General Conditions (27)

The staff remarked that available information regarding the PHV's psychosocial services was not disseminated enough and thought it was unfortunate that not all women were informed about the MUKI's services. Furthermore, they critically noted that turnover was high in both refugee women and MUKI staff. One staff member stated: *When the women leave, they leave with positive experiences. Others may not yet know exactly what MUKI is. To advertise the MUKI, we offer group meals or parties. Some women have been transferred again. So, we have lost a few experienced women again. Sometimes that's a bit of a shame, but that's the way it is* (0506CS/67). In addition, they pointed out that the children made the MUKI a noisy environment to work and be in. One staff member added the following regarding the female-only environment: *I am conflicted somehow. There are great facilities for women, but I also see different offers for refugee females and unaccompanied refugee minors, and the men are always forgotten. [* . . . *]. I think that the slogan 'this is only for women' sends out the wrong message—as if all refugee men were criminals* (2002CR/171).

#### 3.3.3. Suggestions for Improvement (22)

The employees made several suggestions for improvement, which were mainly related to conceptual aspects. All staff members advocated extending the MUKI's opening hours, holding more German lessons, and expanding the MUKI's services in general. One woman pointed out: *We hope we will get a few more co-workers soon so we can open again in the afternoon. We could then have activities in the mornings and offer quiet recreational times in the afternoons* (0506CS/65). To address the MUKI's noise level, the employees suggested introducing rest periods during the opening hours. Generally, the staff said they would like to see a broader range of offers for women and men outside MUKI. One woman stated: *Of course, the optimum would be more German classes. But then, quiet days would be unthinkable inside the MUKI. I think that the women would also appreciate it if they could do something else here, too. And of course, extend the opening hours, but that is not possible right now because of low staff resources. I also think it would be good if we had a kind of terrace where you could sit outside together in summer* (2002CR/67).

#### **4. Discussion**

This study aimed to evaluate a mother–child center (MUKI) providing psychosocial support to newly arrived female refugees in a registration and reception center from the attending female refugees' and MUKI staff members' perspectives. Our results suggest that the MUKI has the potential to establish itself as an important women's hub in the reception and registration center. The interviewed female refugees appreciated the MUKI's psychosocial services and sheltered environment. The interviewees generally reported few attendance barriers, which were primarily related to intra- and inter-individual issues. The staff mainly reported difficulties regarding the MUKI's general working conditions, including insufficient awareness of the provided services and a high turnover of staff and attendees. Interviewees and staff alike were in favor of expanding the MUKI's program.

The refugee women's statements showed that the MUKI's diverse offer, the exchange with others and the welcoming atmosphere motivated them to attend. The interviewees particularly valued the German classes. Deacon and Sullivan [18] highlight that host country language skills can facilitate refugees' successful adjustment. However, as refugee women often have less formal education and weaker foreign language skills, they tend to have more adjustment difficulties. In their study, refugee women stated that inadequate language skills hindered them from forming social networks, reaching out for help, and accessing essential resources [18]. Teaching refugee women language skills and providing low-threshold services can promote their community participation and help them develop agency and empowerment. The interviewees' comments show that MUKI fostered the women's self-efficacy on an inter- and intra-individual level: the women frequently voiced feelings of social acceptance and mutual respect and a sense of security safety in connection with their experiences of the MUKI. Considering the women's harrowing gender-specific reasons for and experiences during flight [3–6], creating a setting such as this is a first step in providing women with the necessary foundation for stabilization and emotional distancing from an experienced trauma. Women's programs are critical. They offer at-risk groups a safe starting point for healing without coercion to self-disclose or shame. The experience of positive emotions and community are protective and stabilizing factors for refugee women [41,42]. Moreover, positive social interaction and acceptance are crucial mental health resources and are known coping strategies for dealing with challenges and acculturation difficulties [43,44]. Across cultures and populations, a sense of community has been identified as an essential resource promoting a collective sense of coherence that supports mental well-being and life adjustment [45].

Although the interviewed female refugees experienced the MUKI as a low-threshold support offer, overexertion, social engagement-related difficulties or fears, and its generally high noise level were seen as key attendance barriers. Intrapersonal factors, particularly anxiety, impede care access [46], and newly arrived refugees are often unfamiliar with the host country's support services. Some of our interviewees stated that they felt overwhelmed when they first attend the MUKI. A peer or staff mentoring program could help take down this barrier. Designating an experienced staff member or long-time attendee as a point of contact may make it easier for women during their first visits to the MUKI. Mentors could make new attendees feel more welcome by showing them around and explaining the available offers. A welcoming ritual (e.g., a weekly greeting session) might also help women get to know each other and socialize more quickly despite the high turnover.

