Using Comfort Theory for Addressing the Psychosocial Needs of an Afghan Refugee Child with Thalassemia: A Case Report

Abstract

Psychological and social support is one of the factors that promote resilience in refugee children. Immigrant children with thalassemia have special psychosocial needs in the host country. The comfort model can help identify psychosocial needs. We applied Kolcaba’s comfort theory to an 8-year-old Afghan boy with a history of thalassemia in Iran. According to Kolcaba’s model, the taxonomy of psychological and social comfort needs were separation from mother, anxiety due to unfamiliarity with the hospital, fear of interaction and preference for silence, different culture and place of living, language barrier. To address his psychospiritual and sociocultural comfort care, we used coaching and comfort food interventions recommended by Kolcaba. The use of Kolcaba’s Comfort Theory was helpful in promoting the child’s emotional and social comfort in the case of an Afghan refugee child with thalassemia in Iran.

Introduction

Iran is one of the countries with the largest number of people of Afghan origin individuals in the word, currently hosting nearly 3.6 million Afghans, with an additional influx of more than 1 million expected by 2021, and children making up about 40% of the new arrivals. ¹ Beta-thalassemia major is one of the chronic diseases affecting Afghan children, ² which becomes particularly challenging when they are displaced. ³ Both the conditions of thalassemia itself and immigration have a significant impact on the psychosocial well-being of patients.^4,5 Children with beta-thalassemia experience feelings of being different their healthy peers, live cautious lives with limitations and discrimination, the burden and stigma of living with beta-thalassemia, a high school dropout rate, and a negative body image that led children to develop feelings of social isolation. ⁶ In addition to the medical conditions, refugee children often face the debilitating effects of post-traumatic stress disorder, anxiety and depression. ⁷ Reports show that many of these children face the looming threat of family separation, a traumatic experience that can precipitate various mental health disorders. ⁸ A systematic review highlighted a wide range of psychosocial issues common to refugee children, including encompassing feelings of displacement, discrimination, language barriers, and cultural differences, as well as difficulties in making friends and maintaining family ties. ⁹

One factor that promotes resilience in refugee children is psychological and social support. ⁷ Evidence suggests that Comfort Theory can guide healthcare providers in promoting psychosocial support for patients. Comfort involves feeling empowered when needs for relief, ease, and transcendence are met across physical, psychospiritual, environmental, and sociocultural contexts. ¹⁰ Although there is a growing interest in Comfort Theory to improve the quality of care for children, it has not been applied to refugee children with beta thalassemia. This report applies Kolcaba’s Comfort Theory to assess and address the psychosocial needs of an Afghan refugee child with Beta-thalassemia in Iran. This work has been reported according to the CARE guidelines. ¹¹

The Report of the Case

An 8-year-old boy of Hazara ethnicity, previously diagnosed with beta-thalassemia, fled Afghanistan with his father and siblings, seeking refuge in Iran. His mother was unable to join them due to immigration complications. He came to the hospital with his father and his main complaint was blood transfusion. He was admitted as an outpatient to the pediatric hematology unit for his first blood transfusion experience in Iran. The doctor took a medical history and physical examination. The management plan for addressing the child’s medical issues included blood sampling for hemoglobin testing, insertion of an appropriate intravenous line, blood transfusion, and monitoring for any associated complications. We assessed the child’s health status for care planning using the “Initial Pediatric Nursing Assessment Sheet.” This is a brief form developed by the Iranian Ministry of Health and used in all children’s hospitals in Iran for the initial assessment of children’s health needs by pediatric nurses. Observations and physical examinations, technical and attempted conversations with the child, and interviews with the father were used to make the assessment based on the tool.

In accordance with this tool, the physical dimension was evaluated through health and medical history, physical examinations, medication history and allergies, assessment of limitations and abilities, nutritional status, and pain assessment. Within the psycho-social-spiritual dimensions, the assessment encompassed communication status, identification of high social risk factors, consideration for social worker involvement, and evaluation of religious and cultural values. The assessment revealed that the child was at high social risk due to beta-thalassemia, non-Iranian nationality, absence of his mother and communication difficulties. In addition, He struggled with effective communication in Persian, leading to a lack of meaningful interaction and cultural disparities with the Iranian context. Consequently, he appeared reserved, anxious, and apprehensive, particularly avoiding interactions with other children and nurses within the unit.

To address the psychospiritual and sociocultural comfort needs of the child, we implemented coaching and comfort food for comfort interventions as guided by Kolcaba with the stage of nursing process (see Table 1). In Kolcaba’s comfort theory, coaching and comfort food Interventions designed to psycho-social-spiritual support through provide reassurance and information, listening, reassurance, education, personal connections, spending time, or play therapy. ¹⁰

Table 1.

Psychological and Social Comfort Needs of the Afghan Refugee Child With Thalassemia Based on Kolcaba’s Theory.

