*1.1. Refugee Women*

Some 70.8 million people worldwide were seeking safety and stability because of war, human rights violations, persecution, and economic hardship in late 2018 [1]. Estimates suggest that at least 48% are forcibly displaced women and girls [1]. This highly vulnerable refugee group is significantly affected by pre-, peri-, and post-migratory trauma and stress factors, leading to severe psychological burden [2]. Sexualized and gender-based violence are among the main reasons women and girls flee their home countries [3]. Forced marriage, family honor-related violence, genital mutilation, rape, and resistance to and or transgression of gender-discriminatory religious practices, cultural traditions, or legislation are just some examples of what females experience before and after armed conflicts [4–6]. During their flight, women and children are particularly vulnerable to sexual and other exploitation forms, including labor exploitation, trafficking, discrimination, and extortion [3,6–8]. A representative survey of 639 female refugees living in German shelters revealed that a significantly higher number of women from African countries had traveled to Germany alone than women fleeing from Syria, Afghanistan, and Iraq. Of these, 81% were accompanied by minors, 2.6% of whom had been born during flight [4].

**Citation:** Zehetmair, C.; Kindermann, D.; Tegeler, I.; Derreza-Greeven, C.; Cranz, A.; Friederich, H.-C.; Nikendei, C. A Qualitative Evaluation of a Mother and Child Center Providing Psychosocial Support to Newly Arrived Female Refugees in a Registration and Reception Center in Germany. *Int. J. Environ. Res. Public Health* **2021**, *18*, 4480. https://doi.org/10.3390/ ijerph18094480

Academic Editors: Lillian Mwanri, Hailay Gesesew, Nelsensius Klau Fauk and William Mude

Received: 13 March 2021 Accepted: 20 April 2021 Published: 23 April 2021

**Publisher's Note:** MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

**Copyright:** © 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

In 2019, women accounted for 43% of all asylum applications in Germany, while 22% of all asylum applications were for young children under one year of age [9]. The European Union Directive (2013/33/EU; Chapter IV, Article 21) states that (unaccompanied) minors, pregnant women, and single parents with minors are the most vulnerable individuals among displaced populations. Many female refugees still experience discrimination and abuse, including sexual harassment and psychological or physical violence, in their host or destination countries [4,10]. Studies have shown that female refugees are more likely to experience psychological stress and have a higher risk of developing mental illness than male refugees [11–14]. Pregnant and postpartum refugees are also more likely to have high-risk pregnancies, abnormal neonatal birth parameters, and show more postpartum depression [15–17]. Female refugees often have limited health and psychosocial care access due to structural factors, stigmatization fears, low self-esteem, and shame [4,14]. Deacon and Sullivan [18] found that 42% of the refugee women preferred a female doctor in their sample. Although the need for gender-sensitive services and gender-specific access to health care is recognized, offers are still sparse [4,6].

#### *1.2. Programs Addressing Specific Needs of Refugee Women*

Internationally, some programs address refugee women's specific needs in their home or host countries. In 2019, Hammer et al. [19] released a review about nineteen programs worldwide addressing the needs of internally displaced and refugee women and girls: for example, The Citizen Charter Afghanistan Project is aimed at developing better infrastructures (clean water, electricity, roads, and irrigation), health care, and education to communities across Afghanistan as well as sensitizing communities to the challenges faced by women (e.g., gender-based violence). The Development Response to Displacement Impacts Project (DRDIP, Horn of Africa, and Kenya) and the Jordan Emergency Health Project were primarily concerned with psychoeducation and prevention of sexual abuse and gender-based violence. The Piloting Delivery of Justice Sector Services to Poor Jordanians and Refugees in Host Communities project developed and implemented training and awareness campaigns on women and children's needs. The IDP Living Standards and Livelihoods Project in Azerbaijan established women-only meetings to ensure their representation in community investment decisions [19]. The Hacettepe University Women's Research and Implementation Center has been operating a women's health counseling center in Turkey since 2015. It provides sexual and reproductive health care and family planning services, gender-based violence prevention offers, counseling, and leisure activities, such as yoga and language courses [20]. Khamphakdy-Brown et al. [21] introduced an empowerment program to prevent domestic violence, offering psychoeducation, workshops, home visits, counseling, and female shelters. Recently, Sabri et al. [22] published an article introducing a web-based application called 'weWomen', including risk assessments and safety planning for immigrant and refugee women facing intimate partner violence. Furthermore, the Utah Refugee Service Office offers refugee women workshops to increase their self-efficacy and management of their and their families' health [23]. In the Netherlands, refugee women can attend special bicycle workshops to improve their mobility, access, and skills and increase their social engagement [24].

