. Women who experience torture or sexual violence are
more susceptible to mental health illnesses and often develop post-traumatic stress disorder,
depression, anxiety, and other severe health concerns. This study focused on Eritrean refugee
women’s mental health needs, including systemic barriers to and facilitators of support. This
study also explored how services in the Eritrean community could support these women’s mental
health. In-depth interviews with eight service providers who have supported this population were
conducted. The results showed that shame and stigma were significant barriers to talking about
trauma, but family and community support were key to healing and building resilience.
Bronfenbrenner’s ecological systems model guided this study. Based on the findings and
conceptual framework, the study includes three recommendations for practice regarding building
mental health awareness and education, therapy, and Eritrean community centers.

v
Acknowledgements
First, I would like to thank the Lord for being my guiding light through this rigorous yet
rewarding journey. You have gotten me through so many difficult times, and I am truly
appreciative of that.
To all of the Eritrean and Tigrayan women. You have not only been the bedrock of the
habesha family, but you have always found ways to persevere through pain, trauma, and conflict.
Your love knows no bounds, and just remember that we see you.
To my wife, Ruth, there is no one else I would want to accompany me through this
journey we call life. You provided me with so much insight, material, and resources for my
dissertation. Your love, support, patience, and encouragement made this whole experience
possible. No matter how old we get or what we go through, you will always be heart.
To my mother, Ghirma, words cannot describe the love and appreciation I have for you.
While pregnant with me and caring for my three brothers, you walked hundreds of miles through
the desert of Eritrea while being shot at and having rockets fired at you so your children may
have a chance at life. There is no greater and unconditional love than that of a mother; you truly
symbolize the meaning. I know my father is smiling from heaven in awe of you.
To my children, Olivia and Iyasu, know that everything I do is for you. Daddy loves you
both always and forever.
I could not forget my Saturday Breakfast Club crew. You have made this journey more
than memorable. I truly appreciate the love, thoughtfulness, and unwavering support we
provided one another. I know that I have a new family for life now. Fight on!
Lastly, thank you to Dr. Hirabayashi, Dr. Muraszewski, and Dr. Andres, my dissertation
committee, for your guidance and patience during my dissertation journey.

vi
Table of Contents
Abstract .......................................................................................................................................... iv
Acknowledgements ..........................................................................................................................v
List of Tables ............................................................................................................................... viii
List of Figures ................................................................................................................................ ix
Chapter One: Introduction to the Study ...........................................................................................1
Context and Background of the Problem .............................................................................1
Purpose of the Project and Research Questions ...................................................................2
Importance of the Study .......................................................................................................2
Overview of Theoretical Framework and Methodology .....................................................3
Definitions ............................................................................................................................4
Organization of the Dissertation ..........................................................................................5
Chapter Two: Literature Review .....................................................................................................6
Historical Background .........................................................................................................6
Outcome and Effects on Mental Health .............................................................................13
Taboo, Stigma, and Fear ....................................................................................................22
Mental Health Support .......................................................................................................25
Conceptual Framework ......................................................................................................28
Summary ............................................................................................................................32
Chapter Three: Methodology .........................................................................................................33
Research Questions ............................................................................................................33
Overview of Design ...........................................................................................................33
Research Setting .................................................................................................................34
The Researcher ...................................................................................................................34
Data Sources ......................................................................................................................35

vii
Data Collection Procedures ................................................................................................37
Data Analysis .....................................................................................................................37
Validity and Reliability ......................................................................................................38
Ethics ..................................................................................................................................39
Chapter Four: Findings ..................................................................................................................41
Research Question 1: What Are the Mental Health Needs of Refugee Women From
Eritrea? ...............................................................................................................................43
Research Question 2: What Are the Systemic Barriers and Facilitators to Mental Health
Support for Refugee Women From Eritrea? ......................................................................52
Summary ............................................................................................................................62
Chapter Five: Recommendations ...................................................................................................63
Discussion of Findings .......................................................................................................63
Recommendations for Practice ..........................................................................................68
Limitations and Delimitations ............................................................................................75
Recommendations for Future Research .............................................................................76
Conclusion .........................................................................................................................76
References ......................................................................................................................................78
Appendix A: Interview Questions .................................................................................................91
Appendix B: Recruitment Email ....................................................................................................94

viii
List of Tables
Table 1: Descriptive Table of Participant Characteristics 17
Table 2: Data Sources 34
Table 3: Interviewees’ Characteristics 42
Table 4: Summary Table of Research Question 1 and Findings (Themes) 51
Table 5: Facilitators to Mental Health Support/Healing: Family Support System 58
Table 6: Facilitators to Mental Health Support/Healing: Community Support System 60
Table 7: Summary Table of Research Question 2, Findings (Themes) and Sub-Themes 61
Table 8: Key Findings: Eritrean Refugee Women and their Mental Health Needs 62
Table A1: Interview Questions 90

ix
List of Figures
Figure 1: Map of Eritrea 7
Figure 2: Armed Conflict, Displacement, and Mental Health 15
Figure 3: Percentage of Participants Reporting Post-migration Living Difficulties 19
Figure 4: Percentage of Participants Reporting Traumatic Life Events 20
Figure 5: Conceptual Framework 31

1

Chapter One: Introduction to the Study
Eritrean refugee women (ERW) have experienced horrific acts of violence and trauma
escaping war, military conscription, and conflict, all while not receiving proper mental health
support (Arega, 2017; Bernal, 2017; Getnet & Alem, 2019). The Eritrean culture sees mental
health as a sign of weakness and, therefore, fewer women will come forward for treatment
(Médecins Sans Frontières, 2018). When a person experiences torture, war, and human rights
violations, they are more susceptible to mental illness (Murthy & Lakshminarayana, 2006). This
study focused on the role of community services in the Eritrean community and how they can
help support the mental health of ERW.
Context and Background of the Problem
Eritrea started as an Italian colony federated to Ethiopia in 1950 (Finaldi, 2016). While
under the governance of Ethiopia and Emperor Haile Selassie, Eritreans endured violence,
repression, and imprisonment while suppressing Eritrean identity, culture, and tradition (Bernal,
2017). An armed struggle between Eritrea and Ethiopia began in 1961 (Gran, 1989). During the
conflict, Eritreans were subject to air raids, and women were kidnapped, raped, and forced to
accompany Ethiopian troops as concubines and servants (Human Rights Watch [HRW], 1991).
The war sent about a third of the Eritrean population, 1,000,000 people, into exile (Bernal,
2017). Many would become refugees in the United States, where it is estimated that about 39,000
Eritreans live (Idris, 2020). These were the first-generation Eritrean diaspora who left the
country between the 1970s and 1980s to escape the atrocities of war from the Ethiopian military
(Hirt, 2021). Eritrea won its independence from Ethiopia on May 24, 1991, after a 30-year war
(Weldegiorgis, 2014).
2

On May 24, 2021, Eritrea celebrated its 30th year of independence. Currently, there is no
civil society, independent public sphere, or free press (Bernal, 2017). Over the last decade,
young people have fled Eritrea due to indefinite military service initiated in 2005 and expanded
during the border war with Ethiopia from 1998 to 2000 (International Crisis Group, 2014). In
1997 the Eritrean Constitution was ratified but never fully implemented (Bernal, 2017). Since
then, ERW have reported abuse, imprisonment, rape, and torture while fleeing the country
(Arega, 2017). Thousands of refugees leave Eritrea every month, and over 130,000 have fled to
neighboring Ethiopia (Arega, 2017; Bernal, 2017). Refugees are at high risk for mental health
problems due to escaping from their countries, cultural conflict, losses of family members, and
traumatic experiences (Lipson, 1993).
Purpose of the Project and Research Questions
The purpose of the project is to focus on the role of community services in the Eritrean
community and how they can help support the mental health of ERW. Two questions guided this
study:
1. What are the mental health needs of refugee women from Eritrea?
2. What are the systemic barriers and facilitators to mental health support for refugee
women from Eritrea?
Importance of the Study
Eritrean refugee women experience torture, rape, and psychological and physical abuse
while fleeing their country (Arega, 2017). Women who experience sexual violence often develop
severe health consequences, such as long-term psychological problems, anxiety, depression, and
post-traumatic stress disorder (PTSD; Watts et al., 2013). The United Nations has declared
sexualized gender-based violence a war crime (Borchelt, 2005). One of the challenges Eritrean
3

refugees face is the fear of being labeled as “crazy” or “weak” by their community, which keeps
them from coming forward and seeking mental health support (MSF, 2018). Although
resettlement might bring increased physical safety and positive adaptation after trauma, women
still face challenges of adaptation and settlement in new countries, including difficulty meeting
basic needs and acculturation stress while facing the stereotypes and stigma associated with
being a refugee (Yohani & Okeke-Ihejirika, 2018). It is important for ERW to get mental health
treatment because if left untreated, it may cause severe behavioral, emotional, and physical
health problems (Mayo Clinic, 2021).
Overview of Theoretical Framework and Methodology
This study utilized Bronfenbrenner’s ecological systems theory. There are four
environmental systems in this theory: microsystem, mesosystem, ecosystem, and macrosystem
(Ettekal & Mahoney, 2017). The microsystem looks at the individual, the individual’s immediate
environment, and the relationship between them (Bronfenbrenner, 1977). The mesosystem looks
at the individual’s major settings, such as home and peer groups, and the interrelations between
them (Bronfenbrenner, 1977). The ecosystem examines the major institutions of society, their
social structures, such as public agencies and mass media, and how they influence the
individual’s setting (Bronfenbrenner, 1977). The macrosystem looks at how an individual’s
society, including its laws and regulations, affects that individual (Bronfenbrenner, 1978).
Bronfenbrenner’s ecological systems theory interlocks a person’s immediate setting and
interconnections among systems, community, and cultural values (Onwuegbuzie et al., 2013). To
understand how a person’s mental health is affected, it is important to know the impact of the
systems and society on that individual. The theory may be mapped to research and qualitative
4

studies, including behavioral, social, and health sciences studies (Bronfenbrenner, 1979). This
was important during the study since a qualitative method and interviews were used.
Definitions
This section provides definitions of frequently used terms used throughout the
dissertation.
Refugee: A person who has fled their country due to violence, persecution, conflict, and
war in order to find safety (United Nations High Commissioner for Refugees [UNHCR], 2017).
Eritrea: An eastern African country located along the Red Sea bordering Ethiopia,
Sudan, and Djibouti (CIA, 2021).
Mental Health: The World Health Organization (2018) stated that “mental health is a
state of well-being in which an individual realizes his or her own abilities, can cope with the
normal stresses of life, can work productively and is able to make a contribution to his or her
community” (p. 1).
Eritrean People’s Liberation Front (EPLF): Formed during 1970 as a left-wing group
that fought for and achieved Eritrean independence in 1991 and then transformed into the
People’s Front for Democracy and Justice (PFDJ), which currently rules as the nation’s only
political party (Plaut, 2016).
Eritrean Liberation Front (ELF): Formed in 1961 as an armed resistance in direct
opposition to Ethiopian rule, it led the start of the independence fight (Omer, 2020).
Tigray People’s Liberation Front (TPLF): Formed in the Tigray region of Ethiopia in
1975 and fought with the EPLF to defeat Ethiopian rule in 1991 (Plaut, 2016).
5

Organization of the Dissertation
This study is organized into five chapters. Chapter One has provided the context and
background of the problem of practice, the project’s purpose and importance, research questions,
terminology, the theoretical framework, and the methodology related to ERW and their mental
health. Chapter Two will cover the literature review, which will build context to the problem of
practice and discuss the conceptual framework used to shape and deliver different systems that
affect ERW mental health. Chapter Three will discuss the methodology, research questions,
setting, the researcher, and the data sources used. Chapter Four will provide answers to the
study’s research questions and a summary of the study’s findings. Chapter Five will cover the
discussions of the findings along with recommendations discovered during the study and a
conclusion.

6

Chapter Two: Literature Review
This chapter reviews literature related to the experience of ERW when addressing their
mental health needs. The first section gives an overview of the historical background of Eritrea
and its impact on ERW. The second section reviews the outcome and effects of the historical
problems on ERW and their mental health. The third section reviews literature related to the
taboo and fear of receiving mental health support in the Eritrean community and the impact on
ERW. The fourth section explores strategies to promote mental health in ERW and their
communities. The chapter ends with a review of Bronfenbrenner’s ecological theory and how the
environment of ERW impacts their mental health needs directly or indirectly.
Historical Background
Country Facts
Eritrea is in Eastern Africa, where it borders the Red Sea to the east, Sudan to the west,
Ethiopia to the south, and Djibouti to the southeast (CIA, 2021). Eritrea has nine ethnic groups
who all speak different languages, with Tigrinya being the dominant language and the two main
religions being Orthodox Christian and Muslim (Plaut, 2016). There is an estimated population
of 6,147,398 people, and 30% of the country’s gross domestic product comes from its large
diaspora (CIA, 2021). Eritrea started as an Italian colony from 1886-1941, then was under
British rule from 1942 to 1952, followed by a United Nations approved federation with Ethiopia
from 1952 to 1960, a fight for liberation from Ethiopia from 1961 to 1991, and independence
from 1991 to the present (Omer, 2020; Plaut, 2016). The Eritrean Defense Forces currently have
an estimated 200,000 soldiers, many serve under forced conscripts, and military service is
usually extended indefinitely (CIA, 2021). Figure 1 below displays the country of Eritrea.