All the interviewees felt that the MUKI's noisy environment was a deterring factor. They suggested the introduction of daily rest times to address this issue. Unfortunately, the MUKI's high noise level is difficult to control because its large, open-plan layout is used by many people for different purposes simultaneously. In light of the interviewees' appreciation and need for the service, it would be great to expand the MUKI's premises and offers with sufficient funding. However, the PHV is located in former military barracks, which were not built to accommodate refugees. The refugees' difficult living situations are well documented: the accommodation's general condition is poor, the noise level is high, and privacy is hard to find in the shared rooms and showers [47,48]. Furthermore, the structural barriers to medical and psychosocial services are also known [49].

While the women appreciated the MUKI as a safe space, they highlighted that it could not help them with their severe long-term concerns. Post-migratory stressors and their effects on refugees' psychological stability, especially refugee women, have been demonstrated in previous studies [14,50]. The MUKI is a low-dose, low-threshold support offer providing refugee women with a safe space to socialize, advance their skills, and maintain a daily routine (e.g., German language or knitting classes). It also offers midwifery assistance and asylum counseling to address some post-migratory needs. At the very least, it gives the refugee women some distraction from their otherwise very monotonous days at the PHV and long-term worries. However, it cannot change post-migratory stressors, such as residency, family reunification, or provide trauma therapy.

The interviewed women emphasized that they had benefited from the MUKI womenonly space. It had enabled them to interact more openly and experience feelings of freedom, ease, and safety. The women saw the MUKI as a space for personal growth and healing after their traumatic flight and personal history. Our results corroborate previous calls

for more gender-sensitive services and gender-specific access to care [4,6]. Nevertheless, Kraus [30] warns against women's stigmatization as victims and assigning them a per se vulnerable position and inferior social status. She pointed out that refugee women's empowerment in social contexts requires both men and women to renegotiate and redefine their roles, identities, and relations [30].

Interestingly, some of the interviewed female refugees expressed reservations about the MUKI's male-free concept. While safe spaces are necessary and valuable to increasing well-being and addressing gender-specific needs, the idea systematically excludes men. Some interviewed women noted that a male-free space was unfair toward refugee men, potentially stigmatizing, and unrepresentative German culture. This may be true; however, refugee women are still at risk for gender-specific violence despite resettlement. Bartolomei et al. [51] showed that resettled refugee females in Australia faced discrimination for being single or having an illegitimate child, forced marriage, domestic violence, and engagement in survival sex. The need for gender-sensitive shelters and psychosocial services for newly arrived pregnant and refugee women, such as the MUKI, is great. Despite limited funding, it would be good to have a similar program for men in the PHV addressing gender issues and promoting equality between female and male refugees. Organized cross-gender and nationality community meetings could improve morale and well-being as well as relieve tensions.

The refugee women had specific ideas about what they wanted to change concerning the MUKI concept. They wanted to see an increase in the number of courses, the provision of more materials, and, more specifically, more joint activities to strengthen their sense of community. The women's ideas reflect their high regard for the MUKI. Olivius [52] stated that the refugees' participation in refugee camps could improve protection and assistance and foster self-reliance. For the refugee women, giving us feedback as quasi-representatives of their host country could also have a participatory aspect in the sense of "being heard" or "having a voice". Kreitzer [53] asked refugee women about their perceived barriers in engaging in program planning in refugee camps. The assessed women frequently gave the lack of childcare as their main reason for non-engagement. In our study, the women asked for more courses and materials specifically for children and, above all, for more support for children in need. Although children are have been recognized as highly vulnerable group among refugees and child-oriented services are extremely sought after, current literature has documented a great lack of offers to date [54]. Bronstein et al. [55] summarize that refugee children experience high psychological distress, with prevalence rates for PTSD ranged from 19 to 54% and depression ranging from 3 to 30% in their review. Internalizing and externalizing problems were frequently found [55]. In refugee camps, adequate toys or other child resources are often sparse. Refugee children must often shoulder responsibility early on, are very closely attached to their parents, and often have limited peer contact. From a psycho-developmental perspective, providing refugee minors with a safe, clean, and pleasant environment to be and play as the children is an essential step on their long road to healing [55].