Regarding refugee camp settings, the humanitarian aid organization Médecins Sans Frontières has established a mental health clinic for female survivors of sexual violence in a Ugandan refugee camp [25]. The provision of better living conditions, such as access to energy and security teams, has been identified as a critical factor in addressing sexual and gender-based violence in refugee camps in developing countries [26]. For example, the Kenyan refugee camp of Kakuma has implemented a gender program: security units monitor women's safety, and there are safe spaces for injured or vulnerable women [27]. They have also established educational programs, including scholarships and grants, and an all-girls boarding school. Empowerment assistance programs, human rights and gender issue workshops, sewing, cooking, knitting, nursing, and computer or electrical repair training courses are also offered [27]. In Cox's Bazar refugee camps, primarily

sheltering Rohingya refugees in Bangladesh, 52 safe access points and prevention programs, including engagement and empowerment interventions, have been set up for females [28]. Stark et al.'s review [29] of safe spaces programs for women and girls in the Democratic Republic of the Congo, Ethiopia, Uganda, Tanzania, Kenya, Bangladesh, and Pakistan found improvements in psychosocial well-being, social support, and attitudes toward rites of passage. Krause [30] highlights that flight can empower women by giving them more agency and choice. The women's sense of empowerment is fostered by confidence-building activities, which are often offered by humanitarian relief organizations.

### *1.3. Study Concept*

While there are special programs and initiatives geared toward improving refugee women's safety and empowerment worldwide, the literature often describes shortfalls in addressing safety and gender needs in shelters or refugee camps leading to refugee women's disempowerment [30]. In Germany, separate housing units and sanitary facilities, or simply lockable rooms and showers, are virtually non-existent [31]. Schouler-Ocak and Kurmeyer [4] point out that female refugee accommodation conditions in the destination or host country facilitate discrimination and sexualized assaults and discourage female refugees from articulating their needs and difficulties. Shelters in centers for newly arrived refugees specifically designed to safeguard female refugees are an exception in Germany [31]. The German Red Cross, Rhine-Neckar/Heidelberg division, has operated a low-threshold, psychosocial care service for newly arrived pregnant refugees and female refugees with children in the Heidelberg-Kirchheim reception and registration center in Germany since 2016 to address this issue. The operated mother–child center (MUKI) is a female-only space offering women and their children a sheltered and friendly environment to socialize, find mutual support, and receive childcare offers. It aims to strengthen psychosocial resources and offers German language, knitting, and cooking classes as well as monthly community cooking evenings focusing on traditional dishes from different cultures. In addition, the MUKI has weekly consultations regarding asylum procedures and midwifery care. Opening Monday through Friday between ten and one p.m., the MUKI's services are open to all refugee women and their children.

This study aimed to evaluate the female refugees' and staff's experiences of the MUKI psychosocial care services for female refugees and their children. The interviews with the female refugees focused on (1) their motives for attending the MUKI, (2) factors impeding their attendance, and (3) their suggestions for improvement. Regarding the main staff members, we were particularly interested in (1) their views on the MUKI's relevance for the female refugees, (2) encountered difficulties, and (3) their suggestions for improvement.

