Mental Health and Integration: A Qualitative Study on the Struggles of Recently Arrived Refugees in Germany.

Introduction: Forcibly displaced people are at particular risk of mental health problems and also face specific integration challenges upon resettlement. Existing literature suggests that there may be a bidirectional relationship between mental health and integration. The present study seeks to understand the relationship between integration processes and mental health problems or significant negative emotional experiences among adult refugees in Germany. Method: Applying a qualitative approach, we conducted 54 semi-structured interviews with refugees and asylum seekers who arrived in Germany between 2013 and 2018 currently residing in Berlin, Leipzig, or the Duisburg area in North Rhine-Westphalia. Data was collected between December 2018 and September 2019. We analyzed transcripts inductively using thematic analysis. Results: Five themes covering the various links between integration and mental health problems or significant negative emotional experiences were identified. First, we found that the mental health consequences of past adverse experiences, as well as ongoing worries about those left behind in the homeland, can seriously impede refugees' ability to pursue activities key to integration. Second, the process of applying for and securing asylum can result in uncertainty and fear, which, in turn, burden the individual and may impact motivation for integration. Third, many of our participants described mental health ramifications related to feeling stuck and thwarted in the pursuit of building a life, especially in securing employment. Fourth, some participants described feeling so overwhelmed by fundamental tasks throughout the integration process, namely, language learning and bureaucratic processes, that these take a psychological toll. Fifth, we identified several forms of social disconnection between refugees and members of the host community due to xenophobia, social and cultural differences, physical and emotional isolation in refugee camps, as well as with co-nationals and fellow refugees. Negative emotions, mistrust, and socio-cultural differences that emerge throughout the integration processes seem to erode social cohesion among refugee communities, potentially further threatening mental health. Conclusion: Mental health problems and integration processes appear to be closely related across different areas of integration. Innovative solutions to challenges identified by members of the refugee community in Germany stand to benefit mental health and integration outcomes simultaneously.

A qualitative study on resilience in adult refugees in Germany.

BACKGROUND: Because refugees face significant adversities before, during, and after resettlement, resilience is of central importance to this population. However, strengths-based research on post-migration refugee experiences is sparse. METHODS: We conducted semi-structured interviews with 54 adult refugee participants who arrived in Germany between 2013 and 2018 in their preferred language. We analyzed different aspects of resilience in these interviews using thematic analysis. RESULTS: Nine themes were identified. Four themes manifest resilience in different ways and encompass cognitive as well as behavioral strategies for facing adversity, self-ascriptions of resilience as a personal trait or lasting characteristic, and the role of volunteering, work, and activism for refugee causes. Five themes capture factors that facilitate resilience: social support, experiencing migration as an opportunity generally and for women in particular, being a parent, and being young. CONCLUSIONS: This study adds to a growing body of knowledge about resilience among adult refugees. It may support clinicians working with refugees by making them aware of specific manifestations of resilience and factors promoting positive adaptation specific to this client group. It also contributes to a more strengths-based view on refugee mental health and processes of integration.

[Aging and dying in diversity-implications of an intersectional perspective for analyzing care policy discourses]. / Altern und Sterben in Diversität ­ Implikationen einer intersektionalen Perspektive für die Analyse pflegepolitischer Diskurse.

In view of the growing population, which is increasingly aging in diversity, questions of social justice and of avoiding discrimination in end of life nursing care become increasingly more relevant from an ethical point of view. This article addresses the discrepancies between normative claims of an equitable approach to provision of nursing services and the sources of structural barriers. In particular at the end of life, often already vulnerable groups are subjected to discrimination in nursing care. Further reflections refer to implications of intersectionality for care-ethical approaches and for the methodology of discourse analysis. This study investigated how diversity and justice are formed in the care policy discourse. It becomes evident how parts of the care policy discourse largely ignore individual ethical implications. Accordingly, critical reflections on inequalities in nursing care remain unconsidered in the discourses. Starting points for processes of change that begin from concepts of individual care ethics are presented.

