[Development and implementation of an outpatient clinic at an initial reception centre for asylum seekers in the German federal state of Baden-Wuerttemberg]

The burden of substance use and (mental) distress among asylum seekers: a cross sectional study

Background

Asylum seekers are a particularly vulnerable population due to a wide range of external stressors. Traumatic events and difficult social/economic prospects can lead to an elevated susceptibility for substance use disorders. The aim of the present study was to determine whether asylum seekers suffering from mental or physical distress present higher levels of substance use disorder (SUD) in a state reception center in Germany and whether there are identifiable risk or protective factors.

Methods

We performed a hierarchical logistic regression on data of N = 238 people who had applied for asylum in Germany to analyze the SUD variance explanation by (1) sociodemographic, (2) flight-specific, and (3) psychometric (ERQ, SOC-9 L, SCL-K9) variables. On level (4), we included the location of data collection (walk-in clinic or accommodation,) as an indicator of individual's need for a psychologist's or General practitioner's help in order to assess for the participant's (mental) distress.

Results

Low educational level, lower sense of coherence, and mental distress (location of data collection in the psychosocial or general medical outpatient clinic) were associated with SUD. Those suffering from SUD seemed to be less aware of external stressors as SUD was also associated with low levels of reported post-migratory stress.

Discussion

The association of SUD with psychological distress and lower education reaffirms the concept that some vulnerable groups are at a higher risk for substance-related difficulties. Strengthening the sense of coherence with targeted interventions might enable at-risk groups to cope better with forthcoming burdens and help with abstaining from current or future consumption.

[Screening for mental distress symptoms among Ukrainian refugees in an initial reception center in Baden-Württemberg]

OBJECTIVE

Millions of people are fleeing the war in Ukraine. Stressors associated with flight can have a massive impact on mental health. The aim of the present study was to perform a low-threshold screening for mental distress symptoms among Ukrainian refugees in an initial reception center in Baden-Württemberg.

METHODS

At the initial reception center in Heidelberg Ukrainian refugees were interviewed about psychological distress during consultations with medical care providers, using four screening questionnaires (PC-PTSD-5, PHQ-9, GAD-7, stress thermometer) in Ukrainian or Russian language, and further sociodemographic data and data about the refugees' background were collected.

RESULTS

More than 90% of the N = 36 respondents reported that they had experienced war, 55.6% reached the cut-off score for post-traumatic stress disorder. One fourth of the participants reached cut-off scores for depression and more than 30% for generalized anxiety disorder. The majority of respondents had relatives living in embattled cities, and in over 36% close relatives were currently deployed in war. In the group comparison there was no significant correlation of symptom burden with the family background situation.

DISCUSSION

In line with the existing literature, many of the participants showed signs of mental distress. Potentially affected persons can be identified using low-threshold screening questionnaires. Adequate care for mentally stressed refugees according to their needs should be established to facilitate integration.

CONCLUSION

Due to the known high prevalence of mental distress, refugees should be screened for mental distress symptoms at a low-threshold level to identify affected individuals. The psychosocial situation of Ukrainian refugees should be considered at an early stage in medical care.

Maternal mental healthcare needs of refugee women in a State Registration and Reception Centre in Germany: A descriptive study

Pregnant refugees and new mothers are at high risk of developing mental health problems. Previous research has highlighted an increase in adverse pre-, peri- and postpartum outcomes in refugee women and their newborns. This descriptive study aimed to present the characteristics and needs of refugee women who attended a psychosocial walk-in clinic addressing pregnant refugees' and new mothers' maternity mental healthcare needs in a state registration and reception centre in Germany. We assessed all patients that consulted the clinic and received interventions during the first 28 weeks after it opened, collecting information on symptoms, diagnoses, attitudes towards and experience of pregnancy, birth, obstetric care and applied psychosocial interventions during consultations. Between November 2017 and May 2018, N = 120 pregnant refugees and new mothers attended the clinic. Most patients were diagnosed with post-traumatic stress-, adjustment- or depressive disorder. While 69.6% of the women reported physical and mental health problems during pregnancy, 87.4% experienced obstetric complications. Trauma-informed and psychoeducational interventions were primarily used during counselling sessions. Our data underpin the glaring disparities in refugee maternal healthcare in Germany. Maternal care designed to meet the specific needs of pregnant refugees and mothers is essential. More targeted, evidence-based and cost-effective interventions are needed. Our psychosocial walk-in clinic is a first step towards ensuring primary care delivery for refugee women during the particularly vulnerable period of pregnancy and early motherhood.