#### **2. Materials and Methods**

#### *2.1. Data Collection and Procedure*

The cross-sectional study using semi-structured qualitative interviews took place in the reception and registration center Patrick-Henry-Village (PHV) in Heidelberg-Kirchheim, Baden-Württemberg, Germany. The PHV is a former US barracks converted into a reception and registration center for newly arrived refugees in 2015 [32] (for further information, see [32–35]). Between February and July 2017, we visited the MUKI and conducted semistructured qualitative interviews with (1) the female refugees attending the MUKI and (2) the MUKI's main staff members. Our inclusion criteria were the age of 18 or older and the ability to give informed consent. We did not specify the total number of interviews in advance.

We recruited our interview partners by directly approaching refugee women attending MUKI onsite and asking them whether they were interested in our study. We made several visits to the MUKI during its opening hours to reach as many refugee women as possible within the study period. As for staff members, we focused on the MUKI's key staff members responsible for and best informed about the MUKI's services. True to the MUKI's womenonly concept, all staff members were female. Interested refugee women and staff members

were informed about the study verbally and in writing. We told them that participation in our study was voluntary and, in the case of refugee women, would have no impact on their asylum procedure. We also informed them about anonymity and pseudonymization procedures, digital recording of the interview data, length of data storage, withdrawal from the study, and data security. Additionally, we told all participants that they did not have to answer a question if they did not wish to.

We contacted a PHV staff interpreter or a telephone interpreter through an interpreter service if the refugee could not converse in German or English. Interviewees were familiar with the PHV interpreter from previous translation occasions. However, the refugee women were still explicitly asked if they felt comfortable with her translating for them. Interpreters working in PHV must sign a confidentiality agreement before starting work at the center. If we used a telephone interpreter, we requested a female interpreter from an interpreter service we have been working with since 2016. The telephone interpreter also first introduced herself, and we then asked the interviewee if she felt comfortable working with her for the interview. Before the interviews, we sent the interview guidelines to the interpreters, and they also signed a confidentiality statement.

As the MUKI is an open plan space, we conducted the interviews in a quiet room located in a building nearby to ensure privacy. First, we collected data on sociodemographic details (age, religion, country of origin, social support, pre-, peri-, and post-migratory distress factors). The sociodemographic questions were available in German and English writing. The interpreter translated the questions for each additional language during the interviews. The interviewer and the interviewee recorded the answers together. Then, the interview was conducted. We approached the key MUKI staff members about our study during their shift. If they were willing to participate, we interviewed them after work. Again, we collected sociodemographic data (area of work, educational level, age, country of origin, history of flight) and then interviewed them. Two female scientific researchers employed at the Heidelberg University Hospital (IT, CDG) carried out recruitment and data collection. One of the scientific researchers has a medical background, and the other has psychological experience. Both were specially trained to conduct the interviews and were supervised by an experienced researcher familiar with qualitative research methods (CN). The interviewee's name was not mentioned throughout the interview to ensure anonymity.

#### *2.2. Semi-Structured Interviews*

We conducted semi-structured interviews with (1) the female refugees attending the MUKI and (2) the MUKI's main staff members. Our research team developed the semi-structured interview guidelines based on the idea of evaluating the MUKI as a low-threshold support offer for newly arrived refugee women and their children, with a particular focus on the attending refugee women's and staff members' perspectives. Methodological aspects of Helfferich [36] were followed. The semi-structured interviews, split into target groups (1) and (2), comprised key guiding questions followed by more detailed questions. Appendix A shows the two interview guidelines.