Figure 1
Map of Eritrea
7
8

Ethiopia Federation
Eritrea was supposed to be an autonomous region when it was federated to Ethiopia in
1952, but Ethiopia was more interested in the land than the people (Omer, 2020; Plaut, 2016).
Emperor Haile Selassie of Ethiopia imposed a series of decrees on Eritrea that included banning
the teaching of Eritrean languages and replacing them with Amharic, the official language of
Ethiopia, and replacing the Eritrean flag with the Ethiopian flag (Omer, 2020; Plaut, 2016).
Political parties and trade unions were crushed and industries moved to Addis Ababa, the capital
of Ethiopia (Omer, 2020; Plaut, 2016). Later, Ethiopia would replace Eritrean officials and
official seals with Ethiopian ones and jail independent politicians or journalists (Omer, 2020;
Plaut, 2016). Under the governance of Ethiopia and Emperor Haile Selassie, Eritreans endured
violence, repression, and imprisonment, all while suppressing Eritrean identity, culture, and
tradition (Bernal, 2017).
Fight for Liberation
Eritreans’ armed resistance against Ethiopia began on 1 September 1961 by a group
called the ELF (Haile, 1987; Omer, 2020; Plaut, 2016). The ELF’s objectives were to organize
Eritrean refugees to initiate political resistance and action while waging an armed conflict
against Ethiopia and its occupation (Haile, 1987). The ELF’s goals were to maintain the unity of
Eritrea, form a democratic system, and achieve complete independence (Omer, 2020). In 1962,
Ethiopia dissolved the federation with Eritrea and absorbed it into Ethiopia (Omer, 2020; Plaut,
2016; Weldehaimanot & Taylor, 2011). This move inspired many Eritreans to join the ELF,
including future president Isaias Afwerki (Plaut, 2016); Weldehaimanot & Taylor, 2011). In
1972, a new group emerged and separated from the ELF, the EPLF, which was led by Isaias
Afwerki and Ramadan Nur (HRW, 1991; Omer, 2020; Plaut, 2016); Weldehaimanot & Taylor,
9

2011). The ELF was made up of mostly lowland Eritrean Muslims with highland Orthodox
Eritrean Christians, but the EPLF was the opposite, mostly comprised of most highland
Orthodox Christians and a minority of lowland Muslims (Omer, 2020; Plaut, 2016; Taylor &
Weldehaimanot, 2011). In 1972, a civil war broke out between the ELF and EPLF (HRW, 1991;
Plaut, 2016). While the civil war was being fought, a more destructive threat was rising from
Ethiopia.
Red Terror
In 1974, Emperor Haile Selassie was overthrown and murdered over the handling of the
war with Eritrea and famine in Ethiopia; a military committee known as the Derg led by Colonel
Mengistu Haile Mariam took over (Haile, 1987; Plaut, 2016). There were hopes of Eritrea
gaining her independence with the Derg in power, but talks broke down while violence,
executions, and the war continued (Plaut, 2016; Shoup, 2017). In 1975, the ELF and EPLF called
a truce and began a concerted war against the Ethiopian government (HRW, 1991). In 1981, the
ELF and EPLF started fighting with each other once again, which led to the ELF being pushed
into and operating from Sudan; the EPLF was assisted by the TPLF (Plaut, 2016;
Weldehaimanot & Taylor, 2011). The TPLF came from the Tigray region of Ethiopia and was
formed in 1975 when they launched a war against Ethiopian authorities (Plaut, 2016).
Genocide
Colonel Mengistu, who would later become President of Ethiopia, used famine and
starvation as a weapon by having his tro’sops destroy crops and cattle and blocking humanitarian
aid to Eritreans (HRW, 1991). Mengistu’s troops would cut off Eritrean women's ears to seize
their earrings (HRW, 1991). The troops would also take women by force to be their sexual
servants while making them sweep, wash clothes, and cook (HRW, 1991). Mengistu engaged in
10

bombing campaigns, primarily targeting civilians believed to be sympathetic to the EPLF, that
resulted in the maiming and killing of thousands of civilians, many being women and children
(Africa Watch, 1990). Ethiopian soldiers carried out massacres and executions, which included
the murder of civilians taking sanctuary in churches and mosques (Bernal, 2017). In 1991,
Mengistu would be defeated by the EPLF, taking over all of Eritrea, and the TPLF entered Addis
Ababa (Keller, 1991). As forces drew near Addis Ababa, Mengistu fled to Zimbabwe, where he
was granted asylum (McAuliffe, 1991). The war created about 1,000,000 Eritrean refugees and
95,000 orphans (Bernal, 2017). The Ethiopian Federal High Court convicted Mengistu of
genocide in 2007 (Tiba, 2007).
Independence
Eritrea achieved de facto independence, was liberated from Ethiopia in 1991, and
formally became independent in 1993 under the referendum (Plaut, 2017; Weldehaimanot &
Taylor, 2011). Women fought for independence alongside men but often faced discrimination,
were ridiculed, at times abused, and suffered violence from their male counterparts (UNHRC,
2015). More than 30,000 women fought for independence, and most of them fought in combat
roles (UNHRC, 2015). Following the vote for independence in 1993, the EPLF under President
Isais Afwerki became the ruling party, the PFDJ (Bernal, 201; Tronvoll, 2001). The president has
ruled with an iron fist since he came to power by ensuring no independent public square, civil
society, or free press (Bernal, 2017; Hirt, 2021). Since Eritrea’s independence in 1991, Isaias
Afewerki has been the only, and unelected, president, as no general election has ever been held
(Plaut, 2017; Weldehaimanot & Taylor, 2011). Many have labeled Eritrea “Africa’s North
Korea” (T.G., 2018). War broke out between Eritrea and Ethiopia from 1998 to 2000 over a
11

border dispute that displaced over 1,000,000 civilians and cost over 100,000 lives (Plaut, 2016:
UNHCR, 2016).
Repression
After the border war, Eritrea instituted open-ended military service for its youth that may
span decades (Bernal, 2017; Plaut, 2017). This call to indefinite national military service has
created a generation of refugees such that, at the end of 2015, there were over 475,000 Eritrean
refugees (Plaut, 2016). From 2014 to 2016, Eritrea was the largest source of refugees from
Africa to Europe (T.G., 2018). If Eritreans are caught trying to leave their country, they are shot
and killed by the military, detained without due process, or tortured (Gebreyesus et al., 2019;
Plaut, 2016). Women are being raped in the military, detention facilities, and military training
centers by trainers, military officials, and guards with impunity (UNHCR, 2016). When women
and girls try to flee their country, they are at high risk of gender-based and sexual violence,
which has caused some women to get contraceptive injections before their journeys, so they do
not get pregnant if raped (UNHCR 2016).
Eritrean refugees usually try to make it to refugee camps in Sudan, Djibouti, or Ethiopia
(Worabo, 2017) and attempt to get to more developed countries like the United States, Israel, or
Italy (Worabo, 2017). They take one of two main routes, one of which is to make it to Libya
through Sudan and cross the Mediterranean Sea on smugglers’ packed boats; this has led to boats
capsizing and over 2,400 deaths (Worabo, 2017). Many have fallen to human organ trafficking,
sexual violence, dehydration, and starvation well before reaching Libya (Arega, 2017). The
second route is through Egypt to Israel; this route is hazardous because refugees are sold to
kidnappers by smugglers or are tortured while their families are called to pay a ransom (Worabo,
2017). Some of the torture techniques used in the Sinai Peninsula of Egypt are (a) burning
12

victims’ body parts and genitalia, (b) electric shocks, (c) hanging victims from ceilings, (d)
molten plastic, (e) boiling water, (f) organ harvesting, (g) rubber and cigarettes, and (h) sleep
deprivation for extended periods (Gebreyesus et al., 2019). The Eritrean government has been
tied to the trafficking of refugees through unofficial channels, transporting them to Sudan if they
can pay the proper fees (Plaut, 2017). The United Nations Humans Rights Council has also
found sufficient evidence that a crime against humanity has occurred in Eritrea against young
women in the military who are forced into domestic servitude and raped (UNHCR, 2016).
Eritrean women have been facing war, discrimination, trauma, stigma, and sexual
violence for decades, with few to no resources available for their mental health needs. According
to the United Nations Human Rights Council’s (UNHRC, 2016) investigation,
Collecting evidence on cases of sexual violence suffered by women and girls in Eritrea
proved difficult due to cultural, social, and religious beliefs associated with marriage and
sexuality. Victims’ reluctance to disclose information stems from the trauma and general
shame they feel as well as the stigma which attaches to them if the harm they have
suffered is known. Indeed, many women mentioned the cultural emphasis on the
virginity, chastity or monogamy as one of the reasons to fear speaking about sexual
violence. As a woman’s virginity and chastity are highly regarded in much of Eritrea,
many victims of rapes are unable to marry and therefore prefer to remain silent. On top of
the trauma, “the honor system causes additional shame.” As a result, in some instances,
women and girls who were raped committed suicide. The Commission also heard
evidence that, within some ethnic or religious groups, if a woman is raped, she is rejected
by her community. Finally, women and girls suffer even more stigma if they have a child
13

from the rape. For all these reasons, rape is an underreported crime in Eritrea, and most
of the victims of such acts live in a culture of silence” (p. 7).
It is difficult for women to receive mental health assistance even if they ask for it; there is only
one mental health hospital in the country, Saint Mary’s Neuro-Psychiatric Hospital, located in
Asmara, the capital of Eritrea (Amahazion, 2021).
Even after women fought for independence for 30 years, they had difficulties
reintegrating into society because the talents that made them courageous soldiers were
considered unfeminine and undesirable in a wife (UNHRC, 2015). After women soldiers
returned home after independence, they were offered plots of land for their service that were
taken away by male family members (UNHRC, 2015). The women who served in the army after
independence faced rape by their superiors, transmission of sexually transmitted diseases, and
physical and psychological impairment due to rape (UNHCR, 2016).
Outcome and Effects on Mental Health
Research has shown a strong connection between forced migration and mental health
disorders in refugees displaying high levels of PTSD, anxiety, and depression compared to the
populations of their host nations (Solberg et al., 2020). Refugees still face a myriad of problems
during the post-migration phase that may hinder their mental health recovery and increase their
mental health stress with difficulties that include social isolation, family separation, loss of
status, and language problems (Solberg, 2020). One study of Eritrean refugees showed that
traumatic life events involving displacement are tied to lower quality of life and increased mental
distress (Araya et al., 2007). Refugees resettled in Western countries are 10 times more likely to
suffer from higher rates of anxiety, schizophrenic/schizoaffective disorders, and PTSD (Yohani
et al., 2020).
14

Women and girls are the most vulnerable among refugees; they are susceptible to
sexualized gender-based violence and are at increased risk for mental health problems
(Gebreyesus et al., 2019; Nakash et al., 2015). Women are more at risk of experiencing sexual
gender-based violence during conflicts than men (Nawyn et al., 2009). Depression, PTSD,
anxiety, and long-term psychological problems affect victims of sexual violence (Watts et al,
2013). Sexualized gender-based violence has gained more attention over the last 2 decades due
to widespread rape in conflict areas and being labeled a war crime by the United Nations
(Yohani, 2018). Trauma and sexualized violence in conflict areas are linked to grief, acute stress
disorders, and psychological distress in women (Yohani, 2018). In a study of Eritrean refugees,
85.2% displayed symptoms of PTSD (Tekie, 2018). While PTSD is common when a person
suffers severe trauma, what is different for refugees is that their traumas are recurring, persistent,
and deliberately caused by another person while living in exile (Brune et al., 2002). Traumatized
refugees living in exile have additional stressors, such as having asylum applications denied
where they once sought protection and choosing to live illegally in exile, facing a second
traumatic burden for those who have experienced torture, and aggravation of symptoms of
depression, anxiety disorders and PTSD (Brune et al., 2002). Figure 2 showcases displacement-
related stressors that branch from the collective experiences of armed conflict and forced
migration with the totality a refugee has to deal with in relation to their mental health.

Figure 2
Armed Conflict, Displacement, and Mental Health

Note. This figure illustrates the stressors refugees face when exposed to war and the need for adequate mental health support.
From “The Mental Health of Civilians Displaced by Armed Conflict: An Ecological Model of Refugee Distress” by K. E. Miller & A.
Rasmussen, 2016, Epidemiology and Psychiatric Sciences, 26(2), p. 4. (https://doi.org/10.1017/s2045796016000172)
15
16

Stress and Symptoms
Refugees’ mental health is strongly influenced by loss and war-related violence pooled
with the circumstances they combat on their passage to and within their host countries (Miller &
Rasmussen, 2016). In a study conducted by Tekie (2018) with 120 Eritrean refugees living in
Europe, 63.7% experienced or witnessed a minimum of one traumatic life event, 38.5% reported
physical assault, and 27.4% reported sexual assault that consisted of attempted rape, rape, or
being forced to perform a sexual act through the threat of harm or force. In the same study, 86%
reported stressors of not being able to return to their family during times of emergency, 83.7%
worried about their family left behind, 79.2% reported additional stressors of family separation,
72.2% were unemployed, and 67.4% reported boredom and loneliness (Tekie, 2018). Knowing
this information is critical to understanding the experience, trauma, and life of ERW and the
associated impacts on their mental health. The details and findings of this study are listed in
Table 1 and Figures 3 and 4, which explain the participants’ characteristics, post-migration living
difficulties, and reporting of their traumatic life events.

17

Table 1
Descriptive Table of Participant Characteristics
Characteristics N M SD
Gender Male 95
Female 25
Age 116 30.14 6.97
18-29 53
30-40 53
>41 10
Place of residence (in years) 68 3.60 2.28
Marital Status
Married

29

Single 52
Divorced 4
Separated 3
Widowed 1
Engaged 7
Military History Yes 67
No 31
Exposure to War/Conflict
Yes
16
No 77
Legal residence Yes 79
No 17
Asylum seeker Yes 87
No 7
Lampedusa survivor Yes 36
No 61
Educational level
Elementary – Middle School

20

High School 35
Technical College 8
University 18
Graduate School 16

18

Note. N = number; M = mean; SD = standard deviation. From The Role of Meaning-Making in
Posttraumatic Growth Among Eritrean Refugees With Posttraumatic Stress Disorder by Y.
Tekie, 2018, unpublished doctoral dissertation, University of Tennessee, Knoxville.

