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Affilia

Responding to the Complex and Gendered Needs of Refugee Women

Zermarie Deacon and Cris Sullivan Affilia 2009 24: 272 originally published online 10 June 2009 DOI: 10.1177/0886109909337401 The online version of this article can be found at: http://aff.sagepub.com/content/24/3/272

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Responding to the Complex and Gendered Needs of Refugee Women

Zermarie Deacon
University of Oklahoma

Affilia: Journal of Women and Social Work Volume 24 Number 3 August 2009 272-284 # 2009 SAGE Publications 10.1177/0886109909337401 http://aff.sagepub.com hosted at http://online.sagepub.com

Cris Sullivan
Michigan State University

Refugee womens experiences and needs are qualitatively different from those of men. However, womens experiences have long been overlooked in favor of a male-centered paradigm that governs the response to survivors of warfare. To close this gap in science and practice, a needs assessment was conducted with 31 refugee women. The findings revealed the importance of considering the impact of refugee womens sociodemographic characteristics on their experiences in resettlement and the significance of their need for basic resources. Meeting these needs may facilitate the resettlement process and ameliorate the gendered effects of resettlement on refugee women. Keywords: needs assessment; refugee resettlement; refugee women

n the context of an increasingly unstable world, a large number of refugees are unable to return to their nations of origin but instead resettle in host nations. These individuals and families are fleeing persecution on the basis of their race, religion, nationality, membership in a particular social group, or political opinions and are not generally able to avail themselves of the protection of their own countries (United Nations High Commission for Refugees [UNHCR], 2007). Notably, a significant percentage of these refugees are resettling in the United States. According to the latest statistics from UNHCR, in 2007, the United States was the single largest recipient of asylum claims worldwide and remains an important host nation for resettled refugees (UNHCR, 2008). Given this large-scale resettlement of refugees to the United States and the significant challenges that refugees face, it is important to consider how social workers in this country can better facilitate refugees adjustment in exile. Although all refugees have significant needs in resettlement, womens gendered experiences during war and flight, combined with the stressors they encounter in exile, result in their needs being qualitatively different from those of men. Nevertheless, womens experiences have long been overlooked in favor of a male-centered paradigm that governs the response to survivors of warfare (Comas-Diaz & Jansen, 1995; Sideris, 2003). If the provision of services that are aimed at refugee women in resettlement is to be maximally effective, it is essential to understand the gendered nature of womens experiences and the ways in which these experiences influence their particular needs. For all refugees, the ravages of war include direct and indirect experiences of violence, fear, and loss (Ager, 1999). However, womens experiences are significantly different from
Authors Note: This research was supported by a Blue Cross Blue Shield of Michigan Foundation Student Award Program Grant received by the first author.

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those of men. During war, women are at a greater risk of sexual assault and are more vulnerable to attacks when performing gender-specific duties, such as agricultural labor or caring for others (Cockburn, 2001; Miller et al., 2002). The experience of flight from war is also much more difficult for women, who are again more vulnerable than are men to sexual assault and exploitation by armed forces, border guards, and refugee camp officials. In addition, refugee camps are often unfriendly to women and may not be laid out with their gendered needs in mind. This situation exposes women to significant threats, including the threat of sexual assault when they perform household duties or when they visit latrines after dark (Hynes & Cardozo, 2000). Finally, in refugee camps, women often have access to few, if any, health resources and may suffer disproportionately from health problems, such as malnutrition. Food is often distributed to male heads of households, and men and boys often eat before women and girls, frequently taking more than their share of the limited resources that are available (Hynes & Cardozo, 2000). These experiences of war and flight may have implications for refugee womens physical and mental health (Hynes & Cardozo, 2000; Miller et al., 2002) and can be exacerbated by the exile-related stressors that women encounter in resettlement (Miller et al., 2002).