Aging in Precarious Circumstances: Do Positive Views on Aging Make a Difference?

Purpose of the study: Precariousness, defined as low income combined with lack of security for retirement, can influence the way people grow old and result in health inequalities in old age. Design and methods: A sequential mixed methods approach was used to identify differences in behavioral (physical activity), social (social network), and psychological resources (positive views on aging) that middle-aged individuals from both precarious and financially secure backgrounds use in preparation for positive aging and keep high levels of health and well-being. It was investigated whether positive views on aging can compensate the detrimental association of a lack of resources with health and well-being in midlife. Data from the German Aging Survey (N = 1,992 in the secure group, N = 240 in the precarious group) were analyzed to understand the relationship between resources on the one hand and health and well-being on the other, as well as to compare the strategies of individuals with precarious and financially secure backgrounds. Semistructured interviews with middle-aged individuals (N = 20) from these two categories were analyzed in order to further explain the quantitative findings. Results: Precarious individuals are indeed disadvantaged in terms of behavioral, social, and psychological resources as well as in health and well-being. However, having a positive view on aging can compensate for insufficient resources. Qualitative findings showed differences in strategies for resource management and perceptions of positive aging. Implications: Secondary analysis of quantitative and qualitative data reflects the importance of positive views on aging as a resource for a healthy old age despite aging in precarious circumstances.

Aging in precarious times: Exploring the role of gender in shaping views on aging.

The present study explores views on aging and how these differ according to gender and precariousness status. Semistructured interviews were conducted with 10 men and 10 women with secure and insecure pensions. Themes like fear of illness and health decline were more present in men, while fear of losing their attractiveness in old age more present among women. For all participants, loss of autonomy and social roles represented a negative view of old age, while activity in the form of work, volunteering, or leisure represented positive views. Differences in views on aging were related to pension security and less to gender. Women with insecure pension plans displayed the most negative views of aging. Implications for practice and policy to prevent health and gender inequalities are discussed.

I wonder if robots will take care of me when I am old: Positive aging representations of professionals working in health promotion services.

How the social and institutional context is structured and represented by its actors has an impact on positive aging representations. This qualitative study explores professionals' views on positive aging, how they promote positive aging in their practice and what disparities occur between their discourses and the actual practice of promoting positive aging. Interviews were conducted with professionals from different active aging promotion services and analyzed with thematic coding. Findings show professionals hold negative views on aging while trying to promote positive views in their work, illustrating an existing theory-practice gap. Strategies used in practice can be integrated in existing agency models and inform interventions and active aging policies.

"I want to be 100 years old, but I smoke too much": Exploring the gap between positive aging goals and reported preparatory actions in different social circumstances.

Preparing for positive aging is shaped by the social context a person lives in. The present qualitative study explores and compares representations about preparatory actions in precarious workers (i.e., with temporary job contracts and insecure pension plans) and individuals with secure pension plans living in Germany. It also examines, the discrepancy between what middle-aged persons think they should be doing in preparation and what they report doing for aging well. Findings from the analysis of the semi-structured interviews conducted here show that people who have insecure pension plans tend to see themselves as social networkers and optimists, while those with secure pension plans see themselves as social activists and careful planners of old age. All participants value an active, healthy body but manage to do little in order to attain it due to lacking time and discipline. In accordance with the socioemotional selectivity theory, perceiving a short-time perspective makes precarious individuals focus on emotional goals, while financially secure individuals value social goals. Implications for practice and policy change are discussed.

[Representations of Care of Migrants from the former Soviet Union with Alcohol or Drug Problems in Germany]. / Versorgungsvorstellungen von Migranten aus der früheren Sowjetunion mit Alkohol- oder Drogenproblemen in Deutschland.

OBJECTIVE: Which representations of care can be found in migrants with alcohol or drug problems from the former Soviet Union? How do they correspond with views in the care system? METHODS: Episodic interviews with 46 migrants, expert interviews with 33 service providers; analysis with thematic coding. RESULTS: For migrants and experts holistic care is important, which include spiritual-religious components but are also control-oriented. CONCLUSION: The cultural specificity of migrants' care representations should be acknowledged by the health care system much more.