Figure 3
Percentage of participants reporting post-migration living difficulties

Note. From The Role of Meaning-Making in Posttraumatic Growth Among Eritrean Refugees With Posttraumatic Stress Disorder by
Y. Tekie, 2018, unpublished doctoral dissertation, University of Tennessee, Knoxville.
19

Figure 4
Percentage of Participants Reporting Traumatic Life Events

Note. From The Role of Meaning-Making in Posttraumatic Growth Among Eritrean Refugees With Posttraumatic Stress Disorder by
Y. Tekie, 2018, unpublished doctoral dissertation, University of Tennessee, Knoxville. 20
21

A study conducted through in-depth individual interviews focused on Eritrean women
who faced challenges through their migration process to Israel and the effects on their mental
and physical health and found that the participants placed the migration journey into three
interconnected segments where sexual violence most often occurred (Gebreyesus et al., 2019). In
the first segment, departure from Eritrea, women were dependent on smugglers and faced an
increased risk of forced repatriation and sexual violence while heading to and arriving in Sudan
(Gebreyesus et al., 2019). Even with the increased risk of sexual violence and lack of
accountability for perpetrators, women participants still decided to make the journey
(Gebreyesus et al., 2019). In the second segment, movement through Sudan, women faced a high
risk of sexual and gender-based violence from smugglers and other asylum seekers with limited
to no protection; this atmosphere created an unsafe and unstable environment for women who
continued their migration despite the fear of repatriation and the presence of smugglers
(Gebreyesus et al., 2019). In the third segment, transition from the Egyptian Sinai to the Israeli
border, all participants reported that sexual violence was common in the Sinai Peninsula
(Gebreyesus et al., 2019). Participants described being in torture houses where they were raped
by traffickers and forced to have sex with male captives to whom they were chained; the sexual
violence perpetrated by traffickers would not end until the Eritrean women crossed the Israeli
border (Gebreyesus et al., 2019). Sexual violence during migration may have caused numerous
mental and physical health problems that can have short- or long-term effects (Nakash et al.,
2015).
In a Swedish study with 510 refugees, participants were either seeking or had been
granted asylum, and over 50% of them suffered significant symptoms of anxiety and depression
(Leiler et al., 2019). Prevalence of anxiety was four times higher in the sample of participants
22

than in the Swedish population, and depressive symptoms were five times higher. Also, PTSD
symptoms were about twice as high as levels discovered in other populations. The study showed
poorer mental health in asylum seekers than among those granted asylum and a residence permit,
showing a correlation between mental health and residency status. Forty percent of the refugees
with a residence permit reported significant anxiety symptoms and risk of PTSD compared to
over 60% of those without one.
In all, ERW face sexual gender-based violence, separation from family, traumatic live events,
and a myriad of other issues while migrating that significantly impact their mental health
(Gebreyesus et al., 2019; Nakash et al., 2015; Solberg, 2020; Tekie, 2018). It is essential to
understand these stressors to provide ERW with the proper support they need, as they already
face difficulties coming forward and requesting assistance due to the stigma of mental health in
the culture that serves as a barrier and fear of how their community might treat them
(Amahazion, 2021).
Taboo, Stigma, and Fear
Women in Eritrea who face violence, especially sexual violence, face stigma and shame
and lack the resources to report and seek justice for the crimes committed against them
(UNHRC, 2015). Victims can rarely seek care and services due to limited financial resources
compounded by the social stigma and isolation that follow (UNHCR, 2015). Many fear speaking
up about their sexual violence due to their loss of virginity; women’s virginity is highly regarded
in Eritrea, and many rape victims are unable to marry, so victims choose to remain silent
(UNHRC, 2016). They are further stigmatized if they have a child from rape, leading most
victims of such crimes to live in a culture of silence (UNHCR, 2016).
23

Stigma
One of the primary reasons refugees give for failing to access mental health services is
the stigma associated with it (Shannon et al., 2015). In the Eritrean culture, mental illness is
poorly understood and stigmatized (Amahazion, 2021). Many Eritreans view mental illness as
witchcraft, possession by evil spirits, sorcery, a source of shame, a contagion, and punishment
from God (Amahazion, 2021). The traditional methods to heal those with disabilities include
divine intervention, medical care, indigenous healing, family care, holy water, and witchcraft
(Teklemariam, 2010). Eritreans with mental illness experience ridicule or blame, encounter
exclusion or isolation, are considered unfit for work or marriage, and are often considered
dangerous (Amahazion, 2021). In Eritrean culture, physical or mental disability is viewed as the
family’s curse, shame, a mark of inferiority, or a genetic problem (Teklemariam, 2010). Family
members of people with mental illness often experience stigma as well (Amahazion, 2021).
Many stigmas come from fear: fear that women will be discriminated against, fear of bringing
shame to their families, and fear of being seen as weak (Amahazion, 2021; UNHCR, 2016).
Fear
Refugees have expressed specific fears that make it challenging to discuss symptoms
associated with mental health, including being seen as crazy or insane, fear of being hospitalized,
fear of losing jobs or housing, fear of being alienated from their community, and fear of not
being able to be treated (Shannon et al., 2015). The stigma around mental health serves as an
obstacle for the mentally ill and their families when seeking assistance and acknowledging the
condition (Amahazion, 2021). This is because many patients and their families fear how they
will be treated if their condition becomes public, consequently decreasing the chances of
requesting treatment (Amahazion, 2021). During Episode 1 of the EriWellBeing podcast, “A
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mental health conversation with Dr. Yacob Tekie,” which aired on October 16, 2018, delved into
mental health in the Eritrean culture. Dr. Tekie stated.
I would go as far as saying that in the Eritrean society it is a matter of discrimination
rather than stigma. I have worked at the St. Mary’s Psychiatric Hospital for 4 years - the
only psychiatric hospital in Eritrea and I have witnessed first-hand people’s attitude
towards mental health. I have noticed passengers starting to cover their faces on the bus
to avoid being recognized as they approached the hospital stop for shame and fear of
being judged and stigmatized for seeking help. It was extremely surprising to see an
average of over 200 people coming to the hospital every single day, either for checkup or
medication: an extremely large and unexpected number, given the societal context. (Zerai
& Woldu, 2018, 15:35)
If a family is known to have physical or mental limitations, they are discriminated against
when it comes to intermarriages, which brings shame on the woman and her family
(Teklemariam, 2010; UNHCR, 2016). Language also plays a significant role in the existence of
fear. In Tigrinya, the most widely spoken language in Eritrea, for example, there is a lack of
vocabulary to refer to different conditions (i.e., anxiety, inquietude, and depression are all
described with the same word ጭንቀት [chnket]), which makes it difficult to express mental health
concerns. Many African cultures do not say mental health but that a person is crazy, which is
taboo (Yohani et al., 2020).
Taboo
Despite suffering from mental health issues, refugees are less likely to seek mental
health assistance due to cultural norms and practices, lack of information, and mental health
stigma (Shannon et al., 2015). Even as refugees make it to the safety of the United States, they
25

still find it challenging to share their experiences and suffering (Shannon et al., 2015). After
experiencing traumatic events, including sexual violence, many societies find it difficult to speak
about a taboo topic without coming to terms with attitudes, practices, and beliefs that may not fit
within their new collective experience (Yohani & Okeke-Ihejirika, 2018). Women may
experience stigmatization and discrimination from their communities during pre- and post-
migration if they have a known history of sexualized violence (Yohani & Okeke-Ihejirika, 2018).
In a study conducted with African women who experienced sexual assault, participants noted
that any type of sexual interference in the African culture is viewed as devaluing a woman,
which makes it more difficult for her to find a husband in her community and sometimes forces
them to leave their community to find a husband who does not know about her secret (Yohani &
Okeke-Ihejirika, 2018).
Thus, ERW face obstacles such as displacement, rejection, sexual violence, and
challenges adapting to a new country that brings stereotypes and the stigma of being an African
refugee while dealing with their mental health needs (Yohani & Okeke-Ihejirika, 2018). Victims
of forms of sexual violence and rape often suffer long-lasting mental pain, isolation, and
stigmatization; this directly affects their overall mental health (UNHCR, 2016). Since it is
difficult to break through the mental health barriers tied to taboos, stigma, and fear, it is
important to promote mental health resources to ERW.
Mental Health Support
With the numerous barriers ERW face, it is critical to encourage family, community, and
mental health support to meet their mental health needs. The UNHCR reported more than
379,774 Eritrean refugees at the end of 2015 (UNHCR, 2016). Since 2010 the United States has
been accepting between 1,300 and 2,600 Eritrean refugees each year while providing social
26

services access to over 200 nonprofit refugee agencies (Eritrean Refugees, 2021). In the United
States, there is a current public health crisis as mental health concerns remain stigmatized, and
between one in four and one in five people have a diagnosable mental health concern (Smith-
Frigerio, 2020). As stigma can inhibit seeking treatment, the World Health Organization (WHO)
has called upon practitioners and researchers to address this crisis (WHO, 2017). A multitude of
practitioners and researchers who work in refugee mental health directly state the importance of
the family in the healing and well-being of the refugee (Miller & Rasco, 2004).
Family
Family separation causes distress among refugees, and they need to maintain contact with
family members to maintain a state of emotional connection that can improve their mental health
(Shah et al., 2019). A qualitative study involving Bosnian refugee women found that their main
influences for developing resilience were their children, spouses, and families (Hutchinson &
Dorsett, 2012). Refugees need to be surrounded by their family members to aid with recovery
from traumatic experiences. Many experts in the refugee mental health field state that the family
is the most important factor in refugee communities (Miller & Rasco, 2004). In a study
conducted with 290 refugees, participants described many emotions when being able to speak
with family members, such included encouragement, social support, and healing (Shah et al.,
2019). Many refugees strive to reunify with their family members in their host country, which
can alleviate stress caused by thinking about them being in danger (Löbel & Jacobsen, 2021).
Several studies highlighted the importance of friends, family, and community in strengthening
resiliency in refugees in the resettlement process (Hutchinson & Dorsett, 2012).
27

Community
In a study conducted in Canada of Iranian immigrant women, volunteering and social
engagement in the community positively affected well-being and mental health (Khanlou &
Pilkington, 2015). Sufficient social support is connected with mental health and well-being,
whereas the opposite is a risk associated with mental illness and psychological stress (Puyat,
2013). Even though refugees use their family and friends for support, they also use their ethnic
community to cope and adapt to their new life (Schweitzer et al., 2007). One study with
participants found that support within the Eritrean community can be vital to the complete
healing process (Yohani & Okeke-Ihejirika, 2018). From a review of 81 studies, Unchino et al.
(1996) discovered that social support influences positive cardiovascular, immune system, health
effects, and physiological mechanisms. Community and social support were identified as critical
for African female survivors in the United States who experienced conflict-related sexualized
violence (Akinsulure-Smith, 2014).
Family and community are essential to provide the support and resources ERW require to
address and treat their mental health needs. Female immigrants have a greater risk than male
immigrants of experiencing isolation, which is why it is essential to provide mental health
services to them, as it could be harmful to their well-being (Khanlou & Pilkington, 2015; Killian
& Khanlou, 2011). If ERW do not have adequate family and community support, they can
continue to suffer in silence, negatively impacting their mental health.
Resilience
Although ERW have withstood a myriad of issues that have impacted their mental health,
they continue to move forward and display a high sense of resiliency. As Khanlou and Pilkington
(2015) described, “resilience involves being able to recover from difficulties or change, by
28

mobilizing personal resources or through the support of one’s family or community” (p. 188).
Thus, the importance of family and community can’t be understated in improving mental health
among Eritrean women refugees and building their resiliency. While refugees face many
difficulties during their resettlement process, experts working with refugees tend to concentrate
on their trauma and not their strengths (Hutchinson & Dorsett, 2012). It takes time for refugees
to adapt to their new country and lifestyle, but they need the opportunity to draw on their
strengths and existing resources to find their way (Hutchinson & Dorsett, 2012). In a study that
covered Eritrean refugees and preventive health care, the author inferred that a grateful attitude, a
sense of hope, and surviving their journey to the United States contributed to their resiliency
(Worabo, 2017). Despite adversities, research suggests that many refugees adapt to their
environment and thrive in their new surroundings and country (El-Bushra & Fish, 2004). With
the difficult journey ERW made, including the support of their family and community, they build
resiliency.
Conceptual Framework
Bronfenbrenner’s ecological systems model is the conceptual framework guiding this
study. During the 1970s, Bronfenbrenner started developing an emerging theory and named it the
“ecological model of human development” (Rosa & Tudge, 2013, p. 245). An ecological
perspective emphasizes development as a function of the interaction between the evolving
creature and the enduring environments or settings in which it lives (Bronfenbrenner, 1975).
Ecology implies that there is a fit between the person and their environment (Bronfenbrenner,
1975). The fit must be even closer if a person is to not only survive but develop (Bronfenbrenner,
1975). Bronfenbrenner (1977) described his theory to be comprised of systems at four different
levels: the microsystem, mesosystem, exosystem, and macrosystem.
29

The microsystem examines the relationship between the person and their immediate
environment, including home, family, friends, or church (Bronfenbrenner, 1977). Relevant to
this study, ERW are heavily influenced by their immediate environment and decisions. During
the study, the objective was to evaluate how people in the immediate environment influence
ERW behavior and decisions. The mesosystem examines the relationships between major
settings that involve the person, such as home and peer groups, home and church, and church and
hospital (Bronfenbrenner, 1977). Due to these relationships, ERW might be influenced to decide
about their health from a spiritual matter versus a scientific matter or go to church for medical
support through prayer instead of to a medical facility.
The study's objective was to examine how the relationships between major settings affect
the mental health of ERW. The exosystem examines the major societal institutions such as public
agencies, mass media, and work and how they impact the person’s environment
(Bronfenbrenner, 1977). The Eritrean government controls public agencies and mass media and
shapes the life and information women experience until they leave the country. During the study,
the plan was to examine how these major institutions inform the idea of mental health and affect
it. The macrosystem consists of cultural beliefs, laws and regulations, state agencies, and how
they impact a person’s development in their environment (Bronfenbrenner, 1977). This is
important as Eritrean women are put into indefinite military service where they are sexually
assaulted, are frightened by seeking mental health support due to stigma and fear, and there is
only one mental health hospital in the country (Amahazion, 2021; Shannon et al., 2015). It was
essential during the study to examine Eritrea's laws, cultural beliefs, and agencies and what type
of impact and influence they have on the development and health of ERW.
30

The core concepts emerging from the conceptual framework are government, religion,
family, and well-being. The government in Eritrea controls all institutions, from hospitals and
schools to the military, while being one of the least developed countries in the world (UNHCR,
2016). Eritrea also has a shoot-to-kill policy for anyone fleeing the country (UNHCR, 2016).
Many Eritreans turn to religion for traditional healthcare beliefs such as visiting holy places,
miracle sites, shrines, and being sprinkled with holy water (Teklemariam, 2010). Family plays a
vital role in the community; it is through the family that women’s marriages are arranged, and it
is the fear of shaming the family that a woman might not discuss being sexually assaulted.
Concern for their health causes many women to leave the country, as being in constant wars,
indefinite military service, and the risk of being sexually assaulted keep women on edge.
Bronfenbrenner’s ecological systems model was important in examining how these government
institutions, laws, religion, family, and cultural beliefs shape ERW’s mindset, character, views,
and mental health needs.