Refugee Womens Resettlement Experiences

Although refugee women often exhibit remarkable resilience in the face of adversity (Davis, 2000), the process of resettlement is extraordinarily stressful and can have significant implications for their physical and mental health. In particular, the realities of adjusting to a new country and language, combined with the stressors that result from the social and economic challenges that refugees encounter in exile, can contribute to poor mental health among refugee women (Lipson, Weinstein, Gladstone, & Sarnoff, 2003; Miller et al., 2002; Pumariega, Rothe, & Pumariega, 2005). Both competence in the language of the host nation and formal education have been found to facilitate refugees successful adjustment to life in resettlement (Dona & Berry, 1999). This transition, then, may be particularly difficult for women, who often have less formal education and weaker foreign language skills than do men (Dona & Berry, 1999). Resettlement challenges can also be exacerbated by economic problems, such as difficulty obtaining employment when refugees skills do not transfer well to their host nations (Dona & Berry, 1999). In addition, refugee women often face challenges that are inherent in negotiating their new gender roles in resettlement. Gender roles in refugees host nations are frequently different from what members of these communities are used to, with women now often having greater daily freedoms than they or their families are accustomed to. Although these new gender roles may represent new opportunities for some women, for many it is difficult to negotiate their place within these new contexts (Kulig, 1994). For example, refugee women who have never worked outside the home may now need to learn how to balance employment with a full load of domestic responsibilities (Benson, 1994; Comas-Diaz & Jansen, 1995; Kulig, 1994). In addition, these gender-role negotiations, when combined with the stressors experienced by refugee men, may also give rise to increased rates of domestic violence within refugee households (Comas-Diaz & Jansen, 1995). Furthermore, many refugees bring with them significant health problems to their host nations, including such lifestyle factors as smoking and unhealthy eating habits and physical health concerns that are related to their experiences during war and flight (Barnes,
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Harrison, & Heneghan, 2004; Hynes & Cardozo, 2000; Lipson, Weinstein, Gladstone, & Sarnoff, 2003; Willis & Nkwocha, 2004). In fact, Willis and Nkwocha (2004) argued that physical health problems can be a significant impediment to refugees adjustment in resettlement because illness and other health conditions may interfere with their employment and ability to effectively access resources such as language education, effectively. Health concerns may be especially pronounced for refugee women, who, as we noted earlier, often face multiple health challenges. Refugee women who are not comfortable or familiar with the medical care available to them may rely on self-medication or folk remedies to avoid drawing on these services (Jentsch, Durham, Hundley, & Hussein, 2007; Lipson et al., 2003). In addition, refugee women who are single heads of households often experience particular difficulties in resettlement. They may face significant pressures to provide for their families and may consequently not be able to take full advantage of resources, such as language learning and education, that would allow them to improve their socioeconomic conditions. Single refugee women may also lack social support because cultural norms that govern womens roles in social situations may render it difficult for them to become part of larger refugee communities (Chung, Bemak, & Kagwa-Singer, 1998). This lack of social support may have significant consequences for womens well-being in resettlement, because the inability to draw on refugee networks can limit the womens access to key resources (Donna & Berry, 1999). Refugee women thus arrive in resettlement with a host of needs. They often rely heavily on social service agencies for assistance in almost every aspect of their new lives. Although social workers provide invaluable support to both refugee men and women by easing their transition to their new homes, it is essential to gain a better understanding of both the particular needs of refugee women and the barriers they face in having their needs met. Such an understanding would improve the provision of services to these women and would facilitate their adjustment to life in resettlement by mitigating the impact of exile-related stressors on them. Toward this end, a needs assessment was conducted with refugee women who had resettled in the United States from Iraq, Afghanistan, and the Horn of Africa. This investigation aimed to answer the following questions: What are the particular needs of refugee women? What barriers exist to addressing these needs? and How can the community best respond to these womens needs? The findings cast light on the ways in which those who work in social work-related professions can best facilitate womens adjustment in resettlement.

