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PubMed2003

Factors associated with poor mental health among Guatemalan refugees living in Mexico 20 years after civil conflict.

CONTEXT: From 1981 to 2001, 46 000 refugees who fled the 36-year civil conflict in Guatemala for Chiapas, Mexico were under the protection of the United Nations High Commissioner for Refugees. OBJECTIVES: To estimate the prevalence of mental illness and factors associated with poor mental health of underserved Guatemalan refugee communities located in Chiapas, Mexico, since 1981 and to assess need for mental health services. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional survey of 183 households in 5 Mayan refugee camps in Chiapas representing an estimated 1546 residents (adults and children) conducted November-December 2000. MAIN OUTCOME MEASURES: Symptom criteria of Posttraumatic Stress Disorder (PTSD), anxiety, and depression as measured by the Harvard Trauma Questionnaire and Hopkins Symptom Checklist-25 (Hopkins-25). RESULTS: One adult (aged > or =16 years) per household (n = 170 respondents) who agreed to participate was included in the analysis, representing an estimated 93% of households. All respondents reported experiencing at least 1 traumatic event with a mean of 8.3 traumatic events per individual. Of the respondents, 20 (11.8%) had all symptom criteria for PTSD. Of the 160 who completed the Hopkins Symptom Checklist-25, 87 (54.4%) had anxiety symptoms and 62 (38.8%) had symptoms of depression. Witnessing the disappearance of family members (adjusted odds ratio [AOR], 4.58; 95% confidence interval [CI], 1.35-15.50), being close to death (AOR, 4.19, 95% CI, 1.03-17.00), or living with 9 to 15 persons in the same home (AOR, 3.69; 95% CI, 1.19-11.39) were associated with symptoms of PTSD. There was a protective factor found for lacking sufficient food (AOR, 0.08; 95% CI, 0.01-0.59). Elevated anxiety symptoms were associated with witnessing a massacre (AOR, 10.63; 95% CI, 4.31-26.22), being wounded (AOR, 3.22; 95% CI, 0.95-10.89), and experiencing 7 to 12 traumatic events (AOR, 2.67; 95% CI, 1.14-6.27) and 13 to 19 traumatic events (AOR, 2.26; 95% CI, 0.65-7.89). Elevated symptoms of depression were associated with being a woman (AOR, 3.64; 95% CI, 1.47-9.04), being widowed (AOR, 27.55; 95% CI, 2.54-299.27), being married (AOR, 1.93; 95% CI, 0.59-6.33), witnessing disappearances (AOR, 2.68; 95% CI, 1.16-6.19), experiencing 7 to 12 traumatic events (AOR, 1.57; 95% CI, 0.64-3.88), or experiencing 13 to 19 traumatic events (AOR, 7.44; 95% CI, 2.18-25.37). CONCLUSION: Psychiatric morbidity related to human rights violations, traumatic events, and refugee status was common among Guatemalan refugees surveyed 20 years after the Guatemalan civil conflict.

Adult↗
PubMedDate not supplied

Tuberculosis in South-East Asian refugees after resettlement--can prevention be improved by better policy and practice?

OBJECTIVE: This study aimed to determine whether incident cases of tuberculosis (TB) in a cohort of South-East Asian refugees followed for 5 years after resettlement were potentially preventable and whether prevention of TB was optimal in a state refugee TB screening program in Victoria, Australia. DESIGN: A retrospective cohort study of 1,101 refugees from Laos, Cambodia, and Vietnam screened for TB in the 6-month period from July 1989 to January 1990 was conducted. Incident cases of TB were identified by matching each refugee with the TB notification database for 5 years from the date of initial screening. Preventability was assessed for incident cases by reviewing medical records. Screening guidelines and practice were reviewed. RESULTS: The main outcome was the preventability of cases of active tuberculosis that developed in the study population in the first 5 years after resettlement. The incidence of active TB was 363/100,000 during the first year and 109/100,000/year during the first 5 years. Five of six incident cases were assessed as potentially preventable, which if prevented would have resulted in an annual incidence of 18/100,000 over the first 5 years. Use of a more sensitive skin test definition of infection would have made an additional 245 refugees eligible for prevention and potentially prevented an additional 25 cases of TB over a lifetime. CONCLUSIONS: There is a high incidence of tuberculosis among SE Asian refugees, particularly in the first year after resettlement. A large proportion of TB may be preventable. Improvement in case prevention may be possible with updated guidelines and better implementation of screening policy.

Adult↗
PubMed2005

Medical complaints among Iraqi American refugees with mental disorders.

