Health disparities among Burmese diaspora: an integrative review

Summary

Tens of thousands of displaced Burmese ethnic minorities have endured various adversities for over six decades but are largely underserved. This study aimed to illuminate the health impacts of their misfortunes and unmet areas of concern. Using a holistic lens, we conducted an integrative review of 47 papers spanning the years 2004 to 2022 from diverse data sources. The results revealed widespread multimorbidity, triggered mainly by displacement. The diaspora's problematic health conditions were worse than their host country's general population. There was a strong indication that the diaspora's unfortunate health trajectory is determined early in life. Ongoing human rights violations and grossly inadequate health care interventions deepened pre-existing health conditions. Noteworthy emerging treatment initiatives, including integrative health care, were underutilized. The persisting health and intervention needs among the diaspora warrant advanced studies to facilitate much-needed resource mobilization and collaboration among stakeholders to promote health equity.

Funding

There was no financial support for this manuscript.

Introduction

Burma (renamed Myanmar in 1989) is a highly diverse country. There are approximately 135 ethnic groups with distinct histories, cultures, religions, and languages. Presently, Burman or Bamar is the majority ethnic group, and Buddhism is the state religion. The widespread political and ethnic strife among the ethnic groups pre-existed the British colonial era and was exacerbated by the British “divide-and-conquer”^1,2 rule favoring one ethnic or religious group over another. The violence increased when the country became an independent nation in 1948, leading to the 1962 military coup by the Burman nationalists.1, 2, 3, 4, 5 Under the military regime, Burmese ethnic minorities were subject to extreme violence and oppression, including killings, torture, brutal (free) labor, and property and citizenship losses. The military crackdown in August 2017, which resulted in the mass exodus of over 730,000 Rohingya Muslims from the Rakhine State, was the most significant military attack on one ethnic group in this country's modern history.⁶ Moreover, the country's violence has contributed to extreme poverty. The country's Gross Domestic Product per capita was estimated to be double that of Thailand until the 1960s.⁷ Currently, Burma is one of the poorest Southeast Asian countries–145 out of 189 countries and territories, as reflected in the United Nations human development index.⁸ Furthermore, frequent natural disasters have compounded the country's social problems.⁹

These adversities have displaced tens of thousands of Burmese, primarily ethnic minorities like Karen, Rohingyas, Chin, Kachin, Karenni, Shan, Mon, and Wa. More than half of those displaced are women, children, and the elderly.⁹ Many are internally displaced (IDP) in tightly controlled camps by the centralized militia or Tatmadaw with minimal life necessities and mobility.^1,9,10 Many fled to neighboring countries like Thailand, Bangladesh, Malaysia, and India. These exiles, however, have been subjected to ongoing multi-level hardships in various asylum sites without clear solutions.^11,12 In response to their plight, the 2004 United Nations High Commissioner for Refugees (UNHCR) initiative offered third-country resettlement to many Burmese refugees in countries like the United States (U.S.) and Australia. It should be noted that Burmese migrants are excluded from refugee status and benefits because they are deemed to have left their homeland for socioeconomic advancement.⁵

A growing body of literature addressing resettled Burmese refugees indicated that this population continues to suffer marginalization, limited access to health care, and poor health outcomes even in Western countries.13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33 While democracy was underway in Burma under Aung San Suu Kyi's leadership, the increased enforcement of repatriation and restrictions on third-country resettlement evoked additional fear and anxiety among the diaspora.^5,34,35 The multifaceted health concerns around the COVID-19 pandemic further complicated the diaspora's pre-existing conditions.36, 37, 38 The military coup on February 1, 2021, is a new development and poses yet another threat to their health and wellbeing. This paper could not cover this ordeal, but future research should investigate the potential health impacts of this shift.

The Burmese diaspora is a highly distressed group affected by multidimensional adversity; however, they are largely underserved. Limited data concerning this population dampens global awareness of the diaspora's problematic health conditions and engagement in intervention. As this population continues to face ongoing hardships, there is a need for a comprehensive understanding of their health phenomena. With this in mind, this study aimed to illuminate the health impacts of their misfortunes and unmet areas of concern. We expected to find substantial health disparities across the board and hypothesized that the protracted oppression in the homeland and ongoing marginalization in host countries would be significant diaspora health determinants. In alignment with a holistic lens,^39,40 this integrative review⁴¹ examines the diaspora's 1) health conditions (i.e., physical, mental, and behavioral health), 2) associated stressors, and 3) intervention. Our discussion includes confounding factors or unmeasured variables that otherwise would contribute to a holistic account. Notably, more studies are dedicated to documenting Karen or Rohingya refugees. However, we believe all displaced require equal consideration as they have been subjected to similar events to varying degrees. Therefore, this paper addresses all displaced Burmese ethnic minority groups that we could identify beyond “the refugee-migrant binary”⁷ orientation. We did not limit our study selection to a specific ethnicity, migration status, age group, or geographic location.