Method
Consistent with principles embedded in feminist methodology (Reinharz, 1992; Roberts, 1990), all data collection activities were resolved in collaboration with key informants who were members of the refugee community and staff members of a local refugee resettlement agency. In addition, three bilingual and bicultural women who were similar to the participants on key dimensions, such as cultural background and refugee status, were employed as translators and to assist with the data collection. When necessary, the translators helped the first author, who was the primary investigator, to navigate cross-cultural interactions and answered all the participants questions regarding the research process. These women were recruited through local agencies that employed translators (e.g., the refugee resettlement agency and the county health department) and were trained by the first author in interviewing techniques, including the importance of accuracy in translation.
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Sample
The participants were 31 refugee women aged 19 to 63 (mean age: 37) who had been resettled in a midsized Midwestern city. Of the 31, 11 were Iraqi, 15 were Afghan, 3 were Sudanese, 1 was Somali, and 1 was Syrian. Although 28 participants indicated that they were or had been married, only 15 reported that their husbands were living with them in the United States. Single women were unmarried, widowed, or were resettled separately from their husbands for reasons that are not known. Six participants did not have any children living in their households, and the remainder had 112 children living with them, with a mean of 4 children per household. Overall, 23 of the 31 participants had children aged 13 or younger living with them. Finally, only women who had been resettled within 5 years of the data collection process was recruited for participation. It was assumed that because of their relatively recent arrival in the United States, resettlement-related stressors would be particularly salient for these women and that these women faced the greatest number of resettlement-related challenges and had the most significant needs.

Procedures
Because refugee women are often isolated and mistrustful of outsiders, the participants were recruited through individuals and organizations with whom they were familiar, including the county health department, a local refugee resettlement agency, and prominent female members of the local Muslim community (because many of the recently resettled refugees were Muslim). Caseworkers at the health department and refugee resettlement agency informed potential participants of the investigation. Similarly, key stakeholders from nations like Afghanistan spoke to refugee women in their communities about the study. If women indicated an interest in participating and provided their consent to be contacted for an interview, their contact information was provided to the first author. This procedure ensured that a representative sample was obtained as participants were recruited from multiple locations and in multiple ways. Interviews were conducted over a 3-month period using a structured interview protocol. Because of the womens lack of access to reliable transportation, interviews were mainly conducted in their homes. All interviews were conducted in either Arabic or Farsi, and the women received a US$15 gift certificate to a local grocery and department store for their participation. Construction of the instrument. Questions were designed to assess gaps between the participants needs and the resources that were being provided to them (Kaufman, Rojas, & Mayer, 1993). The final protocol consisted of 134 items and was translated and back translated into both Arabic and Farsi. Items were constructed to assess refugee womens needs in various areas and required the participants to rate statements regarding areas of potential need on a 5-point Likerttype scale (from definitely agree to definitely disagree). For example, the women were asked to rate general items, such as I am lonely, I feel safe in my neighborhood, and I will be able to learn English; women were asked to rate their experiences with local government and social services (e.g., the county health department and the local refugee resettlement agency) on 5-point Likert-type scales ranging from definitely agree to definitely disagree or very satisfied to very dissatisfied. In addition, the women rated the obstacles they may have encountered to having their needs met (e.g., I dont know how
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to take the bus and we are not able to afford better housing) on a 4-point Likert-type scale (from a big obstacle to not an obstacle at all). The women also rated the degree to which various aspects of their lives in resettlement were a source of concern for them (e.g., transportation and their childrens schooling) on a 5-point Likert-type scale (from never a concern to always a concern). The women were then asked a series of yes/no questions regarding their use of various resources (e.g., child care and public transportation) and their desire for specific services and resources (e.g., additional Englishlanguage classes). Finally, they were asked to rate the quality of various resources available in their neighborhood (e.g., public transportation) on a scale of 1 to 10 (from 1 not satisfied at all to 10 very satisfied).

Power analysis. Power was computed using the PASS computer program (Hintze, 2001). Because of the small sample, power was computed at p < .10 for the parametric tests. The t tests were found to have approximately 80% power to detect significance at p < .10, or a one standard deviation difference between the means. Correlations were likewise found to have approximately 80% power to detect a correlation of .35 or larger that was significant at p < .10. Nonparametric tests were found to have sufficient power at p < .05. The Fishers exact test was found to have approximately 80% power to detect a .50 difference in the proportion between the compared subgroups that was significant at p < .05. Finally, to compensate for the loss of power that resulted from the small sample, the least conservative Bonferroni adjustment was used to account for the loss of power as a result of conducting multiple t tests (the adjusted Bonferroni test; Jaccard & Wan, 1996).

Data analysis. In addition to using descriptive statistics to examine womens overall needs, relationships among the womens demographic characteristics (e.g., marital status, age, and nation of origin) and needs were explored. Correlations between ordered variables were first computed. Then, to understand the effects of these variables on specific aspects of womens needs (both jointly and uniquely), multiple regression was used. Fishers exact test, cross tabulations, and t tests were computed to assess the relationship between individual variables and the participants needs (e.g., the relationship between a participants marital status and specific services that she would like to see more of).