Regarding the relevant factors motivating MUKI attendance, interviewed MUKI staff members' statements were consistent with the refugee women's descriptions. This suggests that the staff members could convey the MUKI's gender-sensitive and culturally adapted offers and conceptual relevance and that the refugees could appreciate this. Therefore, the staff members need to have a culturally sensitive attitude and communication skills. According to Brooks et al. [56], cultural sensitivity 'requires an awareness of cultural diversity, including how culture may influence patients' values, beliefs, and attitudes, and involves acknowledging and respecting individual differences' (page 384). Recently, different health researchers have focused much attention on evaluating and improving cultural sensitivity in communication, including healthcare in general [56], outpatient psychotherapy [57,58], and nursing care [59].

The staff members mentioned few concerns regarding the women-only concept. Yet, the MUKI's safe space for women can also be seen as disadvantageous: Women and men

forfeit the chance to socialize in a sheltered, supervised environment preparing them for German culture. However, male-free areas, such as women-only sports, educational programs, and (international) women's cafés, are also common in Germany. The MUKI's concept aims to strengthen refugee women's resources shortly after they arrive in the host country. Nesterko and Glaesmer [60] note that it is almost impossible for newly arrived refugees and refugees waiting for a decision on their asylum procedure to fully structurally and internally 'arrive' in their host country in light of the many uncertainties. They also point out the refugees' rupture in their relationship with their home country and thus identity. A successful acculturation process always includes participation in both the country of origin and the host country's culture [60]. Understandably, the greater the cultural distance between the host and home country, the more significant the perceived migratory burden [58]. In this respect, you could say that the MUKI provided the interviewees with a feeling of familiarity and offered them an interim cultural 'home'. The MUKI's protected environment allows women from more restrictive, gender-segregated countries in particular to enjoy more freedom and open interaction.

Concerning work-related difficulties, the MUKI's staff members described their work as strenuous and stressful. They emphasized their high workload, the high turnover of staff and attendees, and the female refuges' great need for support. Many employees reported a strong sense of responsibility for the refugee women. At times, they felt emotionality enmeshed and had difficulties in keeping their professional distance. The concept of secondary traumatic stress and burn-out has gained importance in literature and clinical care in recent years. The Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5 [61]) has recognized secondary traumatic stress's impact. Depending on the profession, the prevalence rates for secondary traumatic stress and burn-out are heterogeneous: While PTSD (17.1%) and burn-out (57%) symptoms were high in Greek rescue workers [62], nurses working in a regional trauma center in South Korea showed levels of secondary stress symptoms around 84.4% [63]. In the United States, up to 30% of refugee caregivers exhibited high secondary traumatic stress levels [64]. In contrast, medical students volunteering in a reception center for refugees (3.2%) [65] and humanitarian aid workers in Jordan report low secondary traumatic stress levels (4% burn-out, 7% secondary traumatic stress) [66]. Similarly, Akinsulure-Smith et al. [67] pointed out that passive coping strategies, including general distraction, venting, substance use, behavioral disengagement, or self-blame, were associated to higher secondary traumatic stress and burn-out risk. In contrast, self-efficacy [68], personal commitment, organizational support [69], emotional intelligence, use of active coping, emotional coping, and positive reframing [67] are established protective factors. Wirth et al. [70] uncovered the high workload and caseload of social workers working with refugees and homeless people and recommended increasing the number of professionals and decreasing their caseloads. The authors point out that frustration increased when the employee felt unable to care for clients adequately [70]. As most interview statements referred to difficulties related to the general working conditions, more efforts are needed to improve the MUKI's employees' working conditions. The employees' suggestions, such as extending opening hours, employing more staff, and introducing set rest periods, may help address the noise level and high workload. Isawi and Post [68] highlighted the need for supervision, training, and self-care practice, such as meditation, mindfulness, physical exercise, and social support in taxing working environments.