Effects of social activation and physical mobilization on sleep in nursing home residents.

Age-related changes in sleep physiology, frequent occurrence of health impairments, and a sedentary lifestyle make nursing home residents particularly vulnerable to sleep disturbances. Despite the high prevalence of sleep disturbances in nursing homes, there is a lack of research concerning the use of non-pharmacological approaches for improving residents' sleep. This study aimed to promote residents' sleep by improving their social activation and physical mobilization. An experimental group of residents attending an activation program four times a week during an eight-week study course was compared to a non-treated control group in a cluster-randomized intervention trial among 85 residents of 20 nursing homes. Sleep was assessed by the Insomnia Severity Index (ISI), nurses' ratings of residents' sleep disturbances and actigraphy-based sleep parameters. Although no changes in actigraphy-based sleep parameters were observed, the subjective sleep quality ratings of the intervention participants significantly improved compared to the control group members (p = 0.004). This study suggests that physical mobilization and social activation may improve residents' subjective sleep quality. Further efforts to improve residents' sleep by increasing their physical and social activity should consider existing obstacles to encourage participation and adherence to the program.

"I will never be the granny with rosy cheeks": perceptions of aging in precarious and financially secure middle-aged Germans.

Nowadays people are growing old in a context where youth culture is the norm and where self-initiative is required in order to prepare for a good old age. However, planning old age may be more difficult for certain social groups with insecure work and living conditions. Precariousness, defined as bad financial conditions but also as having an insecure, unpredictable existence, has been little studied in the context of aging. This study brings its contribution by exploring how middle-aged adults with different social security backgrounds (insurance versus no insurance) think about aging. Episodic interviews were conducted to explore their concepts of aging, contexts of thinking about aging and perceptions of aging. These were compared between groups who have a secure old age ahead of them (N=10) versus those who have to struggle with an uncertain present and future (N=10). Also, differences between men (N=11) and women (N=9) were addressed. Results of the thematic analysis showed the predominance of fears related to aging as well as an emerging meaninglessness attached to old age. Starting from the different images of aging found in the two studied groups, the need for tailored interventions and policy are discussed.

Patients' subjective concepts about primary healthcare utilisation: the study protocol of a qualitative comparative study between Norway and Germany.

BACKGROUND: In Germany, utilisation of ambulatory healthcare services is high compared with other countries: While a study based on the process data of German statutory health insurances showed an average of 17.1 physician-patient-contacts per year, the comparable figure for Norway is about five. The usual models of healthcare utilisation, such as Rosenstock's Health Belief Model and Andersen's Behavioural Model, cannot explain these differences adequately. Organisational factors of the healthcare system, such as gatekeeping, do not explain the magnitude of the differences. Our hypothesis is that patients' subjective concepts about primary healthcare utilisation play a major role in explaining different healthcare utilisation behaviour in different countries. Hence, the aim of this study is to explore these subjective concepts comparatively, between Germany and Norway. METHODS/DESIGN: With that aim in mind, we chose a comparative qualitative study design. In Norway and Germany, we are going to interview 20 patients each with qualitative episodic interviews. In addition, we are going to conduct participant observation in four German and four Norwegian primary care practices. The data will be analysed by thematic coding. Using selected categories, we are going to conduct comparative case and group analyses. ETHICS AND DISSEMINATION: The study adheres to the Declaration of Helsinki. All interviewees will sign informed consent forms and all patients will be observed during consultation. Strict rules for data security will apply. Developed theory and policy implications are going to be disseminated by a workshop, presentations for experts and laypersons and publications.

"And mostly they have a need for sleeping pills": physicians' views on treatment of sleep disorders with drugs in nursing homes.