#### *2.3. Quantitative and Qualitative Data Analysis*

Demographic variables were calculated using descriptive statistics (frequencies, means, and standard deviations) using the SPSS statistics program [37]. The face-to-face interviews were digitally recorded and transcribed verbatim by research assistants using predefined transcription rules. Then, the transcripts were evaluated using the program MAXQDA [38] and analyzed thematically following Mayring's qualitative content analysis principles [39]. Before examining the textual material, we defined the content-analytical unit of analysis as every statement (single or multiple sentences) referring to one of our key questions. We removed double statements, and double coding was not possible. Then, we went through the transcribed interviews' textual material and identified a single or few sentences as codes, representing the most elemental unit of meaning [40]. These codes were labeled with a short term or sentence (coding) and summarized into a relevant category. Then, we

checked if other codes matched an already defined category or opened a new category. After analyzing 40% of the textual material (after six refugee women interviews/two staff member interviews), we revised the categories and the whole coding system concerning the previously defined categories' logic. After that, we completed the remaining textual material analysis and grouped the categories into main themes. Finally, the categories and main themes were discussed in detail in the research team and adjusted if necessary [39]. We analyzed the MUKI female refugees and staff interviews separately.

#### **3. Results**

#### *3.1. Sample Description*

We conducted semi-structured interviews with 16 female refugees and all five MUKI employees during the study period. Table 1 shows the sample description of female refugees who attended the MUKI and consented to be interviewed (Appendix B provides further sociodemographic details). The interviewed female refugees were between 18 and 64 years old (M = 31.1, SD = 13.32). Of the 16 women, 12 (75.0%) had children and 3 (18.8%) were pregnant. Two females (12.5%) did not complete the basic sociodemographic questionnaire. We interviewed in English with seven (43.75%) women. One woman (6.25%) was able to speak German, while female interpreters (*n* = 2 (12.5%) with a PHV staff interpreter, *n* = 6 (37.5%) with a telephone interpreter) helped us interview eight women (50%). At the time of the interview, the majority of the female refugees had attended the MUKI on more than four occasions (*n* = 9; 56.25%); five women (31.25%) had come to the MUKI between two and four times, and two women (12.50%) had visited the MUKI for the first time. Most of the female refugees had first heard of the MUKI's services from other refugees in the PHV (*n* = 9; 56.25%). Four women (25%) stated that the "German Caritas Association" (a registered charity) had referred them, while one woman (6.25%) had heard about the service by chance. Two women (12.50%) did not provide information on how they had heard about the MUKI's service.


**Table 1.** Sample description of interviewed female refugees attending the MUKI (*N* = 16).

<sup>a</sup> = Sub-Saharan Africa includes interviewed refugees from Cameroon and Eritrea; the category Middle East includes interviewed women from Syria, Iran, and Palestine; the category South Asia includes interviewed women from Sir Lanka and Pakistan; the category South-East Europe includes interviewed women from Albania and Macedonia. <sup>b</sup> = Multiple answers were possible.

Additionally, we interviewed all five MUKI main staff members who were between 18 and 41 years old (M = 31.7, SD = 11.30) and all women. Table 2 shows their sociodemographic characteristics. Four (80%) were German Red Cross employees; one woman specialized in asylum and procedural counseling. One woman (20%) was a qualified

midwife volunteering at the MUKI. The employees described providing counselling (*n* = 5; 100%), teaching German (*n* = 1, 20%), language assistance (*n* = 1, 20%), and generally supporting the female refugees (*n* = 4, 80%) as part of their MUKI work.

**Table 2.** Sociodemographic sample description of the MUKI staff (*N* = 5).


<sup>a</sup> = In Germany, the Abitur is a valid school certificate for admission to any university-level study or vocational training program.

#### *3.2. Results of the Qualitative Interviews with Female Refugees Attending the MUKI*

Two hundred forty individual statements were coded; then, they were grouped into ten categories and summarized into four main themes. In the following paragraphs, we will describe the main themes and categories, showing the respective number of codes in parentheses and exemplarily quotations from the interviews. We have marked text passages with \* where an interpreter assisted in the interviews.

### 3.2.1. MUKI Attendance Motives (172)

This central theme included the interviewees' statements about their respective motives for attending MUKI.