#### **5. Implications and Future Directions**

Our results suggest several implications and future directions: The MUKI offers a lowthreshold, low-dose, women-only environment in which female refugees' gender-specific needs can be addressed. It has great potential in further establishing itself as an information hub and psychoeducation center facilitating cultural exchange and increasing selfempowerment. Women-specific offers have been shown to improve access to care structures and increase women refugees' integration and participation. Policymakers and relief orga-

nizations responsible for registration and reception centers should consider implementing nationwide MUKI programs for refugee women and children. As discussed above, there are projects worldwide addressing refugee women's needs. Nevertheless, more (shelter) programs are needed for refugee women who have faced/are facing trafficking, gender-based violence, and harassment. In cooperation with the German Interior Ministry, programs are currently being developed to identify trafficked women via screening tools and promote referral to counseling services and therapist, social worker, and lawyer networks.

Moving forward, refugee women attending the MUKI should be more involved in planning and implementing activities: First, the MUKI's opening hours should be extended. This would allow the women to creatively organize their time and ideas, such as talking about cultural issues and showcasing skills. Second, additional group offers or competitive games should be introduced. This could strengthen the overall sense of community, encourage self-empowerment, and foster intercultural exchange. Third, more experienced MUKI attendees (frequent attenders) should have the opportunity to take on more responsibilities in the MUKI and develop their sense of self-efficacy. Attendees should be encouraged to raise awareness for the MUKI's services and to mentor new attendees. Resident refugees can apply for work placements in the PHV, which include working in the gym, serving food, or keeping the premises clean. Consideration should be given to whether such a position could also be created for the MUKI. Fourth, more psychoeducational offers (e.g., lectures, workshops) covering German culture, (mental) health literacy, contraception, communication skills, women's and girls' rights, and equality should be introduced. This could lead to a better understanding of life in Germany and help prevent gender-based violence and provide early access to (mental) health care if needed. In addition to psychoeducational sessions, weekly focus groups could strengthen the sense of community among the attending refugee women. It would be interesting to follow-up if the focus groups could also continue online after redistribution to different shelters to build more lasting relationships between the women.

The interviewed staff members also advocated expanding the MUKI offers and opening hours, and introducing rest periods. Given the heavy workload of MUKI staff, serious consideration should be given to including or employing refugee women as staff in a supporting role. That said, the MUKI still requires qualified and long-term employees to shoulder the workload and opening hours. More funding is needed for MUKI to improve working conditions and implement new conceptual ideas.

On an organizational level, it may help if staff members and interested refugee women received workshops to reinforce culturally sensitive communication and self-care workshops, such as mindfulness and meditation training. In addition, psychoeducation on secondary traumatic stress, burn-out, and compassion fatigue should be addressed. To our knowledge, MUKI staff members already receive regular supervision. However, considering their work with highly traumatized individuals, further staff support offers should be established. Challenges, such as language barriers and rapid transferal to other locations, must not be overlooked.

Future qualitative and quantitative research should examine self-empowerment, sense of (community) coherence, and effects of psychoeducation among refugee women attending MUKI more closely. It would also be interesting to investigate secondary traumatic stress, culturally sensitive communication skills, work-related self-efficacy, and MUKI staff profiles.

#### **6. Limitations**

This qualitative study has limitations that need to be addressed: Firstly, we cannot rule out social desirability-related response biases during the interviews. Secondly, we only assessed the perspective of refugee women who had attended the MUKI. Women who might have considered attending but did not were not interviewed. Unfortunately, we did not record how many refugee women declined participation and why. We estimate that approximately 70% of the women we approached participated in our study, but we cannot