Figure 5
Conceptual Framework: Interaction of Eritrean Refugee Women and Four Systems in Bronfenbrenner’s Ecological Systems Model

Eritrean Refugee
Women
Individual
Microsystem
Mesosystem
Exosystem
Macrosystem
Family
Health Services
Peers
Church
Group
NGOs
Neighbors
Legal
Services
Friends
of Family
Family
Church Group
Peers
Health Services
Religious Beliefs
and Practices
Cultural Beliefs or
Ideologies
State Laws
Politicians
Social
Groups
State Agencies
Talk to a family member or priest
to help you through mental help
needs (Microsystem)
Indefinite Military Service
(Macro- and Exosystem)
Strong Orthodox
Christian Society that
relies on Church
heavily (Macro- and
Microsystem)
Fleeing youth and
families from war and
indefinite military
service (Meso- and
Microsystem)
Refugee Camps
where many Eritrean
refugee women end
up after escaping
war and oppression
(Exo-, Meso-, and
Microsystem)
Lack of mental help
treatment facilities in Eritrea
(Mesosystem)
31
32
Summary
As discussed, ERW continue to face many obstacles to receiving proper mental health
treatment. To inform this study, this chapter reviewed the literature related to the experience of
ERW in addressing their mental health needs. Each topic covered was examined through the lens
of Bronfenbrenner’s ecological model to gauge the impact of environment had on overall mental
health. The literature review identified the historical background of ERW and its effects on their
mental health. Additionally, the literature review assessed the role of taboo, fear, and stigma and
the barriers these set for ERW to overcome. Finally, the literature review identified the
importance of mental health support and the community and family’s role in it. It is essential to
understand all the main ideas and how they play into the environment of the ERW that help
shape their ideas, beliefs, and culture. The main ideas from this literature review help provide
further background to understand the problem of practice.

33

Chapter Three: Methodology
This chapter will discuss the methodology research questions, setting, the researcher, and
data sources used. The purpose of the study was to focus on the role of community services in
the Eritrean community and how they can support ERW mental health. This chapter further
outlines the methodological design, research setting, data collection and instrumentation, ethics,
validity and reliability, and limitations and delimitations.
Research Questions
Two questions guided this study:
1. What are the mental health needs of refugee women from Eritrea?
2. What are the systemic barriers and facilitators to mental health support for refugee
women from Eritrea?
Overview of Design
This study utilized Bronfenbrenner’s ecological systems theory to understand the impact
one’s environment has on one’s mental health. A qualitative method was used to give a voice to
ERW who are rarely heard, illuminate their experiences and complex journey, and gain an
understanding of their mental health needs. Creswell and Creswell (2018) stated that a qualitative
approach is “an approach for exploring and understanding the meaning of individuals or groups
ascribe to a social or human problem” (p. 27). Data were collected through interviews and
documents. Merriam and Tisdell (2016) stated, “qualitative researchers are interested in
understanding how people interpret their experiences, how they construct their worlds, and what
meaning they attribute to their experiences” (p. 6). For this reason, I conducted interviews to
understand the experiences of ERW and their mental health needs.

34

Table 2
Data Sources
Research questions Interviews Document analysis
What are the mental health needs of refugee women
in Eritrea?
X X
What are the systemic barriers and facilitators to
mental health support for refugee women from
Eritrea?
X X

Research Setting
Over 34,000 people from the Eritrean diaspora currently live in the United States, with
the largest number living in California, over 6,200 (Creighton, 2018). I live in California and am
tied into the Eritrean communities in San Diego and San Francisco in California and in Seattle,
Washington, through communities, family, and friends. I used this vast network to find
participants for this study. I interviewed all eight participants via Zoom. All participants are
service providers who assisted ERW through counseling or other essential services. Each
participant assisted ERW with the trauma they faced during their journey to the United States.
The research questions pertain to ERW and their mental health needs.
The Researcher
I am a person who takes advantage of the opportunities provided in life. My family
escaped war and genocide during the late 1970s, fleeing Eritrea to a refugee camp in neighboring
Sudan. I was born at that refugee camp and lived there for 3 years before coming to the United
States in 1982 with my single mother as refugees. My father fought for the independence of
Eritrea and gave his life for it. Being from a Christian Orthodox dominant country, my mother
35

always preached faith and belief in the Lord to me. I served 22 years honorably in the U.S.
Marine Corps. I completed multiple deployments in Afghanistan and a deployment in Iraq,
where I worked directly with the United Nations to assist in providing aid to internally displaced
persons. The Marine Corps instilled discipline, courage, and honor in me. I have completed the
same journey as some ERW to the United States, and I have family living in Eritrea. Due to this
reason, I can empathize with the stories the participants told. Sharing the same culture, religion,
and background as some ERW, I have biases towards their suffering, mental health needs, and
upbringing. I assume that most ERW need some type of mental health support. I concealed my
emotions during the interviews, asked unbiased questions, and did not lead participants toward
certain conclusions.
Data Sources
This study used a qualitative method steered through document analysis and interviews
with service providers that assisted ERW who live in the United States.
Interviews
Interviews were a method and a form of collecting data. A research interview is a process
where the participant and researcher discuss questions focused on a research study (DeMarrais,
2004). Interviewing is essential when we are interested in past events that are impossible to
duplicate and when conducting studies involving few participants (Merriam & Tisdell, 2016). I
used semi-structured interviews to gain new ideas on the subject, the views of the participants,
and the ability to respond during the interview (Merriam & Tisdell, 2016).
Participants
I used purposeful sampling when recruiting participants. Merriam and Tisdell (2016)
stated that purposeful sampling is based on the belief that the researcher would like to learn as
36

much as possible by uncovering and building knowledge about the subject. Since the study
targeted a very specific population, purposeful sampling was key to understanding information-
rich cases. The
The eight participants are service providers who have assisted ERW. I worked through
the Eritrean community to select which organizations to work with, and I asked for volunteers
from those organizations to participate in this study.
Instrumentation
I collected data through interviews and document analysis. Merriam and Tisdell (2016)
wrote, “Interviewing is also the best technique to use when conducting intensive case studies of a
few selected individuals” (p. 108). Since I interviewed a very small and specific population,
interviews worked best to find out what was on the participants’ minds (Merriam & Tisdell,
2016). I collected data by reviewing the interview transcripts to answer the research questions
and better understand the phenomenon examined. One form of collecting data is via document
analysis (Merriam & Tisdell, 2016). Appendix A of this study lists the interview questions. Each
interview question had a potential probing question and addressed a research question. I
formulated each research question to examine how the environment of ERW impacts them
following Bronfenbrenner’s theory, including how their family, religion, society, and beliefs
shaped their mental health needs.
Document Analysis
Document analysis was a method and a form of collecting data. Document analysis is the
process of reviewing documents while examining and interpreting the data to gain an
understanding and knowledge about a subject (Bowen, 2009). Combining interviews with
document analysis assisted in the triangulation and quality of the data (Merriam & Tisdell,
37

2016). I analyzed documents from prior studies with ERW available through the University of
Southern California’s online library, open sources, and books. Documents assisted me in
understanding, gaining insight, and revealing significant data pertinent to the study (Merriam,
1988). Document analysis provides context and supplementary data, assists in drafting research
questions, helps track change and development, and supports verifying findings or evidence from
other sources (Bowen, 2009).
Data Collection Procedures
Data were collected from each interview. Interviews provide a platform for qualitative
data to be absorbed from participants about their opinions, knowledge, and experiences (Merriam
& Tisdell, 2016). Each interview lasted an average of 60 minutes and was conducted via Zoom.
The video was recorded and transcribed by the video platform. Since some of the interviews had
a sentence or two spoken in Tigrinya, I translated the material after the interview was complete. I
speak Tigrinya fluently and spoke a few words as a greeting to participants who spoke it. I
translated material in Tigrinya to English, and I was assisted by an Eritrean translator to ensure
the data’s accuracy.
Data Analysis
Data analysis started during data collection. I wrote analytic memos after each interview
and analysis of documents. I used a journal to document data during interviews and document
analysis. The journal had a running record of my interaction with the data, including decisions,
reflections, ideas, issues, or problems met with collecting the data (Merriam & Tisdell, 2016). I
documented thoughts, concerns, and initial conclusions about the data in relation to the
conceptual framework and research questions. I transcribed and coded interviews and
documents. In the first phase of analysis, I used open coding, looking for empirical codes and
38

applying a priori codes from the conceptual framework. In the second phase of analysis, I
aggregated empirical and a priori codes into analytic/axial codes. The third phase of data analysis
included identifying pattern codes and themes that emerged in relation to the conceptual
framework and study questions.
Validity and Reliability
Validity and reliability in a qualitative study provide rationale and information supporting
the study’s procedures while delivering sufficient evidence so that readers may conclude that the
results are trustworthy (Merriam & Tisdell, 2016). To promote validity during the study, I
performed member checks. Member checks solicited feedback on my initial or developing
findings from some of the participants I had interviewed (Merriam & Tisdell, 2016). By
performing member checks, I received feedback on preliminary findings to validate what the
participant said and ruled out misinterpreting the data. This was instrumental when translating
the Tigrinya language to English, making sure the correct meaning or experience was translated
correctly. Another strategy I used is the researcher’s position. The researcher’s position is how I
affected the research process or was affected by it (Probst & Berenson, 2014). As I am a refugee,
it was essential to explain my assumptions and biases, so the reader may formulate how I
deciphered the data.
Merriam and Tisdell (2016) defined reliability as the extent to which a study may be
duplicated and produce the same results. To bolster reliability, I used the same interview
questions with all participants and provided them the questions 48 hours before each interview,
so every participant had time to think and remember their experiences. I organized my thoughts,
problems, and questions in an audit trail via a journal to give a detailed account of how I
conducted the study and analyzed the data. A researcher documents their questions, reflections,
39

and decisions when collecting data to review issues, difficulties, or thoughts encountered
(Merriam & Tisdell, 2016). This assisted in improving reliability during the research by
capturing my thoughts, decisions, and assumptions.
Ethics
The study had underlying ethical considerations involving multiple participants. The
research served the interest of ERW, as the research revealed new methods to support them and
their mental health needs. These benefits may also extend to organizations that provide aid to
refugee women. Through the reflection of this study, some participants gained additional insight
into their experiences that may be helpful in assisting ERW with their trauma and mental health
needs.
Before conducting interviews or recruiting participants, I completed institutional review
board (IRB) training. After IRB training and certification, I submitted my proposal to the
University of Southern California for review and approval. An IRB reviews research to examine
whether participants could be at risk during the study and is a group located at a college or
university campus (Creswell & Creswell, 2018).
I explained the background of the study and the possibility of strong emotions surfacing,
gave each participant a written consent form, and reviewed it with them to answer their
questions. There was a waiting period of a few days after I gave the consent form to each
participant. During a waiting period, participants should be encouraged to reach out to their
families, friends, and mentors to discuss their possible participation (UCI, 2021). I reminded
participants more than once that the study was voluntary, and they could back out at any time.
Each participant saw the study as voluntary, and I explained the consent form while reminding
them that they could decide not to participate (Creswell & Creswell, 2018). By reviewing the
40

consent form, participants agreed to a set of standards that acknowledges the protection of
human rights (Creswell & Creswell, 2018).
Given the participants’ interaction with ERW and the possibility of feeling vulnerable, I
kept the highest confidentiality for each, which I explained in the consent form. I received
permission before recording any video or audio involving the participant, which was also
included in the consent form. I will keep raw data, instruments, and other materials related to the
study for 10 years. I will keep all materials, instruments, journals, and raw data secure and not
store them online where information may be compromised.

41

Chapter Four: Findings
This study investigated ERW’s various barriers, facilitators, and needs concerning their
mental health and the role of services within the Eritrean community in support of mental health
awareness. This study utilized Bronfenbrenner’s ecological systems theory to study the impact of
the surrounding environments on ERW mental health needs. An ecological perspective
emphasizes development as a function of the interaction between the evolving creature and the
enduring environments or settings in which it lives (Bronfenbrenner, 1975). The study focused
on attaining quality information, knowledge, and experiences of ERW. Questions were
developed and asked during the interviews to gain a deeper understanding and find themes
related to the research questions. Interviewing is essential when examining past events and when
there is a small number of participants (Merriam & Tisdell, 2016). The following research
questions guided this study:
1. What are the mental health needs of refugee women from Eritrea?
2. What are the systemic barriers and facilitators to mental health support for refugee
women from Eritrea?
The eight participants are service providers who have assisted ERW. I assigned them
pseudonyms to provide discretion and anonymity during this qualitative study. Of the eight
participants, six were women, and two were men. Additionally, six participants identified as
being Eritrean. Their experience ranged from 10 to 30 years in their respective professional
fields. Their professional backgrounds included human rights campaigns and work as physicians,
psychiatrists, and psychologists. Their ages ranged from 35 to 64, with most participants between
55 and 64. Table 3 lists their characteristics. The remainder of the chapter presents the interview
results and findings.