Results
Overall, the women tended to be positive about their new lives in resettlement, with 84% either somewhat or definitely agreeing that they wanted to live in the United States at this time. The participants similarly agreed that they enjoyed the new opportunities available to them in resettlement. However, they did have significant unmet needs and encountered multiple obstacles to having their resettlement-related needs met. The womens overarching needs were in the areas of language, finances, social support, the ability to access resources provided by particular governmental and social-service agencies, and the ability to access resources in their communities. These needs, as well as obstacles that the women encountered to having their needs met, are discussed next.

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Learning English
Overall, 81% of the participants expressed confidence in their ability to learn to speak English now that they have been resettled. However, a significant relationship between the participants age and level of linguistic confidence emerged, with the younger participants being more confident in their ability to learn English (r .47, F(1, 29) 8.40, p < .01). In addition, all the participants indicated that they wanted more opportunities to practice English, and 97% endorsed English classes as a resource that they wanted greater access to. Finally, 94% of the participants cited the ability to learn English as a frequent source of concern. In fact, this was the participants most frequently mentioned concern. The importance of refugee womens English-language needs was further illustrated by the fact that the womens lack of facility with English was a significant obstacle to their ability to access key resources. For example, 87% of the women believed that their language skills limited their ability to search for better housing, and 71% expressed a similar concern about their ability to use public transportation. The women also believed that their lack of English-language skills was an impediment to forming social support networks (77%), and 74% believed that their inability to communicate effectively with neighbors was an obstacle to receiving help with day-to-day concerns. Finally, 68% of the women believed that their inability to read food labels was an impediment to preparing enjoyable meals for their families.

Financial and Employment Needs

The participants financial concerns centered largely on the need to support their families on significantly limited incomes. Slightly more than half (58%) the participants were unemployed, and those who were employed were working in low-paying service industries, such as hotel housekeeping. In addition, a significant relationship emerged between the participants marital and employment status. Women whose husbands were residing with them in resettlement were significantly less likely to be employed than were women who were single (Fishers exact test .02). While only 20% of the married women were employed, 69% of the single heads of households were employed. The particular needs of single heads of households were reflected in their endorsement of skills training as a need. Specifically, the single women were more likely than were the married women to want job training (100% vs. 67%; Fishers exact test .04). It is not surprising that a significant relationship also emerged between the participants endorsement of the need for employment and their need for transportation. Although 57% of the women who were not seeking employment cited a need for transportation, all the women who sought employment did so. Similarly, those women who indicated a need for employment were more likely to say that they wanted to learn how to ride a bus (82% vs. 14%; Fishers exact test .01).

Social Support
The participants levels of satisfaction with their social support networks varied. Overall, 55% of the women indicated that they were at least somewhat lonely, and 97% wished that they had relatives living nearby. This finding was further supported by the fact that not having relatives nearby was the second most often endorsed concern for the participants, with 87% of women indicating that it was a frequent concern.
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In spite of these concerns, 68% of the participants stated that they had at least one friend whom they regularly talked to and spent time with, and 74% were at least somewhat happy with the number of friends that they had in the area. However, 90% of the women indicated a desire for more opportunities to meet others like themselves, and 94% noted their desire for organized opportunities to meet others who share their language and culture. In addition, although the women tended to feel comfortable in their neighborhoods, they largely did not interact with their neighbors. Only 42% indicated that their neighbors spoke to them regularly, and only 45% felt comfortable spending time with their neighbors. Finally, the degree of social support available to the participants was significantly correlated with their ability to access help for their needs in resettlement. Women who reported higher levels of social support were less likely to experience obstacles to obtaining assistance with day-today resettlement needs (r(29) .37, p < .05).

