The biopsychosocial- spiritual model of health and illness can be explained with the following model:

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1 Task Four Marisa Schlenker Due Date: June 23, 2015 To begin this task, I will focus on the definition of illness, as it is important to understand the concept before designing a program integrating sport. Similar in understanding the concept of health, illness is quite complex and differs according to the perspective and overall definition of health. As we have seen from this module, a holistic perspective of health and illness takes in the physical, emotional, social, cultural, psychological and spiritual dimensions of the person. Illness is often synonymous with sickness, disease, affliction, and disability while health equates with haleness, robustness, vigor, well-being and strength. There is also a differentiation made between disease and illness although they are often found to be interchangeable. Disease is understood as an objectively verified disorder of bodily functions or symptoms associated with an identifiable group of signs and symptoms and illness is considered the patients subjective experience, signifying that it is the social phenomenon consisting of the meaning actors employ to make sense of observed or experienced events. Being healthy is also understood as being void of illness, so the terms are interlinked. The biopsychosocial- spiritual model of health and illness can be explained with the following model: Here illness refers to the sociocultural context in within which the disease is experienced so that the patient and his or her community members can explain the sickness or disease in a personally and socially meaningful way. The disease refers to the clinical perspective as to what is biologically or physiologically not functioning properly and therefore the sickness is believed to be the combination of the two concepts. In a traditional Western perspective on health, disease is understood to be an objectively measurable pathological condition of the body whereas illness is a feeling of not being normal and healthy, and in fact may be due to the disease. However, it can also be due to a feeling of psychological or spiritual imbalance. Even within cultures, the concept of illness varies, whereas the understanding of disease is pretty much similar across boundaries. (

2 Taking these points into consideration, I will proceed in describing the illness that I wish to address through a sports-based program. As we have discussed through our module on sport and psychosocial health in post-disaster and post-war situations, there are various initiatives working with populations in such conditions, including refugees living in complex situations and we must be critical of the current trend to dub any physical exercise or sports project as a post-war rehabilitation or a project for peace and instead focus on the projects participatory elements, the sustainability of its objectives and actions and the ways in which sport is understood in the complex environment. In relation to projects specific to refugee populations, Harris found that dance and movement therapy can be both effective and relevant to the sociocultural context whereas in Germany, a psychosocial center combined verbal psychotherapy methods with corporal methods and techniques to address the needs of refugees. It is important here to note that refugees is not a homogenous population but rather consist of individuals, men, women and children coming from different experiences and situations and therefore having an assortment of needs, concerns and health issues. The term refugee is comprehensive as it is defined as any person who, owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership in a particular social group or political opinion, is outside the country of his or her nationality and is unable or, owing to such fear, is unwilling to avail himself of the protection of the country; or who, not having a nationality and being outside the country of his former habitual residence as s result of such events, is unable or, owning to such fear is unwilling to return to it. Recently the UNHCR released a report on the current situation of the global refugee crisis and stated that wars, conflict and persecution have forced more people than at any other time since records began, to flee their homes and seek refuge and safety elsewhere. Globally one in every 122 humans is now either a refugee, internally displaced, or seeking asylum. Refugees are finding various ways to reach new countries; one of the most visible has been the dramatic growth in the numbers of refugees seeking safety through dangerous sea journeys, such as by way of the Mediterranean Sea. The UN estimates that already this year, 60,000 people have already made the journey with 1,800 migrants dying along the way while in total for 2014, 220,000 individuals made the journey to the European shores. ( It is critical to note that according to the Global Trends report detailed that in 2014 alone, 13.9 millions people became newly displaced and most alarmingly, half of the world s refugees are children. UN High Commissioner for Refugees António Guterres stated, for an age of unprecedented mass displacement, we need an unprecedented humanitarian response and a renewed global commitment to tolerance and protection for people fleeing conflict and persecution. This is a pressing issue for the European Union as a rising tide of asylum-seekers, fleeing crises in the Middle East and economic desperation in Africa and the Balkans, has pushed the ravages of far-away wars and poverty into some of Western Europe s most isolated reaches. The biggest volume of asylum applications have been directed to