Table 3
Interviewees’ Characteristics
Participants
characteristics
Jeff (P1) Mary (P2) Mike (P3) Sabrina (P4) Helen (P5) Karen
(P6)
Erin (P7) Tracey (P8)
Age group 55–64 45–54 55–64 35–44 35–44 55–64 55–64 55–64
Ethnicity Eritrean
American
Eritrean
American
Eritrean
American
Eritrean
American
Eritrean
American
American American Eritrean
Canadian
Years of
experience
21–30 11–20 21–30 11–20 11–20 21–30 21–30 21-30
Occupational
field
Human
rights
campaigner
Human
rights
campaigner
Physician Refugee
advocate
and human
rights
activist
Human
rights
campaigner
Psychia-
trist and
trauma-
informed
social
worker
Physician Clinical
psychologist
Gender Male Female Male Female Female Female Female Female

Note. All participants were given pseudonyms.

42
43
Research Question 1: What Are the Mental Health Needs of Refugee Women From
Eritrea?
The interview data reviewed in support of Research Question 1 assisted in identifying
and understanding the needs of ERW. The results of data analysis showed that ERW require
various services to support their mental health needs. There were four key findings: (a) sexual
violence and torture trauma; (b) depression from unprocessed pain; (3) suicidal thoughts from
suffering; and (4) refugee integration frustrations. This section highlights the various factors that
influence the mental health of ERW. All eight participants discussed, in some form, that the
trauma that ERW experienced affected their mental health. To support their mental health needs
and deal with the trauma they endured, ERW require assistance for the findings detailed in the
following sections.
Finding 1: Sexual Violence and Torture Trauma
All eight participants acknowledged one or more examples in which ERW experienced
some form of sexual violence that negatively affected their mental health. Jeff stated that human
traffickers caught ERW when they were fleeing Eritrea and sexually assaulted them multiple
times throughout the day. Many ERW started their journey not pregnant but finished it either
pregnant or with a child conceived through sexual assault. The sexual violence ERW endured
during their journeys created a heavy trauma that caused multiple mental health problems,
including “mental breakdowns,” as stated by Mary. As Helen stated, “Honestly, it’s very
different for each woman, and I wouldn’t be able to disclose what this woman went through or
what that woman went through but what I can say is, um, they are raped, many women are raped,
some women become impregnated by the person that has raped them.” When following up with
Helen and asking if the events affected the mental health of ERW, she replied, “Well, 100%. I
44

mean, it affects their mental health, 100%.” As ERW try to escape Eritrea, they risk being shot at
the border and many horrifying events in neighboring countries, including sexual violence. As
Mike described,
Well, first of all, the first thing is to successfully leave Eritrea to go to the neighboring
countries, either to Sudan or to Ethiopia. The first thing, the first risk they encounter is if
they’re found crossing the border, they can get shot at and get killed trying to cross the
border. So, there are refugees of Eritrean men and women who have been shot trying to
cross the border. But once they cross the border and go into the neighboring country, and
they very often become victims of human traffickers. These human traffickers do a lot of
bad stuff to them. There is a lot of sexual violence. There is robbery. Some are killed,
[and] some are held for ransom, especially if the smugglers or the human traffickers are
aware that the refugees have family members that would be able to pay them the ransom
money.
Some ERW made it to Middle Eastern countries like Saudi Arabia, where they were
promised jobs as nannies or housekeepers for a family and were later enslaved to work for that
family. Erin described one situation: “You know, in a Gulf country, I mean [ERW are] literally
enslaved working from 6 a.m. to like 1 a.m. not even allowed to eat, you know. Some have been
sexually abused by the men in the household.” Those who experience this are constantly living in
fear each day until they can escape. While further speaking with Erin, she described how one
ERW escaped enslavement by a Saudi family when she was brought to America on a family trip,
and she ran away while the family was shopping. When speaking with Tracey about some of the
experiences of ERW during their journey to the United States, she stated,
45

For most of them, it might be going to Latin America and then coming [to the United
States], so that process, they have to overcome that process and as women, you know,
traveling with bunch of men and the coyotes that were taking advantage of them. They
could be raped. They could be sexually assaulted.
When speaking with Mary about how the sexual violence affected the mental health of ERW
who were traveling with children, she responded, “I don’t know if they can have a normal life,
knowing that their child went through what they went through also, as a child, so I think that it is
painful. Even to listen to, it’s very painful for me.” Not only do ERW have to worry about being
raped, but they also must worry about any children who travel with them, which causes
unmanageable stress on their mental health. During the interview with Mike, he stated, “They’re
very emotional about [traumatic experiences] when they talk about it, and they don’t easily open
up about it, especially those we suspect have endured sexual violence. They don’t open up and
don’t want to talk about it.”
When speaking with Tracey about the traumatic events ERW overcame and how it
impacted their mental health, she explained,
It’s cumulative, so it worsens the situation. They may say, for example, at home, and I’ll
give you two scenarios if back in Eritrea. The major problem was depression because of
lack of freedom of any sort right or anxiety, but then they leave, and they have now faced
trauma, whether they were raped or any trauma. The trauma itself will be a very difficult
experience to begin with, but at least it’s one trauma; it’s not cumulative. But then, the
other scenario is if they were tortured, if they were raped, and then that now they come to
Sudan or whatever. Then, that journey itself has another element of trauma if they were
harassed or sexually abused. That adds up. So, instead of a single trauma, it becomes
46

cumulative trauma now. Trauma is very subjective, right, so one experience, one
traumatic experience, can be very, very painful, or cumulative one could be painful, too.
Still, it just adds on, that’s what I’m trying to say, so it becomes more difficult.
While living in Eritrea and during their journey to the United States, many ERW
experience torture if human traffickers catch them. Being tortured has led to many mental health
illnesses among ERW that require assistance. When speaking with Karen, she indicated,
Basically, they felt their lives were in danger. So, basically state-sponsored torture.
Typically, being tortured most commonly by the military or other government operatives.
Many of them had been detained or in prison for long periods of time, typically as
political dissidents. Sometimes due to religious reasons and repeatedly tortured, typically
over an extended period of time, always psychologically tortured part of that, among
other things, would include threats, like death threats and threats to harm other family
members, including sometimes their children.
Mary described the torture one ERW experienced, which was detailed: “And this lady, she has
extensive trauma.” Karen spoke about the torture one woman she worked with experienced:
I’m just thinking about the Eritrean women that I’ve worked with, physical torture. I
think all of them experienced some physical torture. Often severe, some of them, quite a
few of them, had physical injuries. Sometimes lasting scars, sometimes some significant
health problems, and again we had an interdisciplinary team, so I worked closely with
physicians in my office, and, unfortunately, a number of them also experienced sexual
torture.
Given these findings, ERW require various forms of support, including mental health, to deal
with the trauma they carry from being tortured. Mary spoke in detail about multiple instances
47

involving ERW traveling through Libya and being caught, tortured, and imprisoned by human
traffickers:
I mean, just unthinkable things when they were in Libya. They can live in a container for
a year, some of them and more. When it is cold, it’s freezing cold in a metal container.
When it is hot, it’s 120 degrees. So, it is not a good place for the mothers or for their kid
not seeing the sunlight for that long. I wonder what it does to their health. Mental health
without sun exposure, it gets worse.
Mary further stipulated that ERW who were caught by smugglers and kept in containers suffer
from fear and anxiety, not knowing if they would ever be free from the imprisonment and torture
they endured. As a result of torture, many ERW need mental health support for anxiety and fear.
Some ERW believed the torture would never end, and thoughts of suicide during the event also
affected their integration into the United States, as described by participant Karen. The torture
that ERW experienced had a profound impact on their mental health. As Karen stated,
I had a client who was tortured and who would be brought in by her sister periodically,
saying she was not functioning well. The client did not want her sister to know that she
was tortured, some in sexual nature, because she did not want to be judged by her.
Finding 1 was that ERW have suffered sexual violence that has had a heavy toll on their mental
health. They suffer from many symptoms caused by torture, including fear, anxiety, and physical
and mental scars that damage their mental health. Thus, ERW require services to assist their
mental health needs in relation to trauma caused by sexual violence and torture.
Finding 2: Depression from Unprocessed Pain
The results showed that ERW have faced numerous forms of trauma, causing many to
suffer through bouts of depression that disturb their day-to-day lives. These bouts of depression
48

have had a negative impact on their lives and require proper mental health support. A common
topic among all eight participants was that ERW try to avoid, repress, and forget their traumatic
experiences, hoping they would vanish from their thoughts. Not being able to open up and
suppressing their feelings led some ERW into depression. Helen mentioned,
One hundred percent, it’s very difficult, you know. Forget a refugee woman, just a
woman who is living with normal status goes through something traumatic, and it’s very
difficult to open up. So, being a refugee, you’re considered, you know, they’re voiceless
in the first place, and then they’re invisible to people to the world. So, just because of
their status alone, it’s very difficult for them to find that type of solace to open up to
anyone.
Not only do ERW have to deal with the pressure of being a refugee, but they often must
deal with the troublesome thoughts of the family they left in Eritrea. Karen described a story of
one of her ERW clients:
I remember one Eritrean woman telling me who’s had a couple of her children murdered
by the authorities when they were looking for my client back home. Tell me, wouldn’t
you be depressed, too? You know, if they tell me I’m depressed, but wouldn’t you be
depressed, too, if your children were murdered, you know, because of you, and so this is
a classic example of, like, that’s the normal course that’s not, and she didn’t want to in a
way. Her depression was a way of keeping her children’s memory alive. Eventually, she
learned to find other ways to do that.
Finding 2 was that ERW live and suffer through depression from the trauma they withstood.
Therefore, they require mental health assistance to deal with the depression that formed from the
unprocessed pain.
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Finding 3: Suicidal Thoughts from Suffering
Six of the eight participants described different events where ERW discussed having
thoughts of hurting themselves or committing suicide due to the trauma they experienced and not
receiving proper mental health support for it. When asked about ERW having thoughts of hurting
themselves or committing suicide, Helen replied, “Yes, absolutely because they feel like maybe
this is a way out of the pain, for sure.” Tracey stated, “I mean therapy is working on the
underlying issue causing that kind of suicidal self-harm behavior, and where it’s appropriate, I
would recommend medication.” Participants described that ERW who experienced torture had
thoughts of suicide due to believing that their torture and sexual assault during their journey
would never end. Karen explained that some ERW had suicidal thoughts due to being separated
from their family in Eritrea and worrying about their safety while blaming themselves.
While speaking with Mary about an ERW who was raped and was giving birth to her
rapist’s child, she stated the ERW said, “If I see that child, I’ll kill that child and hurt myself.”
When asking Mike about suicides among ERW, he mentioned, “Yeah, there are incidences of
suicides. I don’t have a specific statistic, but we hear quite a bit about suicides of those refugees
who after all kinds of problems finally arrive in Europe or the United States.” I asked Karen the
same question about suicidal ideation. She said, “Yes, some of them suicide was an active
concern that I had to attend to.”
During the interview with Jeff, I asked him if ERW discussed having thoughts of suicide
or hurting themselves. He replied, “Many situations, yes. Because of the desperation, it would
look like there was no help. I mean, many of them did try to [kill] themselves. Yes, in some
cases, there were a few that jumped from three-story buildings.” In response to the same
50

question, Mike mentioned there were incidences of suicides among ERW, and when the
opportunity was available, mental health support would be provided.
Finding 3 pertained to the impact of trauma and suicidal ideation, which is a dramatic
impression on ERW mental health. This population requires services for suicidal ideation that
supports their mental health.
Finding 4: Refugee Integration Frustrations
Once they make it to the United States, ERW still face many stressors that affect their
mental health. These stressors include learning a new language, finding a job, raising a family,
adjusting to a new culture, and dealing with their trauma, as all eight participants mentioned.
Participants stated the importance of ERW receiving assimilation assistance through the Eritrean
diaspora, mental health education, and medical services to assist their mental health needs.
Another participant, Mike, mentioned, “I’ve met some married couples, who came here, and
assimilation has been more difficult for them because they are often not well educated, and
they’ve been traumatized. They had very traumatic experiences, so assimilation has been a
problem.”
Although integration into a new society has privileges for ERW, such as freedom of
movement, being able to work, a chance of an education, and not being harassed, the many
options they have now and did not have before can be an extra layer of stress. As participant
Sabrina mentioned, “Having these new freedoms is a big mental, psychological, and physical
freedom, but having those freedoms comes with challenges. All these new options can create a
lot of stress and frustration.” Finding 4 exhibited that even after ERW arrive in the United States,
they still face many new stressors integrating into a new country that affect their mental health
state and require adequate support.
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Summary of Findings for Research Question 1
Research question 1 focused on the mental health needs of ERW. The findings uncovered
four key findings that influenced their mental health: (a) sexual violence and torture trauma, (b)
depression from unprocessed pain, (c) suicidal thoughts from suffering, and (d) integration
frustrations. Unraveling each finding provided concentrated and thorough narratives of the
experiences of ERW concerning their mental health. Table 4 shows the summary of the findings
for Research Question 1.

Table 4
Summary Table of Research Question 1 and Findings (Themes)
Research question

Findings
What are the mental health
needs of refugee women
from Eritrea?