Agency Resources
The three most significant agencies and organizations from which the participants received services were the local county health department, the county welfare agency, and the local refugee resettlement agency. Overall, the participants were satisfied with the health care to which they had access. While 84% were happy with their own medical care, 93% were happy with the medical care their families received. In addition, 97% of the women indicated that they felt comfortable speaking with their doctors if they did not feel well, and 94% felt that they could be honest with their doctors. Furthermore, 87% of the women felt comfortable asking questions when they did not understand medical procedures. Overall, 94% of the participants were satisfied with the services that they received at the health department. A significant difference emerged with regard to the womens desire to be seen only by a female doctor. While 42% of the women indicated that they felt comfortable seeing only a women doctor, the Arab and Afghan women (the largest ethnic groups represented in this sample) differed significantly in this regard (t(24) 3.64, p < .01). On a scale of 1 to 5 (from 1 definitely agree to 5 indicating definitely disagree), the Arab women were significantly more likely to agree with the statement that they only felt comfortable seeing a woman doctor (M 2.00, SD 1.73) than were the Afghan women (M 4.27, SD 1.44). The participants understanding of the various forms and papers that they were required to complete in order to receive governmental benefits was also assessed, as was their ability to seek assistance with this process. This was an aspect of resettlement with which the women experienced significant problems. Only 13% of the participants indicated that they understood the paperwork mailed to them by the welfare agency, and only 17% understood the forms they were required to complete. However, what was perhaps even more significant was that only 55% knew where to go for help with welfare forms and procedures that they did not understand. A significant relationship also emerged between the womens marital status and their understanding of welfare forms and procedures (t(25) 2.79, p < .01). Those women whose husbands were with them in resettlement were significantly more likely to indicate, on a scale of 1 to 5 (from 1 definitely agree to 5 definitely disagree), that they understood welfare forms or procedures (M 3.89, SD 1.43) than were those women whose husbands were not with them or who were unmarried in resettlement (M 5.00, SD 0.00). All the participants were also still receiving services from a local refugee resettlement agency. Overall, they were satisfied with the assistance they received through this agency, with satisfaction with the assistance they received in accessing health care rated the highest
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(71% were at least somewhat satisfied with this assistance). In contrast, the women were the least satisfied with the assistance they received in accessing transportation (32% were at least somewhat satisfied with this assistance) and the degree to which caseworkers helped them get to know others who share their language and culture (37% were at least somewhat satisfied with this resource).

Access to Resources
The participants were asked about their access to various community resources, including banks, transportation, and child care (both formal and informal). Notably, only 16% of the women said that they used a U.S. bank, which limited their financial options and rendered them dependent on expensive check-cashing and other potentially predatory financial services. In addition, while only 7% of the women drove, only 55% indicated that they used the local bus system. The participants willingness to use public transportation was also significantly related to their marital status (Fishers exact test .03); thus, 77% of the single women, but only 33% of the married women, stated that they used the local bus service, even though 74% said there was a bus stop close to their homes. In addition, while only 7% of the women had ever placed their children in formal day care, 47% received child care assistance from family members or friends. This finding is further supported by the fact that only 12% of the women said that they felt comfortable leaving their children with someone other than a family member, and only 50% stated that they understood the American day care system. It is notable that a need for affordable child care was significantly more likely to have been endorsed by the single (100%) women than the married women (50%; Fishers exact test .05).

Obstacles to Having Needs Met

The participants experienced the most significant obstacles when they tried to obtain housing and transportation, primarily for financial reasons (84% for housing and 87% for transportation). In addition, as we noted earlier, 71% of the women found that their lack of English was an impediment to their ability to use public transportation, and 77% stated that they did not feel comfortable going places without their husbands or other family members. Furthermore, 77% of the women did not know how to drive. The more recently a woman was resettled, the less likely she was to say that she had encountered obstacles to obtaining transportation (B .26, t(28) 2.26, p < .05). Their marital status in resettlement also significantly affected the degree to which the women experienced obstacles to obtaining transportation (t(26) 2.80, p < .01), with married women reporting more obstacles. Finally, the participants were the least satisfied with the housing and transportation to which they had access, with transportation receiving the lowest overall satisfaction ratings. On a scale of from 1 to 10 (with 1 not satisfied at all to 10 very satisfied), the women gave their current housing a mean rating of 6.35 (SD 2.86) and the transportation to which they had access a mean rating of 4.74 (SD 2.71).