In this paper, the terms diaspora or displaced refers to IDPs, migrant populations, refugees, and asylum seekers. In contrast, refugee refers only to the registered refugees by the UNHCR. Moreover, Burma was renamed Myanmar by the Burman military junta without democratic due process.^3,42 Thus, many pro-democracy supporters and the U.S. government do not officially acknowledge the new name.³ Furthermore, Burmese is not to be confused with Burman or Bamar. Burmese refers to citizenship or language.¹ Some ethnic minorities prefer to be called by their ethnic names (Ro, personal communication, October 23, 2019). Therefore, if known, ethnic names were used whenever appropriate, considering their distinct cultural identities. Meanwhile, many more culturally sensitive ethnic terms may not have been covered here.

Methods

Inclusion and exclusion criteria

The papers included in our final analysis spanned the years 2004 to 2022. Inclusionary criteria for this integrative review⁴¹ focused on the health information of displaced Burmese ethnic minorities: IDPs, migrant populations, refugees, and asylum seekers. Also included in the final analysis are several broader studies of refugees and asylum seekers^{13,16,18,22,27,37,43} that provided supportive findings on displaced Burmese. Burman and immigrants were excluded for their privileged status compared to the displaced Burmese ethnic minorities. Burman is the majority and immigrants have certain legal status. These groups have additional protective benefits. Studies with different emphases, including themes of anthropology and education, were excluded. Peer-reviewed papers were prioritized, whereas anecdotal sources such as newsletters were excluded. However, given the scarcity of corresponding literature, we had to relax our criteria and incorporate a few additional grey literature sources, including published reports^9,22 and unpublished theses.^5,17

Search strategy

We conducted our initial data search between September 2019 to April 2021, primarily relying on five electronic databases (i.e., PubMed, Science Direct, California State University Los Angeles One Search, Google Scholar, and SocINDEX) and a hand search of reference lists in eligible articles. Eventually, we extended our search and collected additional papers through August 2022. Among grey literature, one unpublished thesis⁵ was collected through ProQuest. The other three papers^9,17,22 were obtained through a google search. The papers included in our final analysis spanned the years 2004 to 2022, and we chose the year of the UNHCR resettlement initiative as the starting year. We synthesized qualitative, quantitative, and mixed-method research papers. Search terms included Burmese, ethnic minorities, Karen, Rohingya, Chin, Kachin, Shan, Mon, Wa, displacement, health, mental health, behavioral health, health disparities, pre- and post-migration risk factors, and health and mental health treatment for Burmese. See Appendix A for an exhaustive list of search terms. We optimized our search using Boolean search phrases, including AND, OR, NOT, and ONLY.

Quality appraisal

We appraised the methodological quality of eligible papers to assess the risk of bias and the presence of confounding factors using the Critical Appraisal Skills Programme checklist⁴⁴ for qualitative research papers and the STROBE statement⁴⁵ (i.e., The Strengthening the Reporting of Observational Studies in Epidemiology guidelines) for quantitative research papers. Both instruments were applied to the mixed-method papers’ qualitative and quantitative aspects accordingly. Later, these papers were reevaluated per PICO standards⁴⁶ (i.e., Patient/Problem, Intervention, Comparison group, and Outcome) to strengthen our content analysis. Overall, the papers had clear objectives with solid advocacy for health equity. However, several factors may have altered the data's validity and generalizability. Sampling was not always up to par. Twenty-one papers did not specify sampling strategies. Only two papers (one cross-sectional and one case-control) randomized samples. Six papers did not identify the sample sizes. Six of the quantitative research papers had less than 25 study participants. Systematic comparison to capture intergroup variances was lacking in most papers. Cultural heritage information was mainly missing, confounding cultural influences. Nonetheless, the papers reviewed provided valuable indicators for future studies.

