This study has shown that pre-migration factors, but more importantly post-migration factors, are associated with self-reported chronic pain and long-term disability in refugee women. Post migration experiences such as general health, discrimination and region of settlement were most likely to be associated with chronic pain.

In line with existing research showing a significant association between chronic pain and general health [30], our study also found that refugee women who reported poorer general health had greater odds of self-reporting chronic pain. Interestingly, the rates of poorer general health also appear to be greater in the initial years of resettlement in Australia [31]. This suggests that there may be many unmet health needs that are compounded by the challenges of resettlement, highlighting the need for greater clinical awareness to help inform and prepare refugee health care and settlement service providers to improve chronic pain management for refugee women who have been systematically marginalised. However, the complexity of health care provision is also influenced by the location refugee women resettle into. Our study has shown that refugee women who resettled in more rural or remote parts of Australia had greater odds of experiencing chronic pain and our interaction effects demonstrated that general health was also influenced by settlement location. Geographic isolation and the scarcity of specialized services affects the experiences of immigrant and refugee women in regional/remote areas [32] meaning that acute conditions such as pain are also more likely to persist longer than needed. Therefore, we need to consider specific strategies that resettlement services, clinicians and policy makers can implement to mitigate the negative effects of migration on chronic pain in refugee women during their initial years of resettlement in Australia.

It has been extensively reported that Australians residing in rural or regional parts of the country have shorter lives, higher levels of disease and injury and poorer access to health care services compared to people living in more metropolitan regions of the country [33, 34]. Meanwhile, primary and allied health services are extremely limited in rural and regional Australia making access to best practice pain management more difficult [34]. A study by Sypek and colleagues found that the difficulties faced by rural Australians securing equitable access to health services are considerably amplified for refugees [35]. Providing opportunities that are available through rural centres or telehealth where women can readily access resources for English upskilling, multicultural supports and health services, including mental health support is needed but would require a strategy to inform women that these opportunities exist and that they are easily accessible. Furthermore, there is a fragility in the health services offered in rural regions to provide a comprehensive approach to chronic pain care. This is in part, a result of a low number of practitioners, high turnover of staff, resulting in an attrition of specialised knowledge among health care workers treating refugees [35]. However, it is not clear how the barriers to access chronic pain management services in rural and remote regions for refugee women may differ from the broader population. Future research in this field could be enhanced by understanding community perspectives of refugee women living in rural and regional parts of Australia who experience chronic pain. These perspectives can guide new and emerging communities’ social integration, sense of belonging and chronic pain settlement outcomes for refugee women.

The post-migration factor that was most significantly associated with reporting chronic pain in our study was stress arising from discrimination. Experiences of discrimination are commonly reported in the resettlement accounts of refugees in Australia and feature prominently in settings of social support, in work and within neighbourhoods [36,37,38,39,40]. A recent study showed that 22% of refugees who resettled in South Australia reported experiencing discrimination, the majority of whom felt that the discrimination had negatively affected their health [41]. A national survey in the United States also found that 4.1 million Americans who experienced chronic pain reported that it was caused by an increase in psychological distress arising from perceived discrimination. Colleagues Fozdar and Torezani suggest that some refugees, particularly women, may consider discrimination to be a single, or rather an individual phenomenon, as opposed to a system that is fundamentally intended to disadvantage them, and therefore feel it is less damaging [36]. Interestingly, previous research has shown that refugee women may buffer the negative impacts of stigmatisation on their health by responding to accounts of discrimination through various cognitive, affective and behavioural pathways [42]. However, there is limited research that directly examines the association between discrimination and chronic pain in women from a refugee background [18, 38, 40, 43,44,45,46,47,48]. Greater insight into how refugee women respond to discrimination may help to understand and possibly interrupt the pathways with which stress from discrimination may impact chronic pain [42]. However, it is important to note that discrimination is a consequence of broader systemic issues and policies that seek to mitigate stigmatisation should not place the burden of responsibility on those who experience discrimination [47].

Consistent with previous findings, pre-migration factors such as age was a risk factor for chronic pain in our cohort of refugee women [49]. Interestingly, our study also showed that migration pathway may also be an important pre-migration predictor of chronic pain. Women who migrated under the 204 Women at Risk visa category had greater odds of reporting chronic pain than women who migrated under any other visa subclass. This may be because women who arrive under the Women at Risk visa category are especially vulnerable to gender-related human rights violations in addition to sufferings often reported by other refugee groups [50]. As a result, their experience and plight for refuge will likely differ from that of their male or not at-risk female counterparts. This finding extends on previous research that shows how recently resettled refugee women living in Australia who are at risk have substantially greater odds of experiencing psychiatric distress such as anxiety, post-traumatic stress disorder, depression in addition to considerable symptom somatization [51]. Likewise, Schweitzer and colleagues revealed that the proportion of women-at-risk who had been exposed to serious injury, detention or imprisonment, were missing or kidnapped, or experienced rape or sexual abuse was over double that reported by women who resettled through other humanitarian and refugee visa pathways [52, 53]. The unique and difficult events described by refugee women-at-risk suggests that many of them will likely experience longer term effects to their health in the post-migration setting. Developing an understanding of the factors that significantly impact chronic pain in resettled women-at-risk benefits health practices and holds particular worth in guiding resettlement policies and programs for individuals who are systematically marginalised.