Discussion
Refugee womens needs are multiple, complex, and intertwined with their sociodemographic characteristics. Effectively addressing these needs has important implications for
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refugee womens health and well-being in resettlement. Therefore, a better understanding of their needs will allow for the provision of better services that are aimed at refugee women and will assist service providers in helping to minimize the gendered impacts of resettlement on these women. First, refugee womens economic needs have significant implications for their and their families overall well-being in resettlement. Poverty is associated with risks to the physical and mental health of both adults and children (Belle & Doucet, 2003; McDonough & Berglund, 2003). In addition, Chung et al. (1998) found that low income was a significant predictor of psychological distress among refugee women. Thus, simply assisting refugee women to meet their economic needs may have important implications for their overall health in resettlement. Notably, the married women were less likely than were the single women to seek employment and related resources. Role conflicts and pressure from their families not to work outside the home may have been pronounced for at least some of these women, who may have found it difficult to become employed while caring for their families (Ha & Mesfin, 1990). This situation may have been made worse for women whose husbands placed pressure on them to remain unemployed so as to maintain their household responsibilities (Benson, 1994). Although not all women want or need to seek paid employment, it would be helpful to find creative ways to provide married women with employment opportunities if they would like them. One strategy may be to help women who want or need it to work from home, allowing them to contribute to their families income while maintaining their household responsibilities. In contrast, financial concerns were pronounced for the single heads of households who may not have had access to many opportunities to improve their economic viability. The pressure to obtain immediate and continued employment to provide for their families may restrict these refugee womens ability to pursue an education that may improve their future chances of obtaining well-paying jobs. This point is especially significant when one considers that households that are headed by single women face particular risks. For example, Siefert, Heflin, Corcoran, and Williams (2001) identified a significant relationship between households headed by single women and the lack of access to sufficient food resources. It is thus especially important to focus on effectively meeting the economic needs of single refugee women while providing them with opportunities to improve their future earning potential (e.g., with accessible and flexible language and other educational opportunities). Womens interactions with the welfare system may have additional implications for their economic well-being in resettlement. Specifically, their lack of understanding of welfare forms and procedures may have detrimental consequences for those women who do not comply with associated regulations and demands. Hence, if the negative consequences of womens economic status in resettlement are to be minimized, it may be necessary to put a system in place whereby refugee women can receive specific assistance with welfare forms and procedures. In addition, the single women were significantly less likely than were the married women to know where to go for help with forms and procedures. It is possible that these women were used to depending on their husbands or other male relatives for assistance with administrative matters and were not certain how to deal with such concerns in their absence. As the sole caretakers of their families, single refugee women are particularly dependent on governmental aid to supplement their incomes, and it is thus especially important that they be familiar with the forms and procedures that are associated with their receipt of such aid. Second, their fluency in the language of the host country has significant implications for refugee womens adjustment to life in resettlement. The results of this study reinforce the
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findings of Ha and Mesfin (1990) that refugee women risk becoming socially isolated because of their lack of English-language skills but do not have the means to attend language classes. This lack of fluency in English may similarly serve to restrict refugee womens ability to obtain employment (Beiser & Hou, 2001; Ha & Mesfin, 1990). This finding is notable because employment may reduce refugee womens levels of psychological distress (Miller et al., 2002). Finally, Chung et al. (1998) found that low English proficiency was a significant predictor of psychological distress among refugee women. Improving their access to opportunities to learn English may thus have multiple, farreaching implications for refugee womens well-being in resettlement. Third, the inability to negotiate the culture of their host nation (or the nation within which they are resettled) may serve to isolate refugee women further (Allotey, 1998). For example, as was found in this study, refugee women may not be comfortable interacting with members of their host nation or venturing from their homes (Chung et al., 1998; Dona & Berry, 1999). For instance, many of the women who participated in this study were not comfortable speaking with or socializing with their neighbors. Although this situation may be consistent with the experience of many Americans, it is likely that linguistic and cultural barriers were particularly salient in determining the womens lack of social interaction with members of their host communities. This situation is important to address, because access to social support networks can buffer refugee women against the stressors they encounter in the early years of resettlement (Chung et al., 1998; Dona & Berry, 1999). In addition, access to preexisting refugee communities may assist refugee women through the process of adjustment and may provide them with a particular buffer against further psychological distress (Dona & Berry, 1999). Unfortunately, this is an area of support that is often overlooked by services providers, as evidenced by the participants general dissatisfaction with the support they received in this regard from the local refugee resettlement agency. Notably, the majority of women in this study also had a significant need for social support, which, a link to an existing ethnic enclave, may help to alleviate. It is thus important to help women to integrate into their host communities and to maintain strong connections with pre-existing refugee communities. Fourth, although the participants tended to be satisfied overall with the medical care to which they had access, some women wanted to see only female doctors and others had communication problems because of their lack of English-language skills. Weinstein, Sarnoff, Gladstone, and Lipson (2000) found that refugee women were unlikely to receive adequate gynecological care in resettlement because of their inability to communicate adequately with medical professionals. Ensuring that women are comfortable with their health care providers would be a significant step toward overcoming this concern. The importance of providing refugee women with health care services with which they are comfortable is further highlighted by the fact that these women are often victims of violence during war and flight and may experience lingering health concerns in resettlement (Allotey, 1998). These concerns may be related to womens sexual health, which the women may not want to discuss with doctors with whom they do not feel entirely comfortable. It is heartening that the majority of participants in this investigation not only felt comfortable speaking to their doctors and indicated that they asked questions about medical procedures that they did not understand but were also satisfied with their medical care. This is an encouraging finding that bodes well for womens use of the health care system but should be interpreted with caution. On the one hand, it is possible that the women may have overestimated their own comfort with the medical system. However, it is more likely that the efforts made by the local county health department to ensure refugee womens comfort and access to
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health care (e.g., employing translators and paying attention to cross-cultural considerations) paid off in the womens increased comfort and satisfaction with their health care providers. Finally, a significant aspect of refugee womens adjustment in resettlement is the ability to navigate successfully the resources that are available in their neighborhoods as well as within their larger community (Indra, 1991). Refugee womens knowledge and use of these resources reflect not only their level of comfort with their new surroundings but their ability to seek and obtain the resources and services that facilitate their day-to-day adjustment and life in resettlement. This is an area of need that remained unmet for many women in this study. Specifically, the women were not comfortable with such resources as banking, day care, and public transportation. However, it should also be noted that these needs were mediated by the participants marital status and related responsibilities. This finding highlights the importance of providing refugee women with practical assistance that is designed to familiarize them with the resources that are available in their communities while bearing in mind their gendered and other responsibilities.