The percentage of nursing home residents treated with hypnotic medications is high, as many authors report, despite the fact that such medications are almost always associated with undesirable effects for old people. This article takes a closer look at nursing home physicians' views of prescriptions when treating sleep disorders of nursing home residents. How do physicians characterize the treatment strategy for residents suffering from sleep disorders? How do they balance the benefits and risks of the hypnotic medication? Under what circumstances do they accept negative consequences? To answer these questions, N=20 physicians (aged 36 to 68 years) in 16 nursing homes in a German city were interviewed. The physicians were either employed by nursing homes or worked on a contract basis. Comparative categorization of the data produced a typology across cases. Three interpretative patterns concerning the use of drugs for treating sleep disorders were identified--"by request," "ambivalence," and "reflected prescription." Differences between them were determined by the significance of residents' wishes, neglect of risks, particularly that of addiction, and the attempt to balance benefits and disadvantages. The study showed deficits in professional management of sleep disorders in nursing homes.

Nursing home residents' psychological barriers to sleeping well: a qualitative study.

BACKGROUND: Sleep disorders are a relevant problem in the nursing home and difficult to treat for the residents' GPs. No intervention has yet addressed psychological factors contributing to nursing home residents' sleep disorders. OBJECTIVE: To explore what nursing home residents perceive as psychological barriers to sleeping well. METHODS: A qualitative research design. We conducted episodic interviews with 30 nursing home residents. Data were analysed by thematic coding. We constructed a typology of residents regarding their perceived barriers to sleeping well. RESULTS: The interviewed residents perceived traumatic memories, family problems, worries about their situation and future, disturbing events during the day, appointments the next day, anxiety and dreams and nightmares as psychological barriers to sleeping well. The residents could be allocated into three types: residents of Type I identified only non-psychological barriers, residents of Type II worried mainly about their current situation and residents of Type III suffered from traumatic memories and were easily disturbed by any type of psychological distress. CONCLUSIONS: Our results show the high importance of psychological factors for sleep disorders of the elderly. Future research should address nursing home residents' psychological barriers to sleeping well and the presented typology should be operationalized and tested quantitatively.

[External barriers to good sleep from the nursing home residents' perspective]. / Externale Barrieren für guten Schlaf aus der Sicht von Pflegeheimbewohnern.

BACKGROUND: Nursing home residents often suffer from sleep disorders. For nurses, nursing home residents' sleep disorders are a complex problem. The nursing home residents' perspective on sleep and sleep disorders has been unknown yet. The Aim of this article is to describe external barriers to good sleep from the nursing home residents' perspective and to deduce implications for nursing practice. METHODS: A qualitative interview study. 30 nursing home residents (at least 64 years old and oriented on place and person) from five different nursing homes in Berlin have been interviewed through episodic interviews. The data has been analyzed by use of thematic coding. RESULTS: The sample consists of 20 women and 10 men, born between 1909 and 1944. From the nursing home residents' perspective, noise and light at night disturb their sleep. Noise and light can be caused by other residents or staff. The interviewed residents perceived disorientated room mates and room mates who needed frequently care at night as disturbing their night sleep. Additionally, the interviewed residents perceived the nurses' nightly rounds as disturbing. CONCLUSIONS: Nurses and residents should look together for possibilities of reducing nightly disturbances of sleep. Nursing home residents who need frequent nightly care should be living in rooms together with residents demanding a similar amount of nightly care. Nightly rounds should be minimized.

Nursing home residents' self-perceived resources for good sleep.

OBJECTIVE: To explore the nursing home residents' self-perceived resources for good sleep. DESIGN: A qualitative research design. Episodic interviews were conducted, and analysis was done using thematic coding. SETTING: Five German nursing homes from different providers. SUBJECTS: Thirty nursing home residents who were at least 64 years old and oriented to place and person. RESULTS: The nursing home residents' self-perceived resources for good sleep can be classified into three general patterns: calmness, daily activity, and environmental factors. The residents see calmness as a psychological state and a prerequisite for good sleep. Rumination was reported as the main reason for disruption of calmness. Daily activity is also seen by residents to foster sleep, but most residents do not know how to be physically active. Environmental factors such as fresh air, silence, or the type of bed contribute individually to good sleep; however, nursing home residents usually lack strategies to foster these resources by themselves. CONCLUSION: The nursing home residents' self-perceived resources for good sleep--calmness, daily activity, and environmental factors--can be starting points for non-pharmacological treatment of sleep disorders. The residents' primary care physicians should explore these individual resources during consultation and attempt to foster them.