In our cohort of refugee women, approximately two-thirds of the women who reported chronic pain also experienced a long-term disability, injury or health condition. This suggests that chronic pain may impede their ability to function day to day, or integrate into their community and may subsequently result in further isolation [47, 54]. However, the percentage of women who had a disability identified at arrival was 37%, whilst five years into resettlement the percentage of women who identified as having a disability dropped to 13%. This ‘change’ over five years may be due to a number of post-settlement factors, however, due to limitations in our dataset it is unclear why this decrease occurred. Furthermore, the severity of tissue injury does not appear to be a good indicator or predictor of eventual disability. Jamison and colleagues found that psychological factors play the most prominent role in whether someone has a pain related disability after an injury [55]. This raises an interesting approach to clinical care for chronic pain sufferers, and more specifically refugee women. Future research in this field could be enhanced by considering better initial pain control which could have an effect of reducing long-term disability and may also work to break fear-avoidance patterns and pessimism around pain [55].

Chronic pain care is complex and oftentimes overwhelming for both the patient and clinician. A study by Bifulco and colleagues demonstrated that chronic pain is underdiagnosed and undertreated in primary care and this is likely to be even greater for people who are systemically marginalised [56]. With a burgeoning number of refugee women reporting chronic pain, a new strategy that values the complex nature of both chronic pain and refugee health concerns is needed to adequately meet these challenges in clinical practice. Mainstream health pathways such as primary care may benefit from the implementation of large, multisite screening tools that evaluates both pain and function upon arrival [56]. Whilst the current study doesn’t support this finding, it does suggest that further research may benefit from exploring refugee women’s perceptions of pain to help develop a guide that considers both pain and function in a routine screening process for health professionals who care longer-term for women belonging to refugee-like backgrounds [56]. To achieve this, a coordinated long term national and state funded approach to ensure consistency of such services to these women is needed. A central or state government funded body such as post-settlement contractors who work in partnership with existing refugee health services and primary care to deliver resources and time for women belonging to refugee-like backgrounds are in an essential position to assist. Resettlement contractors should be funded and supported sufficiently to provide continuity of care for new arrivals over the first five years, rather than short term tenders. A national body that offers a continued record may not only enhance the health and wellbeing of refugee women but overtime allow for further follow up strategies to help positively impact the perceptions and management of their chronic pain.

This study has considered the impact of migration on refugee women’s reporting of chronic pain in Australia. Nevertheless, the results of this study need to be considered in the context of the research limitations. This was a secondary analysis of the BNLA study which did not have the current assumption in mind when the project was first initiated. We were therefore limited to available study variables and we acknowledge that factors such as pre-departure/transit experience, family domestic violence pre- and post-resettlement trauma that may be associated with chronic pain in this population were not captured and included in our analyses. Additionally, there was no specific chronic pain question, nor was our outcome variable measured at every time point. The sampling of women was also restricted to primary applicants, as secondary applicants were not asked the comprehensive version of the survey which omitted the primary outcome variable and several covariates, reducing our sample size. This also meant that the majority of women in our cohort reported good English proficiency, which differs considerably when comparing to other national resettlement trends where humanitarian entrants, particularly women, are reported to have low levels of English proficiency and formal education suggesting that our sample size is small and non-representative of most humanitarian entrant women. Furthermore, the sample also does not reflect asylum seeker cohorts as only 0.7% experienced detention which limits our ability to translate our findings more broadly to those from refugee-like backgrounds.

The capacity for respondents to use the self-administered or interview-administered formats of the assessment may have also introduced some inconsistencies [57]. The measurements were based on self-report questionnaires; therefore, responses are susceptible to bias (e.g., recall bias and social desirability) [57].Future research may benefit from standardised measurement instruments to improve the reliability of data reported and enhance comparability across studies. Our study did not include potential moderating factors such as 1) access to a GP, (2) postcodes (and relative ISRAD/IRSD deciles), (3) linkages to community or multicultural groups, (4) access to extended family within Australia, (5) literacy in primary language, (6) median number of children/dependents, and recommend that future studies incorporate these to provide an even greater level of understanding of the context that these women are in. Finally, causal associations cannot be defined because of the nature with which we defined our chronic pain variable omitted the temporality of pain over time. Studies using prospective designs are needed to determine the causal effects of pre-migration and post-migration factors on refugee women’s chronic pain health.

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