A Qualitative Evaluation of a Mother and Child Center Providing Psychosocial Support to Newly Arrived Female Refugees in a Registration and Reception Center in Germany

Female refugees are frequently exposed to sexualized, gender-based violence and harassment before, during, and after their flight. Yet female refugee-specific care and protection needs are rarely addressed in host countries. This study aimed to evaluate a mother and child center (MUKI) for female refugees in a reception and registration center in Germany. In 2017, we conducted semi-structured qualitative interviews with 16 female refugees attending the MUKI and with its five main staff members. We asked the participants about the MUKI’s relevance, encountered difficulties, and suggestions for improvement. The interviewees appreciated the MUKI’s sheltered environment, care services, and socializing opportunities, as well as its women-only concept. Overall, the participants saw overexertion, social engagement-related difficulties, and the MUKI’s noisy environment as key attendance barriers. Interviewed staff primarily reported problems regarding the working conditions, including the high staff and attendee turnover and low general service awareness. The participants advocated an expansion of the MUKI program. The MUKI project underlines that providing newly arrived, vulnerable female refugees with sheltered surroundings and psychosocial services is an essential step toward addressing female refugees’ specific care needs.

A Walk-In Clinic for Newly Arrived Mentally Burdened Refugees: The Patient Perspective

Providing refugees with psychosocial support is particularly important considering the high level of mental health problems prevalent in this population. A psychosocial walk-in clinic operating within a state reception and registration center in Germany has been supporting mentally burdened refugees since 2016. This study focused on patients' perspectives on their mental health burden, the psychosocial walk-in clinic, and future help seeking. We conducted interviews with n = 22 refugees attending the walk-in clinic from March to May 2019. Qualitative analysis focused on the following four topics: (1) mental burden from the patients' perspective, (2) access to the psychosocial walk-in clinic, (3) perception of counseling sessions, and (4) perception of follow-up treatment. The results show that the majority of interviewees were burdened by psychological and somatic complaints, mostly attributed to past experiences and post-migratory stress. Therapeutic counseling and psychiatric medication were found to be particularly helpful. Most of the participants felt motivated to seek further psychosocial support. Key barriers to seeking psychosocial help included shame, fear of stigma, and lack of information. Overall, the psychosocial walk-in clinic is a highly valued support service for newly arrived refugees with mental health issues.

Health and medical care for refugees: design and evaluation of a multidisciplinary clinical elective for medical students

Objective: Caring for refugee patients places special demands on health professionals. To date, medical students in Germany have rarely been systematically prepared for these challenges. This article reports on the development, conceptualisation, implementation, evaluation, and relevance of a multidisciplinary elective for medical students in the clinical study phase. Methodology: The course content was developed based on a needs-assessment among medical students and in cooperation with medical colleagues working in the field of refugee care. The course consisted of a seminar with medical, legal, administrative and socio-cultural learning content as well as a field placement in the medical outpatient clinic of the local reception centre for asylum seekers, which was accompanied by a systematic reflection process. The evaluation concept contained qualitative and quantitative elements. Results: 123 students completed the elective over six semesters (summer 2016 through to winter 2018). It was continuously evaluated and further developed. The students reported learning progress mainly in the following areas: Legal foundations of the asylum procedure and health care entitlements for asylum seekers; multi-perspectivity through multidisciplinarity as well as professional, ethical, interpersonal, and political insights gained through the practical experience. Summary: To prepare students for the complex challenges to be faced in medical care for refugees, a structured, multidisciplinary teaching programme, which combines theory, practice and reflection helps to foster insights into the many facets of this field of activity. The questions students brought to the seminar, the course contents and evaluation results are intended to inspire the design and implementation of similar courses at other universities.