3 Germany, followed by Sweden, both countries which are known for being relatively open to immigrants. ( The increasing flow of newcomers in Germany has been putting pressure on the support infrastructure and programs in German cities, but also the midsized and smaller towns and cities. The majority of refugees are coming from Syria; however, there are also many others from Kosovo, Iraq, different African countries and other lands. In order to deal with the influx of refugees, the German system places the refugees into towns and cities around the country. For some towns, adapting to and providing for these newcomers poses serious challenges. A mayor of a small village in Saxon with a small population of 175 stated in regards to the 50 asylum seekers which would be moving to her village, There s no way we can even talk about integration as who knows how long they re even going to stay In bigger cities like Berlin there are various groups showing support for the incoming populations. In 2014, Berlin held the first national conference on refugees and sport, where Green party politician and vice president of the German parliament Bundestag, Claudia Roth: stressed that providing access to sport and culture, in addition to the basic services, should be a core principle of countries hosting refugees, and that this should be granted equally for girls and boys, women and men. During the conference, the testimonies of refugees and the contributions of NGOs, who use football as a toll for inclusion, underlined the importance of sport in the social life of refugees, who in the most cases don t have a German work permit and to whom football is the only way to break out of the drab life in the camp. As aforementioned, refugees and asylum seekers are not a homogenous group, therefore it would require individual assessments to determine the health of each of these individuals. It is critical to remember that every refugee population consists of individuals, each with his or her own background and history. (Medicins San Frontieres) There are many studies concerning the mental health of refugees as it is widely understood that in fleeing from war torn countries, conflict and economic deprivation that there are undoubtedly effects on one s psychological health. It must be understood that many times the mental health of the refugees is secondary to other immediate health concerns, which should be addressed first and should be prioritized. These could range from dealing first with providing adequate nutrition, food and water, immunizations, sanitation, control of communicable diseases and dealing with injuries from the specific conflict. These concerns must be handled by health care groups and services and should be the priority of any work that aims to stabilize refugees upon his or her arrival in a new land. In relating to mental health or as often referred to as mental illness, the Center for Behavioral Science at Harvard Medical School found in their report Trauma and Mental Health in Child and Adolescent Refugees that youth and adolescents faced specific mental health challenges during the various stages of migration, including pre-migration, migration and resettlement phases. During pre-migration, this population faced various challenges such as: being exposed to war or witnessed atrocities to themselves or their families,

4 kidnappings, rapes or killings, experienced a disruption of basic needs and could have been separated from their families and community. In the migration process, conditions could have been very challenging including: having limited food and health care resources, never feeling safe and residing in refugee camps and such conditions. Upon arrival in the host country, individuals could face issues relating to stigmatization and there is the possibility that traumatic events can continue to emerge. Taking into consideration these various stages of migration, research has found that, the prevalence of depressions ranges from 4 47% with a high comorbidity with PTSD and associated with recent life stressors and maternal depressions. It is clear that there is a wide range of prevalence and not all refugee youth experience depression or PTSD, so studies which aim to understand why this is have found that the following factors are significant: social support and family cohesion, the level of sense of powerlessness, beliefs and political involvements, and severity of trauma exposure. When looking at reasons why mental health concerns actually worsen during resettlement, research points to: legal status, financial hardships and unemployment, discrimination and acculturation stress. A main concern of the report is that many of the refugee youth who were in need of mental health services when living in the host countries were not utilizing these services even though they were provided for. Many times they found that the parents were not supportive of such services, there was a high level of stigma related to mental illness or simply that services were not seen as appropriate as mental illness was not a primary concern for new arrivals. Addressing this concern of refugee youth not taking advantage of the mental health services, the report suggest that the mental health services must be integrated into the overall system of care so to decrease the stigma associated with mental health services and to build on existing structures. Additionally, if there are different models and understandings of mental health, then such services must be culturally and linguistically appropriate to the youth population and can be combined with other approaches or services that address non-trauma factors. This is where I believe a sport-based program can play a role in the lives of refugee youth. A sound and well planned out and developed sport based program can be fundamental to refugee youth for various reasons. First off, according to the WHO, experience and scientific evidence show that regular participation in appropriate physical activity and sport provides people of both sexes and all ages and conditions, including persons with disabilities, with a wide range of physical, social and mental health benefits. Included in these benefits is sports ability to promote social interaction and integration. Based on the UN chapter on sport and health, sport can generate health benefits in two waysthrough direct participation in sport itself and through the use of participatory and spectator sport as a platform for communication, education and social mobilization. In terms of the direct participation benefits, it would first be critical to determine the type of physical activity that should be introduced with the specific youth refugee population. It is important to find out which sports are