Sexual violence and torture trauma
Depression from untreated pain
Suicidal thoughts from suffering
Refugee integration frustrations

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Research Question 2: What Are the Systemic Barriers and Facilitators to Mental Health
Support for Refugee Women From Eritrea?
The interview data reviewed in support of Research Question 2 helped identify and
understand the different forms of barriers and facilitators to mental health support for ERW. The
results of extensive data analysis showed that ERW battle multiple barriers and have multiple
facilitators for their mental health needs. Finding 1, barriers, included sub-themes of shame and
stigma; absence of psychiatric support in Eritrea; and lack of resources and education. Finding 2,
facilitators, included sub-themes of family and community support systems. In the following
sections, I examine these findings to better understand obstacles to and enablers of mental health
support. This section highlights the various barriers and facilitators to mental health support for
ERW.
Finding 1: Barriers
During the study, multiple barriers came up that affected the mental health of ERW in a
negative way, including shame and stigma, absence of psychiatric support in Eritrea, and mental
health awareness, education, and resources.
Shame and Stigma
Some barriers preventing ERW from getting mental health support are shame and the
cultural stigma surrounding mental health. During the interview with Jeff, he stated, “Back
home, believe it or not, it is shameful to admit that you have a mental health problem. So,
mostly, if it exists, it will be hidden from the family and community.” Due to the stigma in the
Eritrean culture surrounding mental health, it is challenging to get ERW to come forward. Mike
detailed, “The challenge we meet [is that], if they have been exposed to gender-based violence,
53

they do not want to attend [therapy]. They do not want to talk about it, so that is also a
challenge.” About the barriers faced in getting ERW mental health support, Mike replied,
Well, as you know, there is a stigma to any kind of mental health issue in Eritrea and the
community. Then, you know, even if they see a mental health professional, they are not
willing to share, so I think there is a cultural barrier to seeking mental health care.
During the interview with Sabrina, I asked if any ERW she worked with shared their
mental health concerns with their families. She replied by detailing that none have due to the
shaming and people considering them “mad or crazy” for receiving mental health support.
Stigma also keeps ERW from speaking about their traumatic experiences. Tracey said that ERW
attend therapy, get more social support, and work on underlying issues causing self-harming
behaviors, but they do not want to talk about those underlying issues due to stigma. Tracey went
further: “You know, there’s stigma towards mental health, mental well-being, and mental illness
in general because therapy and mental illness or mental health is not very well known or defined
in our Eritrean community.” Karen, who assisted ERW with the asylum process in the United
States, mentioned that some women failed to submit their asylum applications within the first
year of being in the country due to the shame and stigma of revisiting their traumatic
experiences. This was the case for many ERW Karen assisted because they feared speaking
about their traumatic experiences due to the cultural stigma and shame surrounding their trauma
and mental health. Many ERW were terrified of someone in their community finding out they
were receiving mental health support and being labeled.
When I asked Helen if she faced any challenges from stigma when trying to get ERW
mental health support, she replied, “Absolutely, I think, culturally it’s sometimes hard for them
to open up and talk about what’s happened to them during the voyage, during their journey,
54

yeah, it’s very difficult because of the cultural stigmas.” I asked Tracey the same question, and
she confirmed that stigma played a role in getting ERW support due to mental health not being
very well known or defined in the Eritrean community and the possibility of being labeled as
“depressed, crazy, or insane.” When I questioned Jeff about whether he faced challenges when it
comes to stigma and getting ERW mental health assistance, he stated, “In most cases, yeah, is it
hard for them to come talk to you or ask for help, or anything like that. You have to establish
some trust, and the other challenge [is that] I’m a man.”
Shame and stigma continue to remain strong barriers to supporting the mental health
needs of ERW. The fear of being labeled has driven ERW to keep their needs internal and keeps
them from coming forward to receive proper mental health support.
Absence of Psychiatric Support in Eritrea
For many ERW, the first time they received mental health support was outside Eritrea
due to the lack or absence of mental health resources available in the country. Five of the eight
interviewees mentioned the absence of psychiatric support in Eritrea. Mike replied with very
little or none and stated, “Someone I personally know, and I don’t think there are that many, but
a senior psychiatrist has been in jail for 15 years for his religious beliefs.” Sabrina told a similar
story about the only psychiatrist in the country of Eritrea being detained by the government in
2004. He has not been seen since his detainment. When I asked Tracey the same question, she
mentioned there was no psychiatric support available in Eritrea, which is why it is beneficial for
ERW to leave the country. Tracey further explained, “While [the family] give the emotional
support, they’re not the experts, so they may not be able to deal with the trauma.” Even if ERW
wanted to come forward and receive mental health support, it is nearly impossible to do so
55

because of the lack of psychiatric support available in Eritrea. This constitutes a large barrier to
overcome for ERW.
Mental Health Awareness, Education, and Resources
One of the barriers keeping ERW from receiving proper mental health support is the lack
of resources available, including mental health education in the United States. Discussing
barriers she faced getting ERW mental health support, Sabrina replied, “Resources. We don’t
have resources.” She went further: “We’re trying to find resources because most of the civil
society organizations, I’m telling you, are nonprofit and have funding issues. Being under-
resourced and can’t have volunteers forever.” When speaking with Mike about barriers, he said,
“It’s a financial barrier, you know, and a lack of professionals who are able and willing to help
them.” Erin, who is a physician and works at an organization that supports ERW, stated, “Well,
we have, I mean, at this minute, our clinic has, I think, not a single therapist. It’s horrible. It’s a
large clinic, there’s a mental health program, and the therapists just keep quitting.”
Two participants said that organizations and resource centers should be created to support
ERW. Helen said,
There needs to be an organization out there that starts this support while they’re on their
journey. Like, there should be an organization in place that can support them, that they
can call and not wait until they reach their final destination; it’s too late. I don’t know
how realistic that is, but there should be an organization they can turn to when they’re on
their journey.
When speaking with Sabrina, she stated,
I think to create a physical space or resource center. I think that’s very critical; we need to
have a service center where mental health, of course, one of the biggest aspects of it, you
56

know, it could be mental health, medical, and social services. The counselors would have
vocational training. Getting to know your new home kind of thing, you know, you are
educating them about the nuances of being in America.
Tracey spoke about the need for access to information and mental health education.
Tracey stated, “Most of the time, what they lack is information.” She further described how some
ERW do not share information with others because they believe they will lose some power from
the information they hold. Mary stated, “They have language and cultural barriers. They have no
idea what is there, what is out there, and I think they get frustrated.” Educating other ERW who
need the same mental health resources is challenging. Tracey stated,
If an outside person like myself or anyone who works in mental health can educate the
woman, not only about the resources in the community or the community at large but
how to access it and make it easier for them to access it, that will lower not only the
stigma, but at the same time, also educate them about their rights, right.
Raising awareness about mental health education among ERW has been difficult due to
the stigma around it. Helen stated,
Raising awareness and the fact that they’ve been through so much trauma and, within
that, letting them know the services that exist, like therapy or any anything, you know,
anything behavioral type of health. I don’t choose my words carefully because when you
say psychiatric or psychological, they’ll say, “Oh, I’m not crazy.” Again, stigma.
When it came to awareness and education, Tracey stated, “Not only do we need psycho-
education and awareness of their rights but also self-awareness, so that they don’t play their own
issues through their children.” The shortage of resources, mental health awareness, and education
57

remain strong barriers to mental health support. Not having sufficient resources or knowledge to
understand the need for mental health support is an item that needs to be addressed promptly.
Finding 1 pertained to the barriers affecting ERW, including shame and stigma, the
absence of psychiatric support in Eritrea, and the lack of mental health awareness, education, and
resources. If these barriers are left unbroken, ERW will continue to suffer from not receiving
proper mental health support.
Finding 2: Facilitators
During the study multiple facilitators came up that affected the mental health of ERW in
a positive manner including family support system and community support system.
Family Support System
All eight participants described ways ERW have engaged in mental health healing from
the traumatic experiences they endured and still live with daily. Responses from the participants
highlighted many ways ERW engage in healing, one being their families’ support. When asked
about healing in ERW, Sabrina affirmed, “I think the support system is the biggest part I see. …
A family or a support system. It can be your friend, too, I mean, if a friendship is very strong,
also among the community.” Many ERW leave their immediate family behind when fleeing the
country, and they often worry about their family possibly being killed or facing reprimand from
the government for them escaping. Participant Karen told me about one ERW she supported who
worried and stressed about the children she left behind and was finally reunited with them in the
United States after 10 years; it alleviated a lot of the stress in her life and improved her mental
health. Karen further stated, “A number of the women that I’ve seen, an important part of their
healing has been a focus on family and the next generation, you know, really wanting to nurture
and support their own children, or grandchildren, or nieces, or nephews.”
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As ERW continue to live their lives, assimilate into the U.S. culture, and find different
ways to heal from their traumatic experiences, having a family support system helps and has
become an important feature in their healing process. Table 5 highlights essential experiences the
participants shared regarding ERW and how important family is to improving their mental
health.

Table 5
Facilitators to Mental Health Support/Healing: Family Support System
Family support system
Jeff In some instances, that newfound love, family, care, purpose in life, I think that will
give them a way in order to heal themselves.
Mike When some of them come, you know, to this country and get a job, have families,
and live successfully.
Karen In the US, you know, with a different range of opportunities available to them, to
their children, or their grandchildren that perhaps they didn’t have. So, I think that
has been very healing and positive for a number of the Eritrean women I’ve
worked with.
Tracey There is no psychiatric support in Eritrea. Another way to set up just organically are
the families, the support of the family.

59

Community Support System
Support by the Eritrean community is vital in raising mental health awareness and
removing the stigma around it. When I asked Jeff how the Eritrean community perceives the
services he provides ERW, he responded, “Wow, it is well received, and they keep encouraging
you to keep going. They know it is time-consuming, taking care of families in order to help the
community.” When speaking with Mike about raising mental health awareness with ERW and
their community, he commented, “If they live close to each other, they can support each other. If
they can integrate themselves with the Eritrean community in the diaspora and use religious
institutions as a source of support, whether churches or mosques.” This goes to show how
important it is to have the support of the community to raise mental health awareness and break
stigmas. Some ERW want to give back and support current women refugees embarking on the
same journey they traveled. Participant Mary described some of the ERW she worked with by
stating,
They would want basically to help whoever is left in Libya once they can; they want to
do what we’re doing. That made my day because I had no clue, but I’m trying to reach
out and help them, but they’ve seen it; they’ve seen everything over there. The fact that
they will not forget those people who are left in Libya, it really made me happy.
Although community support is important, some participants stated that some ERW are
afraid to share that they escaped to the Eritrean diaspora community for fear of being reported
back to the Eritrean government and what might happen to their family members. For ERW,
connecting and integrating into their community had a positive impact on their mental health.
Table 6 emphasizes the significance of community support in facilitating mental health support
and improvement for ERW.
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Table 6
Facilitators to Mental Health Support/Healing: Community Support System
Community support system
Karen
Well, I’ve seen them do, you know, coffee ceremonies, sharing food, and we did a lot of
that at our women’s group and also the healing club. … They would tell me about
how they would gather, you know, at other venues, or just go to, you know, get
together on the weekends, or when they weren’t working, gather around food
together.

I mentioned a number of the women who I worked with, you know, had been harmed
and tortured because of their political activism or religion and what I found with
Eritrean women, but also other torture survivors, is that, you know, when you’ve been
tortured because of some important part of your identity that, for some, they may lose
faith or feel to you know threatened to be able to engage with that work or that you
know or some of them lost their faith for a while. But it’s a real sign of healing and it
can be an important component to healing when they’re able to reconnect and to
reclaim and, you know, that important part of their identity and a lot of that was, you
know, was done in the community.
Helen
We would hold seminars. We’d bring women together. Many of them are refugees and
in that time, you’d have, like, discussions and, like, heart to heart, you know
conversations with them.
Erin
Her connecting to her community is healing towards her. She likes to bring me other
patients, you know, oh, this one is really sick, can you take care of her? So, you know,
I think reaching out to her community. You know, she finds it helpful. … Like, you
know, oh this person’s worse off than me, but, you know, please come see my doctor.
She’ll help you with that kind of thing.
Tracey
You know, coming together to fundraise, for whatever reason, back home or coming
together when, you know, a member of the community dies and supporting the
person. For example, one, she lost her husband, so there’s a lot of support to help her.
So, those groups that just form organically, you know, and help. They’re both helpful
and sometimes they can be not helpful because then they get into their small groups
and they don’t integrate, but those are the things that they do, that they come, you
know, together as a group.
Jeff
By helping others because a lot of times, you are already familiar. … Very
understanding, they know their pain.

There are a lot of Eritrean community doctors, counselors, and professionals that are
reaching out to help.
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Summary of Findings for Research Question 2
The results pertaining to Research Question 2 revealed several barriers and facilitators
regarding ERW’s mental health support. Finding 1, barriers, with sub-themes of shame and
stigma, absence of psychiatrist support in Eritrea, and lack of mental health awareness,
education, and resources, revealed obstacles ERW face in receiving mental health support.
Finding 2, facilitators, with sub-themes of family and community support, unearthed elements
that assist ERW in their mental health support. Some barriers are interwoven into the Eritrean
culture, making it very difficult for ERW to break through those barriers and acknowledge that
they need help. Table 7 shows the summary of the findings for Research Question 2 and the sub-
themes that emerged under Findings 1 and 2.

Table 7
Summary Table of Research Question 2, Findings (Themes) and Sub-Themes
Research Question Findings Sub-Themes
What are the systemic
barriers and facilitators
to mental health support
for refugee women from
Eritrea?
Barriers Shame and Stigma
Absence of Psychiatric Support in
Eritrea
Mental Health Awareness,
Education, and Resources

Facilitators Family Support System
Community Support System

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Summary
This chapter provided an overview of the findings pertaining to this study’s two research
questions. It shared the experiences of eight participants who have directly worked with and
assisted ERW with their mental health needs. The participants’ stories depicted the trauma,
violence, and various struggles ERW withstood and the impact on their mental health. Although
facing impossible odds, ERW displayed resilience and healing, overcoming the struggles of
integrating into a new country while dealing with their trauma, as shared by stories from the
participants of this study. The study generated five key findings with five sub-themes that
recognize the difficulties encompassing ERW’s journey through multiple life stages while
navigating and trying to satisfy their mental health needs. Table 8 summarizes the key findings,
including the sub-themes.