The Gulf War in 1991 resulted in an influx of refugees from Iraq to the United States and to other regions of the world. The purpose of this study was to describe the self-reported medical complaints of Iraqi American refugees who were seeking mental health services in southeastern Michigan. We anticipated that the frequency and pattern of medical symptoms would differ from that reported in the literature on United States Gulf War veterans or other Arab Americans who immigrated to the U.S. in the 1990s. Potential reasons for such differences include indirect effects, such as neglect of general health prior to and during the war, or direct effects, such as the impact of environmental changes from the war itself. As part of a larger study on the health of refugees from Iraq, self-reported medical conditions and symptoms were analyzed in a sample of 116 adult Iraqi immigrants (46 male, 70 female) who were seeking or already receiving outpatient mental health services (n = 87) or treatment in a partial hospitalization program (n = 29). Measures were translated into Arabic and administered in an interview format by one of two bilingual mental health workers. The results were consistent with other studies on refugees in which the number of medical complaints reported was relatively high. Discussion centers on the importance of addressing the specific medical needs of refugees in general, and of the Iraqi refugees in particular, and on how they may be better served within our primary health care systems.

Adult↗
PubMed1989

A tale of two clinics--primary health care in refugee settings: lessons from Sudan and Somalia.

The elements and techniques of PHC were not developed in and for refugee situations, and the acute needs and transient situation of refugees sometimes attracts a more traditional medical approach. However, as refugees remain in a host country and their situation stabilizes there, attempts are made to convert to PHC. Refugee health programmes face some unique challenges when attempting this transformation, problems that exist even when PHC techniques were present at the onset of the programme. The challenge is to adapt PHC principles for use in acute and chronic refugee situations, and to find ways to develop a community base for health care programmes while at the same time meeting the acute medical needs unique to refugees.

Ambulatory Care Facilities↗
PubMed1992

New paradigms for refugee health problems.

Two paradigms that have shaped our understanding of refugee health are identified: the objectification of refugees as a political class of excess people, and the reduction of refugee health to disease or pathology. Alternative paradigms are recommended: one to take the polyvocality of refugees into account, and one to construe refugees as prototypes of resilience despite major losses and stressors. The article is organized into three sections, mirroring the life history of refugees from internal displacement in the country of origin to asylum in a second (usually neighboring) country, and for some, to permanent resettlement in a third country. In each of the three sections, the primary topics that are treated in the literature are identified, and key problems identified for discussion.

Acculturation↗
PubMed2005

Afghan refugees in Iran model renal transplantation program: ethical considerations.

During 23 years of civil war in Afghanistan, there has been a continuous flow of more than 5 million refugees out of the country. Iran has hosted about 40% of all refugees. The majority have resided outside of camps with opportunities to integrate locally, having access to the Iranian labor market and government services, such as dialysis and transplantation. Iran also has adopted a compensated living unrelated donor renal transplantation program in which foreigners can receive transplants from living related donors or volunteer living unrelated donors of the same nationality. In June 2004, among 241 refugees with end-stage kidney disease in Iran, 179 were on hemodialysis and 62 underwent renal transplantation. Nine patients received kidneys from living related donors, 1 from a spouse, 50 from Afghani living unrelated donors, and 1 from a cadaveric donor. No refugee had been used as a kidney donor to an Iranian patient. Transplantation of all Afghan refugees in need and the absence of their use as kidney donors to Iranian patients proffer strong evidence against commercialism and a reason to believe that the Iran Model transplantation is practiced with ethical standards. In the last 2 years since the civil war has ended, returning these patients to Afghanistan has raised important ethical concerns. Repatriation of dialysis patients and transplant recipients may be tantamount to their deaths. It is expected that The Transplantation Society and the World Health Organization will establish links with the United Nations High Commissioner for Refugee Offices to provide humanitarian assistance to these patients.

Afghanistan↗
PubMed2002

Maternal mortality among Afghan refugees in Pakistan, 1999-2000.

BACKGROUND: Estimated at 3.6 million, Afghans are the largest population of refugees in the world. Information on the magnitude, causes, and preventable factors of maternal deaths among Afghan refugees may yield valuable information for prevention. METHODS: Deaths were recorded between Jan 20, 1999, and Aug 31, 2000, during a census carried out in 12 Afghan refugee settlements in Pakistan. Deaths among women of reproductive age (15-49 years) were further investigated by verbal autopsy interviews to determine their cause, risk factors, and preventability, and to ascertain the barriers faced to obtaining health care. FINDINGS: The census identified 134406 Afghan refugees and 1197 deaths; a crude mortality rate of 5.5 (95% CI 5.2-5.8) per thousand population. Among the 66 deaths among women of reproductive age, deaths due to maternal causes (n=27) exceeded any other cause (41% [95% CI 29-53]). 16 liveborn and nine stillborn infants were born to women who died of maternal causes; six of the liveborn infants died after birth. Therefore, 60% (15 of 24) of infants born to these women were either born dead or died after birth. Compared with women who died of non-maternal causes, women who died of maternal causes had a greater number of barriers to health care (p=0.001), and their deaths were more likely to be preventable (p<0.05). INTERPRETATION: Maternal deaths account for a substantial burden of mortality among Afghan refugee women of reproductive age in Pakistan. The high prevalence of barriers to health care access indicates opportunities for reducing maternal deaths in refugee women and their children.