#### The MUKI's Services (83)

The interviewees greatly appreciated all the MUKI's services but saw the German language classes as the most important offer. One interviewee stated: T*hey teach you anything; you can learn anything. You can learn even to, to knit. I cannot, I have not learned it before, but I see some other women doing it. And they teach you always how to behave to people, how to talk. And this is better. And we come here to learn the German language, that's why we are here. And I especially, I love the language. I love to learn the language* (2302AB/23). Many interviewees told us that learning German and getting to know German culture and customs in general was very important to them. One woman told us: *Our culture is taken into account. For example, we had had a celebration, and they brought halal food. And I think that's good because they also take us into consideration. So as a Muslim and as an Arab*\* (3001FF/12). The interviews also highlighted that the offered childcare was a great relief. They also appreciated that their children could play outside their usual cramped sleeping and living areas and had access to clean toys and a friendly, welcoming environment. One interviewee highlighted: *The atmosphere is good and it is a good idea for the children. All day long, they stay in the rooms, little rooms. And they don't have so many things there. They don't have a TV or a cuddly toy. That is why, I think it is good. Here, they can play together because they don't go to school. They don't go to school, I think so. And they don't know how to get in contact with other children*\* (2303BB/21). The interviewed women also cherished being able to reach out to the MUKI staff and felt the MUKI provided them with a stable point of contact.

#### Socializing with Other Female Refugees (58)

Contact with peers was cited as a significant motive for attending MUKI. They felt that they were able to exchange experiences, reduce prejudices, and create mutual distractions there. One woman pointed out: *That there are so many people from different countries, this made me stronger; if I met different cultures or different nationalities, I would have said, in the beginning,* *that I don't know how they think or behave. So, outside, I now can start talking; that is not a problem for me anymore because I made the experience in here that all are nice*\* (3002FF/14). Furthermore, interviewees described feeling a sense of community. An interviewee answered: *It is calming and relaxing to get outside and let the kids play with each other. You have somebody who listens to you in an atmosphere without pressure. For sure, topics like asylum application arise, and we give each other help*\* (2304CC/37). Above all, they underlined that the MUKI facilitated cultural exchange, acceptance of different religions, and cultural backgrounds and fostered respectful interactions. One refugee woman said: *All, yes, all, with all nationality. There is something amazing to meet people from other countries. To see sometimes talking about traditions, sometimes talking about what they are thinking about. It's beautiful. I like them all* (1954AA/26).

### Friendly Sheltered Atmosphere (31)

Interviewees valued the MUKI as a friendly environment and felt that the MUKI's welcoming atmosphere contrasted strongly to their sparsely furnished accommodations. One woman described: *Everything is just relaxed. Everybody is looking happy. So, another world, I think. [..] For, for a moment, I forgot totally I'm in the camp* (1711FN/57). They said that they felt more relaxed and calmer when they attended the MUKI and that the sheltered space fostered a sense of security. One interviewed woman noted that she was able to find "inner peace" there. Another woman explained: *I am so, so happy about the MUKI. There, I can relax my soul. If it did not exist, I would have gotten crazy*\* (3002FF/18).

#### 3.2.2. Factors Impeding Attendance (12)

The interviewed female refugees named intrapersonal and interpersonal difficulties in attending the MUKI.

#### Intrapersonal Factors (5)

A few interviewed women said they felt overwhelmed during their first visit because no one had introduced them to the MUKI services and premises. *I did not know where to start. Yes, I think that's one thing; I don't know how they can fix. [..]. So, I was just lost* (1711FN/29). Other women reported that the MUKI's services could only provide short-lived distraction and comfort from their troubles. One interviewee stated: *During the time I attend the MUKI, I forget about my problems. But as soon as I leave, all the problems come back, for instance, about my sick son and that she is threatened by deportation to another country*\* (2304LL/21). Some pointed out that they sometimes had difficulties finding the energy to come after not sleeping because their children had cried all night.