Data extraction and analysis

We extracted and tabulated relevant data according to study source, setting, study aims, study design or type, sampling strategy or characteristics, data collection strategy or instruments, results, and implications (see Extraction Tables in Appendices B to D). We used Endnote, Excel, and Word to organize the data. This extraction process also served as a secondary screening stage to determine the final selection of papers with the most salient health information (see Results section for additional details). First, results from qualitative, quantitative, and mixed-methods papers were synthesized separately, as demonstrated in the Extraction Tables. Then, we conducted a content analysis of the study findings. Data findings were categorized into open codes according to our research categories (i.e., health conditions, associated stressors, and intervention) and subcategories (i.e., physical, mental, behavioral health, comorbidity, pre- and post-migration stressors, macro- and micro-level interventions, and confounding factors). We refined our analysis iteratively until we reached data saturation for our research scope.

Results

Our search returned 466 potentially relevant titles; however, through an initial review, most were deemed ineligible because they did not specifically relate to our population of interest. This is because Burmese and other Asians, as well as refugees and immigrants, were indiscriminately lumped together. The number drastically dropped to 177 after excluding duplicates and studies not matching our demographic characteristics. We excluded an additional 64 papers because they had different emphases or anecdotal sources. Given the limited space in this paper, the final selection focused on the findings with the most salient health information. Hence, after a full–text survey of the remaining 113 papers, we excluded 66 more in two phases because they had partially matching themes or did not contribute new health data. The final selection included 47 studies (43 peer-reviewed papers and four grey literature sources, including two reports and two master-level theses). Many excluded records were retained in the reference list for their contribution to our knowledge base. The PRISMA flow chart in Figure 1 illustrates our search and selection process.

Figure 1.

PRISMA inclusion and exclusion flow diagram [adapted from Moher et al. (2009)].⁴⁷

Study characteristics

In the final selection, a total of 47 papers spanned the years 2004 to 2022 and covered various asylum and resettlement countries, ethnicity, migration status, and age groups. The papers included quantitative (n=23), qualitative (n = 16), and mixed-methods (n = 8) methodologies. The most represented host country in the studies was the U.S. (n = 15), followed by Thailand (n = 11), Australia (n = 6), Bangladesh (n = 6), Malaysia (n = 2), India (n = 1), and Southeast Asian countries (n = 2). Two papers signified Burma, and two papers identified home and host countries in combination. Many papers were dedicated to Karen (n = 15), followed by Rohingyas (n = 10), Chin (n = 8), Shan (n = 4), Karenni (n = 2), Kachin (n = 2), and Mon (n = 1). Some papers included more than one ethnicity, but their findings were generalized in most cases. Seven papers referred to their study participants as Burmese without delineating ethnicity. One paper mentioned Myanmar ethnicity, but it was unclear which Burmese ethnic group it referred to. Another paper broadly referred to migrants from Myanmar. Three papers also included Burman, but it should be noted that these papers focused on ethnic minorities. Although an anecdotal source indicated their displaced status, no paper mentioned Wa. The sampling included refugees in thirty papers, migrant populations in eight, and IDPs in four. There was no separate empirical data for asylum seekers. Ten papers included professionals serving the diaspora. The sample sizes ranged from three study participants to 1,136 pathology test results. A substantial number of papers (n = 24) exclusively focused on adult diaspora, followed by two papers on adolescents and one on children. One paper covered both young children and adolescents. Seven papers addressed all ages. There was no separate empirical data for older adults. Not all papers identified age groups. Overall, the gender distribution of the participants was comparable across the papers, although not all papers reported gender. See Extraction Tables in Appendices.

Findings

Below, our findings are outlined according to our research categories (i.e., health conditions, associated stressors, and intervention). The health conditions include physical, mental, and comorbidity. The associated stressors mainly include migration-related factors. The intervention consists of macro and micro-level treatment initiatives.