Adult↗
PubMed2002

A social and demographic study of Tibetan refugees in India.

The social and demographic characteristics of approximately 65,000 Tibetan refugees in India were determined from data collected 1994-1996. Approximately 55,000 refugees were living in 37 settlements widely distributed around India. The remaining 10,000 refugees were monks living in monasteries associated with some of the settlements, mostly in the south of India. In the settlements, a community-based surveillance system was established and data were collected by trained community health workers in house to house visits. In the monasteries, data were collected by the community health workers in monthly interviews with a designated liaison monk at each monastery. These data indicated little immigration of new civilian refugees in the past 10 years into the settlements but a steady influx of new monks into the monasteries. The age distribution in the settlements showed a prominent mode in the 15-25 year age range, a declining birth rate, and an increasing proportion of elderly. In general, refugees born in India were educated through secondary school, while refugees born in Tibet were often illiterate. The principle occupations were education involving 27% (including students), farming, 16%. and sweater selling, 6.5%; another 6.5% were too young or too old for employment, and only 2.4% were unemployed. The overall crude birth rate was determined to be relatively low at 16.8/1000. although this may underestimate the true figure. Infant mortality varied from 20 to 35/1000 live births in the different regions. Child vaccination programs cover less than 50% of the population. The burden of illness in this society was mainly characterized by diarrhoea. skin infections, respiratory infections, fevers, and, among the elderly. joint pains and cardiovascular problems. Although calculated death rates were unrealistically low, due to under-reporting, causes of death, derived from "verbal autopsies", were mainly cancer, tuberculosis, accidents, cirrhosis and heart disease in order of decreasing frequency. Overall, the sociodemographic and health characteristics of this population appear to be in transition from those typical of the least developed countries to those typical of middle income and more affluent societies.

Adolescent↗
PubMed2000

Refugee families' experience of research participation.

Because refugees can experience crisis, bereavement, and traumatization, there has been a rapid increase of research carried out with refugees. This study investigated how refugee families respond to participation in research. A previous study explored how adults and children had communicated about the difficult question of repatriation after arriving in a new country. Did the in-depth interviews harm or benefit them? Are there any ethical risks in research on traumatized refugees? From an original sample of 74 Bosnian refugees (5-73 years), 30 family members from 9 families including 14 children aged 6 to 19, were re-interviewed. The refugees rated participation as positive. A few parents lacked information that could have enabled them to inform the children better before the interviews. The study shows that studies on traumatized/bereaved populations can have beneficial effects.

Adolescent↗
PubMed2001

PTSD among Bosnian refugees: a survey of providers' knowledge, attitudes and service patterns.

The objective of this study was to investigate providers' knowledge, attitudes and service provision patterns for Bosnian refugees with PTSD and to consider the overall implications for trauma-related mental health services. A survey instrument was developed and administered to 30 randomly selected service providers working with Bosnian refugees in Chicago. This sample includes primary medical care providers (n = 7), community social service providers (n = 12), and mental health service providers (n = 11). Results showed that knowledge about PTSD is highest in mental health service providers, as is amount of previous training and education about PTSD. Less than half of all providers systematically assess for PTSD, and standardized instruments for PTSD are rarely used. The top three overall recommendations for services were ranked as: 1. Psychotherapy; 2. No intervention; 3. Psychiatric evaluation. In general, less than half of providers hold attitudes toward refugees as suffering from illnesses or mental disorders, or that "something" is wrong with them. Likewise, only half of the providers reported providing education to refugees and their families about the possible mental health consequences of trauma. In conclusion, assessment, intervention and educational activities of providers are not consistent with literature documenting that PTSD is highly prevalent in refugee populations. New training programs, model development, and research initiatives are needed to address the needs of refugees.

Analysis of Variance↗
PubMed2002

Effect of political imprisonment and trauma history on recent Tibetan refugees in India.