#### Interpersonal Factors (7)

Some women reported that new female refugees were sometimes deterred by the noise and presence of so many women in the MUKI's limited space. One female said: *I would put the children in here or another room, separated room because I want to and I like to concentrate on the teacher without hearing noise* (1954AA/55). Furthermore, one woman stated that she had not felt included by the other women during her first visit and found it challenging to engage with them. She said: *The first time I came, it was not very easy because I was alone, nobody to talk to. Everybody really is talking* (1711FN/25). In addition, she added that children of all age groups played together in the same room due to the limited available space, which could sometimes feel too crowded and noisy for some women looking for a retreat.

#### 3.2.3. Suggestions for Improvement (25)

In the interview, the female refugees made several suggestions on how the MUKI's services could be improved, including offering more services and fostering the women's sense of community.

#### Expansion of the MUKI's Services (18)

Most of the interviewed female refugees would like to see an expansion of the MUKI's services. They especially asked for more, ideally daily, German classes. One refugee woman explained: *If they learn us if they would give us another two hours of learning, I would be really happy. They give a learning from 10 to 12. Very intensive information, very useful. Another two hours. I like learning* (1954AA//75). They also hoped for additional German lessons for children, more experienced German teachers, and more interactive lessons. They also expressed their desire for more leisure and education materials, particularly CDs, films, books, and musical instruments. *I don't know if they have, maybe, books. Because someone like me, I like poetry. As maybe some books to read. Maybe in English* (1711FN/87). One woman specifically hoped for longer MUKI opening hours. Some of the women desired a separate children's playroom and more support offers for their children. One interviewee pointed out: *There are some children who are aggressive. They come from war regions, and what did they see? Only war and blood. I think it would be better if a woman could help them*\* (2303BB/34).

#### Strengthening the Sense of Community (7)

The women made specific statements concerning possible ways to improve the MUKI women's sense of community. They suggested that their cohesion might increase through regular joint activities, games, or simply tidying up together at the end of the day. One woman said: *Maybe they organize some games, people play. Not just toys. We can organize small competitions, small presentations. What do you think? Because I check somewhere at another office and so I saw the right conferences and stuff. We can make our little presentations here* (1711FN/92). She further stated that women might enjoy holding short, informative presentations on various topics, such as their cultural or culinary background, for each other.

#### 3.2.4. MUKI as a Women-Only Space (31)

Most female refugees welcomed the MUKI's male-free concept, but it also led to some concerns.

#### Facilitating Open Engagement (16)

Most women supported the MUKI's women-only concept and reported being able to engage more freely and open-mindedly with each other in a safe, male-free environment. An interviewee answered: *We can do everything that we want. If we were men here, we cannot do it, I think. To speak about everything, to talk, to do something. Because I am, for myself, I am afraid about other people. I am a closed woman. It is better that it's only women* (2401AA/55). One woman said she felt it was sheltered enough for her to take off her headscarf, while another noted that she could breastfeed openly at the MUKI without being censored or sexualized. One interviewee stated: *I think it is a very good atmosphere because you come together and for a short time, you can leave your problems behind. I personally do not have any problem with men. But I think it is easier if there are no men because women with each other can have fun, can laugh, and can share their problems. If men would be around, the females would be shier than now*\* (2304LL/19).

#### Feeling Safe (8)

Many women reported feeling sheltered and secure in the MUKI's male-free environment. One woman said that she feared men in general, while two other women stated that they felt nervous and insecure in the presence of men. One commented: *I think that's good because then I can move around here easily. And also sit down in a very relaxed way*\* (2307EE/14). Furthermore, the women remarked to experience interpersonal difficulties with men generally. One interviewee mentioned that during the German class: *If men are there, I don't ask anything because I am nervous. This house is free. All are women, no nervousness, and free talk* (1801AM/47).