5 played by the youth and also whether these sports are supported by the wider community, including their parents, caregivers, etc. Additionally, it is key to think of other social factors, such as whether girls and boys can normally play together, what kind of equipment is available or needed and what cultural factors are associated with the sport. If the sport is to be used to also connect with youth in the host community, then it would be key to determine which sports are already existing in the community and part of the social fabric. Additionally, it would be key to connect with already existing sports-based programs to create connections and links with already existing supporters of sport in the community. Also, it could be a key way to connect with potential coaches and sports leaders who could also play a potential role in the program with the refugee youth. My proposed sports program would concentrate more on the latter benefit, which is based on the understanding that, a powerful social connector, sport can bring people together, expand and strengthen social ties and networks, link people to resources and provide them with a sense of belonging. Sport can also work to reduce the social stigma experienced by marginalized groups. This relates to refugee youth populations who even upon arriving and settling in a new community, are often looking for ways to connect with the community, resources and find ways to feel a sense of belonging. This sense of belonging can come from longer-term well planned and implemented sports programs which are ideally run by trained coaches and sports leaders. It is not enough to just simply present a sport, but it is important to consider and address the various other components that are integral to designing a sportsprogram and realizing that refugee youth have unique needs that can be very distinct from the needs of youth in the host country or city. Sport alone cannot prevent or treat disease, or in this discussion, change the mental health of refugee youth. However, as aforementioned, it can be integrated into the overall program and applied in a holistic manner which aligns with the health objectives of the overall program and is informed by an in-depth knowledge of the participants and their socio-cultural context. Sport is believed to contribute to an individuals resilience, which is defined as, the inner strength, responsiveness and flexibility that individuals possess that enables them to withstand stress and to recover quickly to a healthy level of functioning after a traumatic event. Connected with resilience are the following protective factors that help to reduce the effects of risk factors in the lives of children and youth including: community support in the form of caring interactions between adults and children, unconditional acceptance of a young person by an older person, the development and promotion of healthy peer relationships and youth opportunities to help others and make a contribution to their communities. When setting up a sports-based program, it is critical to also consider the following suggestions taken from literature on working with refugee populations: Do not make the mistake of considering refugees and displaced people as helpless individuals totally dependent on outside assistance. It should not

6 automatically be assumed that they are incapable of any independent action and unable to organize themselves in any way. Refugees must be able to start to create a new and worthwhile life. They should be allowed to participate actively in the planning and implementation of programs, which are meant to support them. Helping them to help themselves should be the principle behind refugee assistance; given responsibility for their own future, they are more likely to have hope in that future. Without refugee involvement and the information this brings in regard to culture, religion and traditional differences between groups, some services may prove inaccessible to part of the population. Taking these best practices into consideration, I would also model the sportsbased program on the curriculum developed by Edgework Consulting which guides coaches and sports leaders in their interactions with refugee youth as well as the German organization, Champions ohne Grenzen, which offers football trainings for refugees in Berlin. The organization offers a mixed program for men and women, an all female program and a youth program. The programs are free of charge and in addition to weekly programs; various tournaments and friendly matches are set up to offer refugees connections and experiences outside of their communities and also to make more visible the conditions of refugees in Germany. In terms of their work with youth, they offer training programs for youth between 6-15 years of age, where fundamental football skills are introduced in a team play manner. The youth program can be run in a mixed group, however, it is important to make these decisions based on the respective community. In terms of the coaches, the organization tries to create local-refugee coach pairs for the youth, so that there are benefits for both youth and coaches themselves. With two coaches, there are more possibilities for the youth participants in creating strong and stable relationships with adults in the community and ensuring that youth feel supported in the program. Additionally, Champions ohne Grenzen aims to create a larger support network around the refugees, so that sports is not the only service provided but rather they have connections to other resources and greater networks. These networks could possibly provide support in legal issues, language acquisition, housing and employment concerns, among others. The development of the curriculum for the sports-based program would be based off the work of Edgework Consulting, specifically looking at their Playing to Heal; Designing a Trauma-Sensitive Training Program as it provides a comprehensive guideline for coaches and sports leaders who aim to turn their sports program into a trauma sensitive model for working with youth who have experienced intense conflict, such as the refugee population. This curriculum sees the investment in coaches and sports leaders as being crucial to any effective sports-based program, as they are the adult individuals who direct the programs and frame the relationship with the youth participants. In terms of their roles in addressing the mental health of the youth participants, not only is the coaches relationship with the participants essential, but also the practices which represent specific things that can be

7 done to organize the sport experience to become a climate that supports and even helps to facilitate the healing work for all players in the sport experience. These include: coaching in pairs (as aforementioned), committing to a consistent practice plan, creating a clear behavior code, practicing positive traditions, creating contribution opportunities, planning for intentional connectivity, providing a regular time to reflect, focusing on skill development and adjusting the game to fit to the program context. Even with this focus on the curriculum and the coaches role in addressing trauma sensitive approaches and the healing of its participants, the actual mental health services provided by other providers must not be ignored, as these should be part of the overall program and the sport aspect should be a supplementary component.