Table 8
Key Findings: Eritrean Refugee Women and their Mental Health Needs
Eritrean refugee women and their mental health needs: Key findings
RQ 1: What are the mental health needs
of refugee women from Eritrea?
RQ 2: What are the systemic barriers and facilitators to
mental health support for refugee women from Eritrea?
Sexual violence and torture trauma Barriers

Shame and stigma: Absence of psychiatric support in
Eritrea; mental health awareness, education, and
resources
Depression from untreated pain Facilitators

Family support system, community support system
Suicidal thoughts from suffering

Refugee integration frustrations

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Chapter Five: Recommendations
This study investigated ERW’s various barriers, facilitators, and needs concerning their
mental health and the role of community services within the Eritrean community in supporting
mental health awareness. The following research questions guided this study:
1. What are the mental health needs of refugee women from Eritrea?
2. What are the systemic barriers and facilitators to mental health support for refugee
women from Eritrea?
This chapter concludes by discussing the findings identified in Chapter Four and
recommendations for future research. The recommendations will be reinforced by academic
literature centered on the theoretical framework for this study. The chapter concludes with
limitations and delimitations of the study and recommendations for future research.
Discussion of Findings
During this study, participants discussed the relationship between the mental health of
ERW and their environment. The findings aligned with Bronfenbrenner’s ecological systems
model and what was presented in the literature review in Chapter Two. Bronfenbrenner
described his theory as comprised of systems at four levels: the microsystem, mesosystem,
exosystem, and macrosystem (Bronfenbrenner, 1977). In the microsystem, ERW’s mental health
was heavily influenced by their immediate environment, including their family, friends, peers,
and church. The interactions ERW had with their immediate environment negatively and
positively impacted their mental health. Family separation causes distress among refugees, and
they need to maintain contact with family members to maintain a state of being emotionally
connected, which can improve their mental health (Shah et al., 2019). The relationship between
ERW and their hospitals represents the mesosystem in Bronfenbrenner’s ecological model. As
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mentioned, ERW have been affected negatively by the lack of mental health hospitals and
resources in Eritrea. There is only one mental health hospital in Eritrea, Saint Mary’s Neuro-
Psychiatric Hospital, and it is in Asmara, the capital (Amahazion, 2021).
Also, ERW’s mental health has also been affected negatively by the indefinite military
service in Eritrea, which has caused thousands to flee the country; this falls under the exosystem,
where the relationship between major societal institutions and a person’s environment is
examined. This call to indefinite national military service has created a generation of refugees,
such that at the end of 2015, there were over 475,000 Eritrean refugees (Plaut, 2017). The most
significant factor affecting the mental health of ERW is the shame and stigma surrounding
mental health in their community. This directly correlates with the macrosystem, which assesses
how cultural beliefs may affect a person’s development in their environment. One of the top
reasons refugees do not access mental health services is the stigma associated with it (Shannon et
al., 2015). This study’s findings address the problem of practice by identifying the lived
experiences of ERW and how they impact their mental health.
During the study, several recurring themes were revealed to affect the mental health of
ERW. Those significant findings included sexual violence and torture trauma, suicidal thoughts
from suffering, and depression from untreated pain. When examining the findings,
Bronfenbrenner’s ecological model was used to understand how the environment of ERW
influenced their mental health needs. Participants revealed several systemic barriers and
facilitators that either positively or negatively affected ERW when receiving mental health
support. The most significant barrier was shame and stigma, while the most significant facilitator
was family and community support. Shame and stigma play into Bronfenbrenner’s macrosystem
and how cultural beliefs affect a person. Family and community support directly relate to
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Bronfenbrenner’s micro and mesosystems and how family, including community, influences
whether ERW will come forward or not to receive mental health support.
Sexual Violence and Torture Trauma
Participants during the study disclosed the negative impact sexual violence and torture
had on the mental health of ERW. Depression, PTSD, anxiety, and long-term psychological
problems affect victims who have experienced sexual violence (Watta, 2013). Trauma and
sexualized violence in conflict areas are linked to grief, acute stress disorders, and psychological
distress in women (Yohani & Okeke-Ihejirika, 2018). When a person experiences torture, war,
and human rights violations, they are more susceptible to mental illness (Murthy, 2006). The
study findings revealed that ERW experienced different mental health illnesses related to the
sexual violence and torture they endured and were more susceptible to these deplorable acts than
men. Lastly, women are more at risk of experiencing sexual gender-based violence during
conflicts than men (Nawyn et al., 2009).
Suicidal Thoughts from Suffering
Since ERW have suffered through different forms of trauma that have negatively affected
their mental health and caused forms of mental illness, participants described moments where
ERW contemplated and acted on thoughts of suicide, believing their suffering would never end.
Windfuhr and Kapur (2011) stated that suicide risk is most associated with mental illness and
increases the risk of suicide between five- and 15-fold compared with the general population. As
a woman’s virginity and chastity are highly regarded in much of Eritrea, many victims of rape
are unable to marry and, therefore, prefer to remain silent; in some instances, women and girls
who were raped committed suicide (UNHCR, 2016). Rather than suffer in silence, some ERW
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commit suicide due to multiple causes such as societal pressure and the shame of being a victim.
Suicide is hardly the effect of a single cause and is multi-layered (Windfuhr & Kapur, 2011).
Depression from Untreated Pain
During the study, all participants mentioned that the ERW they assisted had suffered
from depression that affected their mental health. Research has shown a strong connection
between forced migration and mental health disorders in refugees displaying high levels of
PTSD, anxiety, and depression compared to host nations (Solberg, 2020). Since many ERW are
afraid to come forward, seek help, and speak about their trauma, their illnesses manifest in
different ways, including depression. Depression, PTSD, anxiety, and long-term psychological
problems affect victims who have experienced sexual violence (Watta, 2013). The study findings
demonstrate that ERW experienced bouts of depression caused by their traumatic experiences,
which directly affected their mental health.
Barrier: Shame and Stigma
The most common barrier and theme that kept coming up among all participants is the
shame and stigma surrounding mental health in the Eritrean community, which keeps countless
ERW from seeking appropriate mental health support. Despite suffering from mental health
issues, refugees are less likely to seek mental health assistance due to cultural norms and
practices, lack of information, and mental health stigma (Shannon et al., 2015). Victims of sexual
violence and rape often suffer long-lasting mental pain, isolation, and stigmatization; this directly
affects the overall mental health of ERW (UNHCR, 2016). Due to the stigma of mental health,
many ERW remained silent out of fear of being labeled as crazy or weak or seen as unsuitable
for marriage, which brings shame on their family. Eritreans with mental illness experience
ridicule or blame, encounter exclusion or isolation, are considered unfit for work or marriage,
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and are often considered dangerous (Amahazion, 2021). Most of the shame and stigma ERW
faced came from fear. Many stigmas come from fear, fear that women will be discriminated
against, fear of bringing shame to their families, and fear of being seen as weak (Amahazion,
2021; UNHCR, 2016).
Facilitator: Family and Community Support
Family and community support was the most significant facilitator that encouraged ERW
to seek mental health support and improve their mental state during the study. Family separation
caused distress among refugees, and they needed to maintain contact with family members to
maintain a state of being emotionally connected to improve their mental health (Shah et al.,
2019). Many participants described how being separated from family caused emotional distress
but explained that mental health improved when the family was reunited. Many refugees strive to
reunify with their family members in their host country, which can alleviate the stress refugees
face when thinking about their families being in danger (Löbel & Jacobsen, 2021). Participants
described that the family is the core of the Eritrean culture, and the decisions ERW make are
based on their family values, which directly affects whether they will seek mental health support.
Many experts in the refugee mental health field state that the family is the most important factor
in refugee communities (Miller & Rasco, 2004).
Participants stressed the importance of ERW integrating into their new country and
seeking community support if available. During the study, participants described how significant
it was for ERW to have a sense of community belonging to aid their mental health support.
Sufficient social support is connected with mental health and well-being, whereas the opposite is
a risk associated with mental illness and psychological stress (Puyat, 2013). Even though
refugees use their family and friends for support, they also use their ethnic community to cope
68