Putting prevention into practice: qualitative study of factors that inhibit and promote preventive care by general practitioners, with a focus on elderly patients.

BACKGROUND: General practitioners (GPs) have a key role in providing preventive care, particularly for elderly patients. However, various factors can inhibit or promote the implementation of preventive care. In the present study, we identified and examined factors that inhibit and promote preventive care by German GPs, particularly for elderly patients, and assessed changes in physicians' attitudes toward preventive care throughout their careers. METHODS: A qualitative, explorative design was used to identify inhibitors and promoters of preventive care in German general medical practice. A total of 32 GPs in Berlin and Hannover were surveyed. Questions about factors that promote or inhibit implementation of preventive care and changes in physicians' perceptions of promoting and inhibiting factors throughout their careers were identified. Episodic interviews, which encouraged the reporting of anecdotes regarding daily knowledge and experiences, were analyzed using ATLAS/ti. Socio-demographic data of GPs and structural information about their offices were collected using short questionnaires. The factors identified as inhibitory or promoting were classified as being related to patients, physicians, or the healthcare system. The changes in GP attitudes toward preventive care throughout their careers were classified as personal transitions or as social and health policy transitions. RESULTS: Most of the identified barriers to preventive care were related to patients, such as a lack of motivation for making lifestyle changes and a lack of willingness to pay for preventive interventions. In addition, the healthcare system seemed to inadequately promote preventive care, mainly due to poor reimbursement for preventive care and fragmentation of care. GPs own attitudes and health habits seemed to influence the implementation of preventive care. GPs recognized their own lack of awareness of effective preventive interventions, particularly for elderly patients. GPs were motivated by positive preventive experiences, but often lacked the necessary training to counsel and support their patients. CONCLUSIONS: German GPs had positive attitudes towards prevention, but the implementation of preventive care was neither systematic nor continuous. Identification and elimination of barriers to preventive care is crucial. Further research is needed to identify effective practice-based approaches to overcome these barriers.

Health and ageing--challenges for health psychology research.

In the light of ageing populations, three general issues of health and ageing become relevant for research and intervention in health psychology: ageing in the general population, among those who are confronted with frailty and illness, and on the ageing experiences of specific populations. In all of these areas there is a need to understand the factors (such as social engagement) that promote well-being and compression of ageing in community or institutional dwelling elders, while being aware of the impact of ageism, inequalities and exclusion on different people's access to health related policy resources and health care.

Sleep disorders and activities in long term care facilities--a vicious cycle?

Sleep disorders are symptoms of many diseases. Persons suffering from multiple morbidities are affected most. We investigated the relationship between sleep and activities using assessment data of 2577 German nursing home residents. In total, 37.3 percent were affected by insomnia, 29.6 percent by non-restful sleep. We used SEM to analyze the relationship between sleep disorders and activities. Residents with sleep problems exhibited low levels of activities and social engagement and high levels of communication impairment and interpersonal conflicts. They received less activation than persons without sleep disorders. We found significant evidence that sleep disturbances and lack of activities influence each other negatively.

'When they sleep, they sleep': daytime activities and sleep disorders in nursing homes.

Are nurses aware that activities can reduce residents' daytime sleepiness and increase sleep quality at night in nursing homes? This question is studied in a project focusing on sleep disorders and multi-morbidity in long-term care. In Germany, episodic interviews with 32 nursing staff members (age 24-60 years) with different qualifications addressed their views on links between residents' daytime structure and activities and their sleep/disorders. Three interpretive and activity patterns (intervention; missed opportunity; ignorance) were found, which differ in relation to how far the interviewees motivate residents' activity. Implications for a training program based on these different premises are discussed.