Health conditions

Physical health

Nineteen papers identified multiple physical conditions commonly experienced by the displaced. Nutritional deficiency-related and infectious diseases, including anemia, hepatitis B, tuberculosis, mumps, and measles, were substantial among all ages.^6,9,19,25,31 Other prevalent physical conditions among adult populations included hypertension, heart and pulmonary-related diseases, diabetes, and obesity.^38,48,49 Poor reproductive health, including pregnancy complications, was notable.50, 51, 52 Limited data revealed kidney disease,²⁶ HIV,⁵ and poor dental health.¹⁸ Several papers also documented physical assault^16,52 and landmine injuries.^9,31,53 Interestingly, one paper identified early pneumococcal colonization in refugee infants despite maternally derived antibodies.⁵⁴ Elevated blood lead levels among refugee children were significantly higher than their host country's general population and worse for children under two years.^23,55

Mental health

Nine papers identified mental health conditions exclusively. As expected, depression, anxiety, post-traumatic stress disorder (PTSD), and somatization were widespread among the diaspora of all ages.^{12,15,17,28,32,34,35,43,56} Surprisingly, Zuniga¹⁷ found that the depression among refugees worsened after host country resettlement. Schweitzer et al.²⁸ estimated a greater refugee mental health problem than the host country's general population. Crumlish and O'Rourke⁴³ pointed out that the rate of PTSD is ten times that of the general population in host countries.

Comorbidity

Sixteen papers addressed cross-cutting comorbid conditions. As identified above, many displaced with multiple physical illnesses or physical injuries, including landmine injuries, also had significant mental health symptoms.^{6,16,22,31,38,52,53,57,58} An interesting finding by Ziersch et al.¹⁶ indicated that mental health symptoms were more significant than physical health symptoms. Moreover, substance dependency (e.g., alcoholism, smoking, betel quid chewing) was rampant among many of these people.^{6,9,11,16,21,22,30,48,49} Notably, Aung et al.⁴⁹ found that alcohol drinking was more prevalent among those with higher income or better acculturated into the mainstream. Smoking was more prevalent among those with lower income or more marginalized. Further, domestic violence and suicidality had a strong positive association with mental illness and substance dependency.^11,52,59 The suicide rate may be the highest globally in refugee camps near the Thai-Burmese border.¹¹ A noteworthy comparative analysis by I. Kim²¹ revealed that whereas behavioral health symptoms were high for both Karen refugees and Burman political dissidents, the mental health symptoms of Karen refugee females were higher than that of Burman. Additionally, Mahmood et al.⁶ projected that the Rohingyas suffer a higher rate of cross-cutting comorbidity than their counterpart diaspora due to their dual ethnic and religious minority status based on their systematic review of general studies of Rohingyas.

Associated stressors

Migration-related factors

All papers except two quantitative studies^25,54 accounted for cumulative pre-, during-, and post-migration stressors as health determinants. Pre-migration stressors included exposure to killings, torture, forced displacement, loss of home or property, hard labor, poor environment, landmine, rape, enforced bribery by Tatmadaw and ethnic minority armies, starvation, and lack of health care. Interestingly, Schweitzer et al.²⁸ revealed that lack of food and water was the most significant pre-migration stressor and had lasting health impacts despite other traumatic events. Cardozo et al.⁵⁷ found that hiding in the jungle without life necessities during migration was a significant stressful experience. Noteworthy post-migration stressors included the effects of a global profit-making economy that deepened the diaspora's pre-existing health conditions through extensive labor exploitation without safeguards.^37,50,53 Other common post-migration stressors included ongoing landmine exposure, family separation, societal discrimination, unemployment, acculturative stress, gendered violence and constraints, the lack of resources, inadequate health care system, and broken hopes. The prolonged stay in camps for refugees and enforced repatriation or deportation of migrant populations were also significant.

Several findings are worth additional attention. There was a strong association between the number of trauma exposures and diaspora mental health. The refugees with extensive psychological symptoms were exposed to an average of 10.1 traumatic events.⁶⁰ Migrant adolescents with a higher rate of mental illness were exposed to an average of 5.7 trauma events.⁵⁶ The use of traditional Burmese remedies, including Daw Tway, as an alternative solution to the widespread lack of resources was another significant source of maladies addressed, especially in elevated blood lead levels among refugee children.^23,55 Noteworthy findings by Ziersch et al.¹⁶ revealed that the extended stay in the host country and exposure to societal discrimination had higher health impacts, bolstering the significance of discrimination. At the same time, this study found that Southeast Asian refugees were less affected by societal discrimination than refugees from Africa or the Middle East. I. Kim²¹ further substantiated the significance of ethnicity and gender for mental health. Karen women sustained more mental health symptoms than Burman. Additionally, there were significant add-on health impacts of COVID-19 as it elevated the pre-existing adverse conditions among the diaspora.^37,38 Limited resources for the diaspora made it impossible for them to navigate the pandemic effectively, which worsened their precarious conditions.