We sought to examine the impact of political imprisonment on anxiety, depression, and somatic symptoms reported by newly arrived Tibetan refugees in Dharamsala, India. We used the Hopkins Symptom Checklist-25 to compare 76 previously imprisoned with 74 never imprisoned recent Tibetan refugees. Previously imprisoned refugees reported more traumatic events, especially torture and deprivation. Previously imprisoned refugees reported more anxiety than nonimprisoned refugees, but the groups were similarly high in terms of depression and number of somatic complaints. According to assessment with the Harvard Trauma Questionnaire, 20% of the tortured and imprisoned refugees met criteria for posttraumatic stress disorder.

Adolescent↗
PubMed2004

"Traveling pains": embodied metaphors of suffering among Southern Sudanese refugees in Cairo.

This paper presents the results of a larger study conducted among Southern Sudanese refugees in Cairo, Egypt. "Illness talk" and body metaphors are the focus of the present work, which is based mainly on an analysis of the illness narratives of people attending a church-run medical clinic. The findings suggest that refugees use certain narrative styles in discussing their illnesses that highlight the interconnection of bodily ills and refugee-related trauma. The refugees narrated the histories of their illnesses in terms consistent and coterminous with their refugee histories, and articulated illness causes in terms of threatening assaults on their sense of self as human beings and as part of a distinct community and culture. The use of embodied metaphors to understand and cope with their current and past traumatic experiences was echoed in narratives that were nonillness related. Metaphors such as "the heart," "blood," and "body constriction" were consistently used to discuss social and cultural losses. Understanding the role that the body plays in experience and communication within a given cultural context is crucial for physicians and others assisting refugees.

Attitude to Health↗
PubMed2004

Struggling with imaginaries of trauma and trust: the refugee experience in Switzerland.

This article discusses some effects of migration politics on asylum seekers and refugees and on the Swiss health services. It is based on multisited ethnographic research that tracked interpretative concepts of the refugee experience. Following a grounded theory approach, it identifies imaginaries of trauma and trust as key categories in the field of transnational migration and health. The psychiatric concept of trauma and a more popularized discourse of traumatic memory are strongly emphasized in all of the investigated field sites: the providers of primary health care and psychosocial services and representatives of social welfare agencies and law-making bodies use this "diagnosis" extensively. This leads refugees to develop tactics of a) identifying with the trauma discourse in order to become "good refugees" and achieve legal status in Switzerland; b) struggling with the ascribed pathologies and suffering from retraumatizing effects of these predominant trauma policies; and c) trying to refuse or subvert them by emphasizing the existence of structural violence in the receiving countries. An analysis of the interactions of health providers and refugees shows that it takes place in an environment of social and economic insecurity and in a shared imaginary of (mis)trust, putting at stake the moral economy of recent migration politics and the refugee experience.

Diagnostic and Statistical Manual of Mental Disord↗
PubMed1991

Clinical issues in mental health service delivery to refugees.

Serious limitations exist in the delivery of mental health services to refugees throughout the resettlement process. Having survived harrowing physical and psychological traumas prior to reaching refugee camps, many refugees encounter mental health services in overseas camps that are characterized by fragmentation, instability, language barriers, and severe staff shortages. Refugees requiring mental health intervention after resettlement in the United States confront additional barriers, including frequent misdiagnosis, inappropriate use of interpreters and paraprofessionals, and culturally inappropriate treatment methods. Suggestions for improving mental health services for refugee populations emphasize modifying diagnostic assumptions and treatment approaches, recognizing potential problems associated with using interpreters and paraprofessionals, and examining the role of consultation, prevention, and outreach services in addressing refugee mental health concerns.

Acculturation↗
PubMed2002

Insecticide-treated plastic tarpaulins for control of malaria vectors in refugee camps.