and adapt to their new life (Schweitzer et al., 2007). Participants said that using community
resources such as mosques and churches and volunteering to help other refugees improved the
well-being of ERW. Community and social support were critical for African female survivors
living in the United States who experienced conflict-related sexualized violence (Akinsulure-
Smith, 2014).
Recommendations for Practice
Based on the findings of this study, this section presents recommendations that may
improve services in the Eritrean community and help support ERW mental health. The
recommendations are based on findings that depicted strategies and solutions to improving and
expanding mental health support for ERW. By focusing on building mental health awareness,
this section focuses on the removal of barriers. In addressing the need for individual or group
therapy, this section highlights the benefits of therapy. By establishing Eritrean community
centers, this section describes practices that may be put in place to assist ERW.
Recommendation 1: Build Mental Health Awareness in Eritrean Community
This study showed that the lack of mental health awareness and education contributed to
barriers such as shame and stigma in the Eritrean community and ERW. Despite suffering from
mental health issues, refugees are less likely to seek mental health assistance due to cultural
norms and practices, lack of information, and mental health stigma (Shannon et al., 2015). These
barriers will continue to play a dominant role in the Eritrean community until proper steps are
taken to educate and build mental health awareness.
As demonstrated in the study, Eritrean communities play a prominent role in facilitating
mental health support. Therefore, community members should be trained on their roles in mental
health barriers, such as how shame and stigma are seen and spread in the community.
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Implementation of mental health education and awareness training should be incorporated in
these communities. The implementation process is a two-prong approach that addresses the
following needs: (a) mental health education and (b) building mental health awareness. The
recommendation has two phases:
• Phase 1: Reach out to Eritrean community leaders, including churches and mosques,
to receive buy-in, as it is essential to have their support before moving forward. Once
receiving buy-in, the next step is scheduling and conducting mental health education
training that encompasses two 1-hour presentations taught within 7 days. The
presentations will be given in Tigrinya and English to ensure everyone in the
community may understand what is taught. The material will go over what mental
health is, including contributing factors such as biological, family history, and life
experiences. Additionally, symptoms related to mental health problems will be
covered, how they impact a person and community, and how to possibly identify
those symptoms. There will be open forums after each presentation to answer
questions. Lastly, information will be provided on resources available to assist with
mental health issues and self-care.
• Phase 2: This phase includes receiving feedback on the training from the community
leaders and members. Feedback is vital to have the learner reflect on what they
learned, understand if what was taught was understood, and identify whether the
community’s mental health barriers are being breached. The next step is to
incorporate feedback and refine the training plan to improve learning after receiving
feedback. Significant reasons for evaluating the training plan include (a) improving
the program, (b) maximizing the transfer of learning to behavior and proceeding
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program results, and (c) demonstrating the value of training to the community
(Kirkpatrick & Kirkpatrick, 2015). The plan will be to continue mental health training
quarterly to serve new community members and to distribute any new mental health
information received to community members.
Finally, I am recommending any resources including organizations and publications that
have research related to community engagement with refugee communities, which may assist the
Eritrean community in addressing shame, stigma, and mental health needs.
Recommendation 2: Individual or Group Therapy
The second recommendation is to encourage ERW to take advantage of individual or
group therapy in addressing their mental health needs. The study revealed the various types of
traumas that ERW have encountered that have caused depression, PTSD, suicidal thoughts, and
long-lasting mental pain. Therapy would allow ERW to treat a mental health condition, address
symptoms, and improve their quality of life. This population requires mental health treatment
because, if left untreated, it may cause severe behavioral, emotional, and physical health
problems (Mayo Clinic, 2021). The American Psychological Association (2021) has stated that
about 75% of people who try mental health therapy find it helpful. With a high rate of people
finding therapy beneficial, it is essential for ERW to be engaged in it. Therapy has many
potential benefits that include increased happiness and life satisfaction, improved sleep, better
communication skills, development of coping skills, improved mental functions, better
relationships, and improved management of behavioral health challenges (APA, 2021). The need
for mental health care is so essential for refugees that one of the public health objectives of the
UNHCR is to improve and increase mental health care access and psychiatric referrals for
refugees (UNHCR, 2014).
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Although individual and group therapy are recommended, due to the stigma and shame
surrounding therapy in the Eritrean community, other language is encouraged to be used to make
the therapy sessions more welcoming. This includes using the term counselors rather than
therapists, group support rather than group therapy, or calling the therapist a doctor, physician, or
adviser to assist getting through those barriers. Minor changes to the language will go a long way
in getting ERW adequate mental health support and making them feel more comfortable.
Individual Therapy
Individual therapy is helpful for ERW who do not feel comfortable speaking about their
trauma in a group therapy environment due to the shame and stigma surrounding therapy in the
Eritrean culture. There are many forms of individual therapy, but I believe cognitive-behavioral
therapy would provide the most benefit. This type of therapy is entrenched in the thought that
most behavioral and emotional reactions come from our way of thinking about our environment
and ourselves (Gonzalez-Prendes, 2016). This thinking is important because it ties into
Bronfenbrenner’s ecological systems model and the impact one’s environment has on an
individual. Cognitive-behavioral therapy addresses an extensive collection of psychosocial issues
supported by wide-ranging research (Dobson & Dobson, 2009); its efficacy has been validated
by over 325 published outcome studies (Butler et al., 2006). It was also discovered to be four
times more effective for culturally homogeneous groups than for culturally heterogeneous groups
(Haefner et al., 2019). With ERW experiencing many forms of trauma and mental health issues,
it is imperative to have a therapy that may address many matters.
While CBT is recommended, there are many different forms of trauma-focused
treatments that would be highly beneficial to ERW. Trauma-focused treatments highlight and
understand how traumatic experiences impact a person’s overall well-being. Trauma-focused
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treatment will offer ERW the copings skills required to process memories and emotions tied to
their traumatic experiences and assist in constructing a healthier and further adaptive meaning of
them.
Individual therapy is not only crucial for ERW to heal, but it also shields them from the
shame or stigma they might feel in receiving mental health support and provides confidentiality.
Since language may occasionally be a barrier, ERW may bring in someone they trust to translate,
as was described by some of the participants in the study in assisting ERW. Trauma manifests in
different ways, including stomachaches, sleep issues, dietary changes, pain, and headaches
(Abrams, 2021). It is vital for ERW to receive therapy and develop coping skills to manage their
mental health problems appropriately. Due to the symptoms they might exhibit, individual
therapy might be best for some to receive more specialized individual care. Individual therapy
may be customized to each ERW’s needs, providing more flexibility when scheduling therapy
sessions. Individual therapy allows each ERW to build a strong relationship with their therapist,
which is key to having successful therapy sessions and improving their overall mental health.
Group Therapy
Group therapy can be helpful for ERW to let them know they are not alone and help them
find comfort being surrounded by others who understand them and their trauma. This will allow
ERW to learn from other women who have had similar struggles and potentially address the
barriers such as shame and stigma. As stated by Haefner et al. (2019), “Group therapy provides a
foundation of support and helped participants understand and learn new skills that strengthened
not only their adaptation into communities, but also their individual confidence in their unique
wholeness, and their own and others’ personal integrity” (p. 6). When ERW can attend group
therapy with others like them, they can form support systems outside the group therapy setting
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with each other. In one study dealing with refugees with PTSD and group therapy, new refugees
spoke about the anxiety of assimilating into a new country and how more established participants
guided them through the changes they were experiencing to help reduce that uneasiness (Kira et
al., 2012).
During the study, some participants explained that they brought groups of ERW together
to discuss what they had experienced; getting a chance to speak empowered them and gave them
a chance to heal. Participants also explained that ERW formed groups outside of therapy that
continued the healing process through drinking coffee or sharing a meal together. Group therapy
gives ERW a chance to escape the isolation they might feel, as discussed in the study, while
allowing them to meet new people, build relationships, and learn new strategies for tackling their
issues. Groups not only act as a support network, but group members may also give ideas to
challenges in life while holding you accountable along the way (Johnson, 2019).
Recommendation 3: Establishment of Eritrean Community Centers
Eritreans are deeply family and community-centric people by nature. Asgary and Segar
(2011) found three types of barriers affecting refugees: structural (i.e., limited services, poor
cultural competency, inadequate interpretation, and health care issues); internal (i.e., mistrust,
mental illness, and alleged discrimination); and social assimilation (i.e., trouble traversing a
complicated system and inadequate community support). All the participants in the study
mentioned the level of stress ERW experience assimilating into a new culture. As brought out
during the study, ERW face difficulty finding work, communication barriers, family separation,
and experience loss of their community network, which all cause additional stress and make it
challenging to find mental health support. Even though there are some Eritrean community
centers across the United States, there must be additional ones established to support the influx
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of refugees. These community centers may aid with housing, clothing, language assistance, basic
needs, mental health care, and a sense of belonging. Also, through mental health training, these
community centers may be used as an institution to address the barriers around mental health
support that include shame and stigma.
The establishment of Eritrean community centers is recommended since, as indicated in
this study, ERW face language and cultural barriers when receiving mental health support that
prevents them from receiving the total value of the treatment and creates cultural roadblocks for
providers. Providers working with refugees must remember that various cultural beliefs surround
mental health and that thoughts concerning mental illness differ among families and individuals
based on religions, cultures, ethnicities, and countries of origin (Unite for Sight, 2015).
Therefore, establishing Eritrean community centers is essential; ERW being assisted by other
Eritreans eliminates the cultural barriers they face with other organizations and providers. In
these spaces, ERW can feel accepted and comfortable at the community centers, allowing them
to assist other ERW who come after them, providing them a sense of healing as described in the
study.
In 2011, an Eritrean Women’s Community Center (EWCC) was formed in Tel Aviv,
Israel (Gagne, 2021). The EWCC was established to assist Eritrean women who were victims of
human trafficking. Since then, the EWCC has fought for the rights of Eritrean refugee men and
women by assisting in mobilizing the largest refugee-organized protest movement in Israeli
history, including building a nursery and establishing enrichment classes and workshops. The
same level of effort, influence, and care is required for ERW in the United States by establishing
community centers. All participants in the study mentioned either the establishment of an
organization, support from community members, or the establishment of community centers as a
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way for ERW to build mental health awareness, heal, and have a one-stop center where different
social services are provided. Providing a feeling of community and family through community
centers gives ERW the tools to build resiliency and trust and gives them a chance to restore their
life and mental well-being.
Limitations and Delimitations
During the study, I encountered several limitations. The study was dependent on the
truthfulness of the participants. People have different motivations for not disclosing a fact, one
being shielding themselves from revealing the truth and unpleasant effects (Arcimowicz et al.,
2015). There were also limitations in the knowledge and experience I had conducting qualitative
studies, including the level of experience participants have with ERW, which could have affected
the study. Since I interviewed service providers and not ERW, there might have been
information lost in translation or opinions offered by participants that were not reflective of
ERW.
This study has several delimitations. The scope of the study is limited to ERW and leaves
out the perspectives of spouses, children, and families who may have faced the same traumatic
events. I conducted eight interviews that may have constrained the amount of data from
participants I received. The study was limited to participants who were service providers
assisting ERW. Service providers were chosen as participants instead of ERW due to the trauma
and damage it could cause ERW to relive agonizing experiences. I chose to conduct a qualitative
study with interviews that might have limited the data I received compared to a quantitative
study with surveys which might have provided more anonymity to participants and encouraged
additional to come forward to participate. This study was grounded in Bronfenbrenner’s
ecological systems theory, which looked at how environment and relationships influenced ERW.
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Other theories might have provided more insight into the social and biological factors affecting
ERW.
Recommendations for Future Research
The findings of this study, including its limitations and delimitations, raised many
questions that can be addressed through future research. Service providers were interviewed
instead of ERW due to the emotional response it may trigger because they might not have felt
comfortable speaking about their experiences to a man out of shame and fear. Future research is
recommended that includes interviews with ERW administered by an Eritrean woman who is
also a service provider to get direct details about their experiences including what supports the
want and need, so they may feel comfortable in the interview setting by creating less hesitancy
and worry. This study was just limited to ERW; future research is recommended into Eritrean
refugee men and children to evaluate the impact of war and trauma on their mental health and the
resources they require. What the men and children go through also affects the mental health of
ERW. Eritrea has produced hundreds of thousands of refugees; future research should be
considered to produce broad findings regarding the factors causing thousands of Eritreans to flee
the country yearly. From 2014 to 2016, Eritrea was the largest source of refugees from Africa to
Europe (T.G., 2018). Finally, there is only one mental health hospital in Eritrea, so future
research should explore its impact on citizens who cannot travel hundreds of miles for care.
Conclusion
This study regarding the mental health needs of ERW, including the systemic barriers and
facilitators to their mental health support demonstrates the importance of Bronfenbrenner’s
ecological theory in understanding the negative and positive impacts a person’s environment has
on them. The findings identified a strong relationship between cultural stigmas, trauma, lack of
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mental health awareness, and insufficient resources, which negatively affected the mental health
of ERW. Victims can rarely seek care and services due to limited financial resources
compounded with the social stigma and isolation that follows (UNHRC, 2015). The findings also
identified how important family and community are in supporting ERW’s healing process and
mental health. Several studies highlighted the importance of friends, family, and community in
strengthening resiliency in refugees in the resettlement process (Hutchinson & Dorsett, 2012). It
is important to emphasize that even though ERW have endured gender-based violence, torture,
family separation, and resettlement problems, they have displayed a high level of resiliency.
Taking the study recommendations and placing them into action is imperative to
improving the mental health and resources available to ERW. As stated by Kirmayer et al.
(2010), who reviewed 840 articles relating to mental health problems in immigrants and
refugees, “Refugees who have had severe exposure to violence often have higher rates of
trauma-related disorders, including PTSD and chronic pain or other somatic syndromes” (p. 1).
Ostracized groups like refugees face more demanding challenges and barriers in receiving mental
health care than the local population. They must overcome cultural and language barriers,
stigma, and not being familiar with local healthcare policies and systems. Migrants, compared to
the general population, are less likely to pursue treatment for their mental health conditions
(Fenta et al., 2006). Lastly, as the political climate in Eritrea remains the same, there will
continue to be an influx of refugees fleeing the country and embarking on a journey to the United
States or other countries.

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91

Appendix A: Interview Questions

Research Questions:

RQ1. What are the mental health needs of refugee women from Eritrea?
RQ2. What are the systemic barriers and facilitators to mental health support for refugee women
from Eritrea?
Respondent Type: Service Providers
Introduction to the Interview:
Thank you for volunteering to meet with me today. This interview is part of my doctoral
dissertation at the University of Southern California. The purpose of the study is to focus on the
role of community services in the Eritrean community and how they can help support the mental
health of Eritrean refugee women. With you being a service provider and working with Eritrean
refugee women, I am trying to understand their experiences, surroundings, trauma and how the
services provided within their own community assists with their mental health needs. The
duration of this interview will be around 60 minutes, with 14 interview questions.

If you do not feel comfortable at any time during this interview, you may stop it or ask to skip a
question. This interview is voluntary. Your identity will remain anonymous, and any information
relating to your identity will remain private and secured.

I want to record our conversation if you allow it, and I will delete the video after I have
transcribed and translated everything. Do I have your consent to record the interview?

Do you have any questions before we proceed?

Table A1
Interview Questions
Interview questions Potential probes
RQ
addressed
What type of services do you provide to
help ERW with their mental health
needs?
Do you feel the services are
helping? Why or why not?
1
92

Interview questions Potential probes
RQ
addressed
Do you face challenges when it comes to
the stigma of mental health assistance
in serving ERW?
If so, may you describe those
challenges? If not, what have
you done to combat that stigma? 2
What are some the reasons ERW shared
with you for leaving Eritrea?
Do they feel it was the right
decision and why? 1
Was their psychiatric support available
for ERW in Eritrea?
Is so, what type of support did they
receive? If not, is this the first
time they are receiving mental
health support? 2
Can you describe in detail the events they
overcame on their journey to the USA?
How much do you feel those
events affected their mental
health and how? 1
Did their assimilation into the USA affect
their well-being?
Did it increase or decrease the
stress in their life and how?
What challenges did they face
during assimilation? 1
May you describe in detail the emotions
ERW display when speaking about
their traumatic experiences?
How difficult is it for ERW to
speak about their traumatic
experiences? Do they try to
evade those painful memories? 1
Do ERW share their mental health
concerns with their family?
If so, does it assist them with their
well-being? If not, why do they
choose to keep it from them? 2
Have ERW discussed having thoughts of
hurting themselves or taking their own
lives?
If so, what is provided to assist
them through that mental state?
1
What are some of the barriers you face in
getting ERW support?
Are those barriers coming from the
individual, their community, or
both? 2
What have you learned from ERW that
may assist future refugee women in
receiving support?
Was there a method or process
used to gain this information and
how was it implemented? 2
How are the services you provide seen by
the Eritrean community you serve?
If seen in a negative aspect, what
may be done to change that? If
seen in a positive aspect, what
may be done to promote and
spread the services? 2
From all your experience with assisting
ERW and their community, what are
your top three recommendations for
building mental health awareness in
ERW and their communities?

If you would like to provide more
than three, feel free to do so.
Why do you feel these are the
best recommendations for
building mental health
awareness and how would you
implement them? 2
93

Interview questions Potential probes
RQ
addressed
What are the ways in which you see
Eritrean refugee women engaging in
healing?
Is there any method that works
well more than others?
2

94

Appendix B: Recruitment Email
To Whom It May Concern:

My name is Madehania Baheta, and I am an Eritrean refugee who grew up in the United States. I
am also a doctoral candidate in the Rossier School of Education at the University of Southern
California, conducting a research study as part of my dissertation. I am examining the role of
community services in the Eritrean community and how they can help support the mental health
of Eritrean refugee women. The study includes interviews and your participation in the study is
completely voluntary and participant identities will not be known. If you are interested in
participating in this study, are at least 18, and have worked with Eritrean refugee women as a
service provider, please let me know if you are interested in conducting an interview. Each
interview may last up to 60 minutes. This research has been approved by the institutional review
board (IRB).

If you have any questions, please feel free to contact me at baheta@usc.edu or 808-389-XXXX. I
have also attached the interview questions and information sheet for your reference.

Thank you in advance for your participation.

Madehania “Med” Baheta
Doctoral Candidate - Rossier School of Education
University of Southern California

Abstract (if available)

Abstract Mental health in the Eritrean community has long been seen as a stigma or taboo, which has kept many Eritrean women from coming forward and receiving proper mental health support. This has been especially true for Eritrean refugee women who experienced rape, torture, war, and other forms of abuse while fleeing Eritrea. Women who experience torture or sexual violence are more susceptible to mental health illnesses and often develop post-traumatic stress disorder, depression, anxiety, and other severe health concerns. This study focused on Eritrean refugee women’s mental health needs, including systemic barriers to and facilitators of support. This study also explored how services in the Eritrean community could support these women’s mental health. In-depth interviews with eight service providers who have supported this population were conducted. The results showed that shame and stigma were significant barriers to talking about trauma, but family and community support were key to healing and building resilience. Bronfenbrenner’s ecological systems model guided this study. Based on the findings and conceptual framework, the study includes three recommendations for practice regarding building mental health awareness and education, therapy, and Eritrean community centers.

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Asset Metadata

Creator Baheta, Madehania (author)

Core Title The experience of Eritrean refugee women in addressing their mental health needs

School Rossier School of Education

Degree Doctor of Education

Degree Program Organizational Change and Leadership (On Line)

Degree Conferral Date 2022-12

Publication Date 09/08/2022

Defense Date 09/06/2022

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag community,Eritrean refugee women,family,mental health,OAI-PMH Harvest,shame,stigma

Format application/pdf (imt)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Hirabayashi, Kimberly (committee chair), Andres, Mary (committee member), Muraszewski, Alison (committee member)

Creator Email baheta@gmail.com,baheta@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-oUC111833351

Unique identifier UC111833351

Legacy Identifier etd-BahetaMade-11189

Document Type Dissertation

Format application/pdf (imt)

Rights Baheta, Madehania

Type texts

Source 20220908-usctheses-batch-978 (batch), University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the author, as the original true and official version of the work, but does not grant the reader permission to use the work if the desired use is covered by copyright. It is the author, as rights holder, who must provide use permission if such use is covered by copyright. The original signature page accompanying the original submission of the work to the USC Libraries is retained by the USC Libraries and a copy of it may be obtained by authorized requesters contacting the repository e-mail address given.

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA

Repository Email cisadmin@lib.usc.edu