Intervention

Macro-level initiatives

Practically all papers advocated for macro or system-level interventions, including the advancement in diaspora health studies, international aid, community-level resource mobilization, and timely and culturally relevant health programs. Considering limited resources, several of these papers emphasized the importance of integrating mental health care into primary health care to address comorbidities effectively.^22,61 Several papers further recommended partnering with diaspora communities to mobilize their networking systems and human capitals.^{11,13,29,33,34,58} The Burmese diaspora has a robust networking system.^29,34 Moreover, Saraphi Community Hospital in Northern Thailand facilitated refugee registration for migrants with HIV. This increased health care use among this population, and Murray⁵ suggested replicating this model for other migrants. Kunpeuk et al.³⁷ contended that there are universal protective measures available in Thailand presently, but they are non-functioning for migrant populations primarily due to problems with policy implementation. Similarly, a few refugee studies in the U.S. found inconsistencies in the U.S. refugee health care system.^13,27 These studies stressed the importance of improving coherency between health policy and practice to mitigate the health effects of the diaspora's adversities.

Micro-level initiatives

Several papers also presented micro-level or specific treatment initiatives. Wells et al.⁶² found a community-based physical activity (e.g., soccer) a well-received biopsychosocial intervention by the Rohingya refugee community, albeit it could not be implemented due to a lack of resources. Tay et al.⁶⁰ and Mahmuda et al.⁶³ recommended Group Integrative Adapt Therapy (IAT/G) to treat trauma-driven mental health symptoms among the displaced. IAT/G is a group-based therapy that helps refugees restore a disrupted sense of safety, networking, access to justice, self-efficacy, and existential meaning. Tay et al.⁶⁰ found that this treatment method significantly reduced all common mental health disorders more than cognitive-behavioral therapy (CBT). However, it should be noted that Crumlish and O'Rourke's systematic review⁴³ found CBT a preferred treatment option along with a narrative approach. Dance and Movement Therapy (DMT) was another treatment option initiated by Rahapsari and Hill.³² The study participants said that DMT helped them express feelings they cannot say, stay focused on their assets, be less worried, and control anger. Zuniga¹⁷ and Tay et al.⁵⁹ also pointed out that the Burmese diaspora has a holistic view of health and wellbeing. Stakeholders should construct treatment according to how these people conceptualize their ordeals.

Discussion

Displaced Burmese ethnic minorities have endured multi-level adversities for over six decades but are largely underserved. This integrative review synthesized 47 papers to evaluate their health conditions, associated stressors, and treatment initiatives concurrently, gain a holistic account of their health phenomena, and promote health equity. Similar to other refugee populations, the general trend among displaced Burmese ethnic minorities showed a high level of poor physical, mental, and behavioral health conditions or cross-cutting comorbidity across the board. The diaspora's problematic health conditions were estimated to be worse than the general population in host countries.^6,9,11,28,55 Notably, there was a strong indication that their immunity is compromised early in life, subjecting them to a higher risk for complex health issues.^23,54,55 Moreover, certain groups of diaspora (e.g., Rohingyas, “border people,” women, and children) may be at higher risk than the other diaspora due to their dual minority status, geographic location, or social position.^{5,6,9,11,12,34,35,50,51,53} Migrant populations and IDPs may also be at higher risk than their counterpart refugees as they are as traumatized but exempted from refugee benefits.^{5,9, 10,34,35,48,57} While limited data precluded us from achieving a strong conclusion on intergroup variances, the overall adverse health outcomes among the diaspora are indisputable. There is an urgent need for adequate health care for this population and critical factors to bear in mind.

Given the complexity of the diaspora's health conditions, it is essential to understand their multi-level stressors. As hypothesized at the outset, the persisting political and ethnic conflicts resulting in unsustainable lifestyles in their homeland and ongoing adversities in host countries posed significant challenges to their health conditions.^5,6,9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24^,26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38^,43,48, 49, 50, 51, 52, 53^,55, 56, 57, 58, 59, 60, 61, 62, 63 The diaspora suffers a substantially higher number of trauma exposures than the general population in host countries, and this was a significant contributing factor to their health disparities. Ongoing lack of support and broken hopes compounded their morbidities. The unprecedented COVID-19 elevated their precarious conditions as limited resources further hampered their capacity to navigate the pandemic effectively.^37,38 Additionally, Kusakabe et al.⁵⁰ and Hengsuwan's⁵³ focus on the broader political and economic context of the dire conditions among migrant workers was a stark reminder of what is often left out in analyses that take such “external forces” for granted. The profit-making geopolitical economy takes advantage of the diaspora's vulnerability and scale-up labor exploitation without providing adequate protective benefits.^37,38,50,53 This ordeal deepens diaspora misfortunes and health impacts. Data analysis needs to include this global factor to understand the diaspora health phenomena better.