Implications for Policy and Practice

Services that are aimed at refugee women should be tailored to take into consideration the differential needs of single and married refugee women. These considerations should include a focus on refugee womens different employment, language, transportation, and other needs. Accessible language-learning opportunities should also be provided to refugee women, at various times and in multiple, easily accessible, locations. Furthermore, in addition to financial and other services, providers should assist refugee women in alleviating their need for social support. Greater access to social support will not only provide these women with significant psychosocial benefits but may also help them become more selfsufficient. Finally, service providers should focus on effectively orienting refugee women to services that are available in their communities. Refugee women may also benefit from social policies that give them easier access to public assistance and longer term access to such aid, which will give women additional time for language learning, job skills training, and education and hence improve their overall adjustment in resettlement.

Limitations of the Study

There are three important limitations to consider when interpreting the findings of this investigation. First, the relatively small sample rendered it difficult to examine all differences across groups that may have existed. Second, the participants were unfamiliar with the research process and potentially wary of outsiders, which may have affected their responses to certain items and limited the validity of the findings. Finally, important relationships existed between the participants demographic characteristics. For example, many single women were more recently resettled than were the married women. This limitation represents a potential confound to some of the findings and speaks to the need for further investigations with recently settled refugee women.

Areas for Further Research

The findings of this study point to two important areas for further research. First, the significance of refugee womens sociodemographic characteristics to their experiences in resettlement should be further explored so that services can be more effectively tailored
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to the womens particular needs. Second, a longitudinal investigation of refugee womens experiences in resettlement may cast further light on the ways in which these womens needs in resettlement change over time and may allow for a deeper understanding of the gendered nature of resettlement.

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Zermarie Deacon, PhD, is an assistant professor in the Department of Human Relations, University of Oklahoma, 601 Elm Street, 728 PHSC, Norman, OK 73019; e-mail: zermarie@ou.edu. Cris Sullivan, PhD, is a professor in the Department of Psychology, Michigan State University, 130 Psychology Building, East Lansing, MI 48824; e-mail: sulliv22@msu.edu.

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