Nursing process	Psychospiritual and sociocultural needs
	Relief	Ease	Transcendence
Assessment	He was anxious and sad due to being separated from his mother and the unfamiliar hospital environment, which made him uninterested in interacting with others.	He and his family faced cultural and language barriers that further added to their challenges.	Thalassemia, combined with the challenges of migration, has created a difficult and complicated situation for him to manage.
Goals	Reducing his anxiety and sadness	Promote a sense of calm and belonging by respecting cultural differences	Developing resilience
Interventions	1. The child took part in a group drawing activity we organized for hospitalized children, where they were asked to draw their families (see Figure 1). In his drawing (see Figure 2), he depicted his family members, with the noticeable absence of his mother. During this activity, the child expressed his longing for his mother, which provided an opportunity for emotional expression and bonding with his peers. 2. After the drawing session, the child played with some of the other children and explored the inside of the ward.	1. Due to the linguistic similarities between Persian and the Afghan language, the hospital staff was able to use shared phrases or words to improve communication. We also enlisted the help of other hospitalized children and their caregivers to familiarize the Afghan child with hospital procedures and surroundings, which helped promote the child’s socialization and acclimatization to the hospital environment. 2. The hospital had patients of Afghan nationality in both inpatient and outpatient departments. To address language barriers, an adult caregiver fluent in Afghan and Persian was asked to communicate by phone with the child and his father, acting as an intermediary between the nurses and the family to facilitate information exchange. 3. We respected the cultural significance of the Afghan handicraft necklace worn by the child, allowing it into the hospital environment without objection.	1. We provided the child’s father with guidance on coping strategies to support his son, such as play, encouragement to express feelings, and music. 2. We provided the child’s father with resources for emotional and social support, including access to a psychologist and a social worker.
Evaluation	Sharing his story and feelings, along with playing and drawing, helped reduce his anxiety and encouraged peer support. This led to greater comfort and improved communication with other children and nurses.	He and his father expressed feeling comforted by the respect they received.	His father expressed his awareness had increased.

Figure 1.

An 8-year-old Afghan refugee boy with beta-thalassemia draws a picture of his family during an art activity with other children in the hematology unit.

Figure 2.

An 8-year-old Afghan refugee boy with beta-thalassemia described his drawing as including (from left to right) his brother, his father, his brother, himself, his brother, his mother and his sister. He drew lines on her and in the description of the picture; he said that she did not fit into the picture, that she was far away from the family.

Discussion

In this case, the Comfort Model has helped us address the psychosocial needs through assessment and intervention. The assessment highlights the child’s vulnerability to psychosocial problems, with the main contributing factors being thalassemia, separation from his mother, and differences in nationality. These findings are consistent with those reported in several studies on thalassemia and immigration issues in children.^4,8,9 One of the strengths of the case was that, we were able to identify and classify the psychosocial needs into 3 levels of comfort: relief, ease, and transcendence. In fact, we gained a clear and practical perspective on how to provide comfort at each level, effectively addressing the psychosocial needs in this case. Although Kolcaba’s Comfort Theory assisted us in assessing the child’s psychosocial status, there is currently no specific tool for evaluating the psychosocial needs of immigrant children with chronic diseases. The tool we used only indicated that the child was at high social risk and did not offer any suggestions for interventions or care approaches. A study indicated that promoting psychosocial care for children requires addressing obstacles such as a shortage of specialists, inadequate tools for assessing psychosocial problems, and insufficient knowledge. ¹²

Psychosocial interventions guided by comfort theory enable us to develop and implement appropriate interventions tailored to the specific needs of the child. We utilized play and drawing as comfort interventions to address his psychosocial needs that have been widely validated by numerous studies for their positive effects on children’s psychosocial well-being. ¹³ Despite the absence of native interpreter services in the hospital, which we acknowledge as a limitation, we sought to find a compatriot within the hospital to facilitate communication between the healthcare team and the patient, thereby increasing their comfort. We also recommend providing interpretation services with professional translators fluent in the child’s native language or utilizing smart translation devices to enhance the effectiveness of care. As part of the psychosocial care, our comfort interventions were tailored to respect the child’s cultural background and individual experiences, such as simply allowing him to wear his necklaces. Another intervention we implemented was to increase fathers’ awareness of the psychosocial support available for their children and to introduce social worker services. While parents play a crucial role in fostering their children’s psychosocial resilience during challenging times such as illness or migration, it is equally important that their own psychosocial needs are addressed by health services. ¹⁴

Overall, in this case, applying the comfort model was effective in addressing the child’s psychosocial needs. Although we evaluated the interventions by observing behavior and interviewing both the child and the father, research using standardized measurement tools has demonstrated that the comfort model is effective in improving children’s health outcomes.^15,16 In addition, we suggest that researchers conduct a study with an appropriate sample size of Afghan refugee children with a comfort-based intervention and evaluate the improvements in the psychosocial status of the children using different scales.

Conclusion

This study not only highlights the unique challenges faced by Afghan refugee children with thalassemia but also presents a transformative framework for addressing their psychosocial needs in refugee settings. The application of Comfort Theory in addressing these needs stands out as a practical and adaptable care intervention.