Several system-level treatment initiatives promoting universal health benefits,^5,37 integrative health care,^22,61 and community engagement,^{11,13,29,33,34,58} are noteworthy but confined to local practices. Similar calls for the promotion of equitable access to healthcare, integrative health care, and the critical importance of community engagement in addressing the unmet health and mental health needs in other refugee groups residing in high-income countries of resettlement are emerging in recent research.64, 65, 66, 67 However, the obstacles are high. These initiatives will require meaningful collaboration among policymakers, funders, health care professionals, and the diaspora communities to yield widespread health benefits. Researchers play a vital role in mobilizing this collaboration through advanced studies. The specific treatment options, such as DMT,³² CBT,⁴³ IAT/G,^60,63 and community-based physical activity,⁶² may improve diaspora health and psychosocial well-being. However, the caution is that “one size does not fit all.” Already, findings by Crumlish and O'Rourke⁴³ and Tay et al.⁶⁰ show discrepancies, wherein the former indicates that CBT is a preferred treatment option, and the latter discounts it. Therefore, planned clinical treatment must consider diverse challenges and needs. Also, a reoccurring theme in these studies aligning with similar refugee studies68, 69, 70, 71, 72, 73 was that clinical treatment needs to be culture-specific to be effective. Zuniga¹⁷ and Tay et al.,⁵⁹ in particular, underscored that the Burmese diaspora conceptualizes their health and wellbeing differently and stakeholders need to construct treatment accordingly.

Unfortunately, despite the diversity among the displaced, the uneven coverage of ethnic groups (e.g., Karen vs. Wa), various migration statuses (e.g., refugees vs. asylum seekers), age groups (e.g., adults vs. children), locations (e.g., U.S., vs. India), and health conditions (e.g., general health vs. HIV) limited the quantification of the unique challenges and needs of the diverse groups. The information about their cultural heritage was mainly missing. Except for two studies,^16,21 most papers reviewed failed to measure intergroup variances systematically. Limited data impeded a deeper understanding of cultural influences on their health conditions. More importantly, the confounding factors or unmeasured variables that otherwise would strengthen the knowledge base pose challenges to health equity advocacy. Even with the difficulty of gathering and integrating health data, research must provide a holistic account. Future research should consider the population's heterogeneity, cultural influences, intergroup variances, and up-to-date nuanced health conditions. Additionally, adopting “a salutogenic approach”^11,29 or identifying the diaspora community assets may be beneficial. The consolidated data from these studies might inspire much-needed resource mobilization and collaboration among stakeholders. It may aid in implementing a sustainable intervention that yields widespread health benefits for all Burmese diaspora. The benefits may extend to other Southeast Asians in similar situations.

Limitations

This study has limitations that alter generalizability. The demographic data does not represent all Burmese diaspora. Many more Burmese ethnic minorities were dislocated from their homeland and migrated to many other countries beyond what was identified in this study. Moreover, our findings are limited to the main thread of the diaspora health phenomena. The diaspora ordeals are complex, and we could not capture all other possible health conditions, stressors, and treatment initiatives. Also, we could not measure intergroup variances, which are essential for considering culture-specific interventions. In brief, our findings do not represent all there is to know about this population. Hence, the readers should not generalize about these people's conditions based on our findings. On the other hand, a strength of this study lies in its holistic approach to advancing a comprehensive knowledge base. There needs to be a holistic account of their health phenomena. We provided vital preliminary data to continue researching this critical matter and promoting health equity for this underserved population.

Contributors

EK conceptualized this study, led the integrative review process, and drafted the initial manuscript. QA provided supervision throughout this study and contributed to the final selection of articles. QA, CS, and HS have been involved in the critical review and revision of the manuscript and contributed to the necessary intellectual content.

Declaration of interests

We declare no competing interests.