Spraying of canvas tents with residual pyrethroid insecticide is an established method of malaria vector control in tented refugee camps. In recent years, plastic sheeting (polythene tarpaulins) has replaced canvas as the utilitarian shelter material for displaced populations in complex emergencies. Advances in technology enable polythene sheeting to be impregnated with pyrethroid during manufacture. The efficacy of such material against mosquitoes when erected as shelters under typical refugee camp conditions is unknown. Tests were undertaken with free-flying mosquitoes on entomological study platforms in an Afghan refugee camp to compare the insecticidal efficacy of plastic tarpaulin sprayed with deltamethrin on its inner surface (target dose 30 mg/m2), tarpaulin impregnated with deltamethrin (initially > or = 30 mg/m2) during manufacture, and a tent made from the factory impregnated tarpaulin material. Preliminary tests done in the laboratory with Anopheles stephensi Liston (Diptera: Culicidae) showed that 1-min exposure to factory-impregnated tarpaulins would give 100% mortality even after outdoor weathering in a temperate climate for 12 weeks. Outdoor platform tests with the erected materials (baited with human subjects) produced mosquito mortality rates between 86-100% for sprayed or factory-impregnated tarpaulins and tents (average approximately 40 anophelines and approximately 200 culicines/per platform/night), whereas control mortality (with untreated tarpaulin) was no more than 5%. Fewer than 20% of mosquitoes blood-fed on human subjects under either insecticide-treated or non-treated shelters. The tarpaulin shelter was a poor barrier to host-seeking mosquitoes and treatment with insecticide did not reduce the proportion blood-feeding. Even so, the deployment of insecticide-impregnated tarpaulins in refugee camps, if used by the majority of refugees, has the potential to control malaria by killing high proportions of mosquitoes and so reducing the average life expectancy of vectors (greatly reducing vectorial capacity), rather than by directly protecting refugees from mosquito bites. Mass coverage with deltamethrin-sprayed or impregnated tarpaulins or tents has strong potential for preventing malaria in displaced populations affected by conflict.

Afghanistan↗
PubMed2006

Anaemia, iron status and vitamin A deficiency among adolescent refugees in Kenya and Nepal.

OBJECTIVE: To investigate the prevalence of anaemia (haemoglobin<11.0 to 13.0 g dl(-1) depending on age and sex group), iron deficiency (transferrin receptor concentration>8.3 microg ml(-1)) and vitamin A deficiency (serum retinol <0.7 micromol l(-1)) in adolescent refugees. DESIGN: Cross-sectional surveys. SETTING: Kakuma refugee camp in Kenya and seven refugee camps in Nepal. SUBJECTS: Adolescent refugee residents in these camps. RESULTS: Anaemia was present in 46% (95% confidence interval (CI): 42-51) of adolescents in Kenya and in 24% (95% CI: 20-28) of adolescents in Nepal. The sensitivity of palmar pallor in detecting anaemia was 21%. In addition, 43% (95% CI: 36-50) and 53% (95% CI: 46-61) of adolescents in Kenya and Nepal, respectively, had iron deficiency. In both surveys, anaemia occurred more commonly among adolescents with iron deficiency. Vitamin A deficiency was found in 15% (95% CI: 10-20) of adolescents in Kenya and 30% (95% CI: 24-37) of adolescents in Nepal. Night blindness was not more common in adolescents with vitamin A deficiency than in those without vitamin A deficiency. In Kenya, one of the seven adolescents with Bitot's spots had vitamin A deficiency. CONCLUSIONS: Anaemia, iron deficiency and vitamin A deficiency are common among adolescents in refugee populations. Such adolescents need to increase intakes of these nutrients; however, the lack of routine access makes programmes targeting adolescents difficult. Adolescent refugees should be considered for assessment along with other at-risk groups in displaced populations.

Adolescent↗
PubMed1999

High frequency of gastrointestinal parasites in refugees and asylum seekers upon arrival in Sweden.

The results of routine screening for intestinal parasites in 1377 refugees and asylum seekers within 2 weeks of arrival in Sweden showed that protozoa, mainly Giardia intestinalis, were found in 235/1377 (17%) and helminths, mainly hookworms, in 264/1377 (19%). Intestinal parasites were more frequently recovered in refugees coming from South East Asia, Africa and Latin America (infection rates 48%, 43% and 42%, respectively) than in those from Eastern Europe (22%) and the Middle East (32%). Refugees who reported gastrointestinal symptoms were less often infected than those without symptoms (p < 0.001). Of the European refugees, 127 came from Bosnia. A high rate of hookworms was found in this group (15%), suggesting that hookworms may also be transmitted in temperate areas under special conditions. We thus identified relatively high rates of pathogens in all groups of refugees. Screening may therefore be recommended, though more for the benefit of refugees than for the prevention of further spread of the infections.

Adolescent↗
PubMedDate not supplied

Pregnant women at risk: an evaluation of the health status of refugee women in Buffalo, New York.

Each year, conflicts escalate the need for women, children, and men to seek refuge outside their home countries, and the United States and Canada provide asylum for many of these refugees. However, few researchers have investigated the health status of specific populations of refugees sojourning or newly arrived in the United States. As nurses at a Buffalo, New York, refugee shelter for Canada-bound asylum seekers, we provided health assessments to this group of refugees at their on-site clinic. Pregnant women were of major concern, being potentially at risk for poor pregnancy outcomes. We found that our sample of pregnant refugees had several previously undetected health problems and suggest that further research on refugee populations is needed.

Adolescent↗