specify a drop-out rate. In the case of MUKI staff, we focused on the key employees. We felt that their intimate experience of the service would provide comprehensive insight. We did not include temporary MUKI workers in the study. Third, the number of interviewees in our study is small (16 refugee women and five staff members). We did not pre-set the number of MUKI interviews for the following reasons: (a) this was the first study we conducted there; accordingly, we did not know how many refugee women would be willing to participate in our survey at the outset; (b) the MUKI is a drop-in center open to all refugee women and their children. Rapid reassignments to other shelters leads to fluctuating attendance and poor predictability are characteristic of all PHV-based services. That said, qualitative research aims to capture the participants' perspectives by systematically analyzing the collected narratives. Often, the concept of data saturation, referring to the point when no new information is discovered in data analysis in the research process, is used to provide insight into the quality of the categories and major themes identified during the analysis. While different recommendations regarding the sample size of interviews exist (range from six to 50 interviews), Hagaman and Wutich [71] note that saturation of the most common themes should be reached within 16 interviews. In relatively homogeneous groups on focused topics, 13–31 interviews might be required to identify significant themes. Following these recommendations, our study's sample size of refugee women attending the MUKI was sufficient to achieve data saturation. Furthermore, we conducted five interviews with the key MUKI staff members. Although the total number of staff member interviews is small, we interviewed all primary employees. Nevertheless, the interviews' validity may be limited by the small sample sizes in both groups. We cannot rule out a biased representation of the MUKI's acceptance. Fourth, the interviews were conducted in 2017. However, the MUKI concept described in this study is still up to date. Before the COVID pandemic, no fundamental changes were made to the services provided by MUKI. Since the onset of COVID in early 2020, MUKI services have had to be significantly reduced, and participation has been curtailed in line with severe public and private life restrictions implemented nationwide. The confined living conditions are highly conducive to coronavirus infection in the shelter. Although urgently needed, all projects operating within the center can only be carried out with restraint, under great caution, and in compliance with the regulations and hygiene standards in force. However, especially in times of COVID, safe spaces for refugee women and their children remain crucial. Fifth, due to the setting inherent high turnover of refugee women in the PHV reception and registration center, no attention was paid to heterogeneous distributions of age, education level, and country of origin when selecting interview partners. While we focused on the experience of the MUKI as a low-threshold psychosocial service for pregnant refugees and refugees with children, we did not assess possible cultural differences, which might have affected the responses of the refugee interviewees. However, we did not know which refugee women would attend the MUKI and participate in the study and did not select the interviewees according to their cultural background

#### **7. Conclusions**

Female refugees are frequently exposed to gender-specific dangers before, during, and after their flight while often carrying the sole responsibility for their accompanying children. Their specific care needs are rarely addressed in their destination or host country shelters. Our data suggests that the MUKI has established itself as an important hub for newly arrived female refugees and their children by providing psychosocial care and a sheltered environment. Our findings show that refugee women appreciated the MUKI's offers, including German classes, childcare, leisure activities, and socializing in a welcoming atmosphere. The majority of the refugee women valued the MUKI's women-only concept enabling them to feel free and safe. The interviewed refugee women were also eager to participate in the planning and implementation of future MUKI offers. Data have shown that addressing gender-specific needs can help refugee women in their empowerment, self-efficacy, and personal growth.

In the future, the MUKI needs to address attendance barriers and take the attendees' ideas into account. Establishing a mentoring or buddy system (refugee to refugee) and expanding MUKI opening hours could be critical next steps. Policy efforts to introduce the MUKI concept as a gender-specific care program for vulnerable refugee groups in registration and reception centers at a national level are ongoing in Germany. Future services should include psychoeducation and information on culture, (mental) health literacy, contraception, and women's rights to promote gender equality and improve future integration. The refugee women need to be actively involved in the program development and implementation.

Furthermore, long-term screening and protection programs for refugee women affected by trafficking, gender-based violence, and harassment are desperately needed. A multidisciplinary approach involving therapists, social workers, and advocates should be adopted and evaluated for feasibility and effectiveness. Furthermore, more attention needs to be paid to refugee aid workers working conditions. More studies assessing work-related mental health problems, such as secondary traumatization, are required. Refugee aid workers' coping strategies and intercultural skills should also be examined. Future research must improve the identification of female refugees affected by gender-based violence and trafficking and develop interventions to improve literacy, psychoeducation, and overall empowerment of refugee women. These efforts must not end in registration and reception centers but should also extend to subsequent shelters and municipal housing.

**Author Contributions:** Conceptualization, C.Z., D.K., C.D.-G., A.C., H.-C.F. and C.N.; Formal analysis, C.Z. and I.T.; Investigation, I.T. and C.D.-G.; Methodology, C.Z., D.K., I.T. and C.D.-G.; Supervision, H.-C.F. and C.N.; Writing—original draft, C.Z.; Writing—review and editing, C.Z., A.C. and C.N. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research received no external funding.

**Institutional Review Board Statement:** The study was conducted according to the Declaration of Helsinki's guidelines and approved by the Ethics Committee of the University of Heidelberg (S-612/2016).

**Informed Consent Statement:** Informed consent was obtained from all subjects involved in the study.

**Data Availability Statement:** The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.

**Conflicts of Interest:** The authors declare no conflict of interest.

#### **Appendix A**

**Table A1.** Semi-structured interview guidelines for the interviews with female refugees who attended MUKI (N = 16) and with the MUKI's main staff members (*N* = 5).

