Embodiment of Structural Vulnerability: Complex Illness Experiences of Somali Refugee Women in Displacement

Background & Purpose: Forced migration and its subsequent sequelae have caused refugees to face significant adversities throughout the migration phases, making them susceptible to significant health issues. Refugees displaced in Africa are a group especially vulnerable to poor health outcomes secondary to forced displacement, experiencing a documented decline in overall physical and mental health status and rise in mortality from non-communicable diseases. Despite the heightened health risks experienced by Somali refugees, particularly women, research into their complex illness experiences and co-/multi-morbid health conditions is scarce, leaving a gap in our understanding of the multifaceted health challenges of this population. Little attention has been paid to the systemic dynamics among structural health risks, such as restrictive policies, the lack of social and legal protections, and chronic discrimination/marginalization confronting the forcibly displaced community. Using structural vulnerability theory, this study explores how the broader host context shapes illness experiences for Somali refugee women in Kenya. Specifically, the study seeks to elaborate on the factors associated with illness experiences of urban refugee women and how these factors compare to women with other similarly situated identities.

Methods: This study was conducted as part of a multi-year community-based participatory research project that adopted an interpretive ethnography method to examine the complex health and mental health issues experienced by refugee women in Eastleigh, Kenya. The researchers used a purposive sampling strategy to recruit 43 women who were experiencing physical and mental health conditions, and semi-structured, in-depth interviews were conducted at local health clinics with Somali Kenyan women, Kenyan women, and non-Somali refugee women, which were compared with those of self-identified Somali refugee women. A hybrid thematic analysis yielded emergent themes that informed the development of a framework of structural vulnerability, which considers the intersectionality of participants' identities and the different phases of migration they have experienced.

Results: The hybrid thematic analysis revealed several themes organized around three domains: 1) multimorbid/complex illness experiences; 2) embodiment of structural vulnerability; and 3) distinct/shared vulnerability among refugee/non-refugee women. The first domain includes themes related to the embodiment of multimorbid illness experiences, trauma, and life adversities interfering with illness and coping capacities. The second domain includes themes related to socio-structurally imposed risks and amplified vulnerability. The final domain includes themes related to intersecting marginalization through refugeeness, liminal legality among Somali women, and shared vulnerabilities through environmental health risks and low medical capacity in the local community.

Conclusion: The study's findings suggest that participants' positionality and prescribed social statuses predispose them to social risks that contribute to complex health problems. The participants’ illness experience is closely tied to multi-level stressors encountered and often exacerbated across migration phases, highlighting the interconnectedness of health and broader social and political systems. This study also emphasizes the need for a more participatory approach to refugee health research, which prioritizes the voices and lived experiences of refugees. Recentring knowledge on the lived experiences of refugees and engaging in more collaborative research practices is essential to creating meaningful change and improving health outcomes for marginalized communities in low-resource settings.