[Healthcare provision for asylum seekers in reception centres : Qualitative survey from the perspective of healthcare providers]

Im Zuge der gestiegenen Zahlen Asylsuchender in den Jahren 2015/2016 haben sich in Deutschland, geprägt durch lokale Akteur*innen, sehr unterschiedliche Konzepte zur medizinischen Versorgung in Aufnahmeeinrichtungen (AE) etabliert. Ziel unserer Studie war es, unterschiedliche Versorgungskonzepte in AE abzubilden und die Herausforderungen der Verstetigung bedarfsgerechter medizinischer Versorgungsstrukturen herauszuarbeiten.

Daten wurden aus 13 semistrukturierten Interviews und im Rahmen einer Fachtagung mit Workshops und Gruppendiskussionen erhoben und durch eine qualitative Inhaltsanalyse ausgewertet. Teilnehmer*innen waren Akteur*innen der medizinischen Versorgung in AE, darunter ärztliches und Gesundheitsfachpersonal, Verwaltungsbeauftragte, Vertreter*innen des öffentlichen Gesundheitsdienstes und Wissenschaftler*innen.

Als Antwort auf die gesundheitlichen Bedarfe von Asylsuchenden und die komplexen Rahmenbedingungen der Versorgung haben sich unterschiedliche Ambulanzkonzepte gebildet, deren Zweck, Organisation und Management in vielen Aspekten über das Angebot einer ärztlichen Sprechstunde hinausgehen. Die Ambulanzen unterschieden sich in organisationsbezogenen Aspekten z. B. hinsichtlich des Betreibers, der Personalstruktur und des Umfangs der Versorgung. Gemeinsame Herausforderungen stellen eine adäquate Bedarfsplanung, der Mangel einheitlicher Leitlinien und fehlende Schnittstellen zwischen den in der Ambulanz tätigen Akteur*innen dar. Dringender Handlungsbedarf im Sinne eines strukturierten und kontinuierlichen Erfahrungsaustauschs sowie in der Implementierung bundesweiter Standards ist geboten, um Ad-hoc-Initiativen in resiliente Ambulanzstrukturen zu überführen. Die erarbeiteten Handlungsbedarfe und Lösungsvorschläge können hierfür als Grundlage dienen.

Self-Practice of Stabilizing and Guided Imagery Techniques for Traumatized Refugees via Digital Audio Files: Qualitative Study

Background

Refugees have an increased risk of developing mental health problems. There are insufficient psychosocial care structures to meet the resulting need for support. Stabilizing and guided imagery techniques have shown promising results in increasing traumatized refugees’ emotional stabilization. If delivered via audio files, the techniques can be practiced autonomously and independent of time, space, and human resources or stable treatment settings.

Objective

This study aimed to evaluate the self-practice of stabilizing and guided imagery techniques via digital audio files for traumatized refugees living in a reception and registration center in Germany.

Methods

From May 2018 to February 2019, 42 traumatized refugees participated in our study. At T1, patients received digital audio files in English, French, Arabic, Farsi, Turkish, or Serbian for self-practice. Nine days later, at T2, a face-to-face interview was conducted. Two months after T2, a follow-up interview took place via telephone.

Results

At T2, about half of the patients reported the daily practice of stabilizing and guided imagery techniques. At follow-up, the average frequency of practice was once weekly or more for those experiencing worse symptoms. No technical difficulties were reported. According to T2 and follow-up statements, the techniques helped the patients dealing with arousal, concentration, sleep, mood, thoughts, empowerment, and tension. The guided imagery technique “The Inner Safe Place” was the most popular. Self-practice was impeded by postmigratory distress factors, like overcrowded accommodations.

Conclusions

The results show that self-practice of stabilizing and guided imagery techniques via digital audio files was helpful to and well accepted by the assessed refugees. Even though postmigratory distress factors hampered self-practice, “The Inner Safe Place” technique was particularly well received. Overall, the self-practiced audio-based stabilizing and guided imagery techniques showed promising results among the highly vulnerable group of newly arrived traumatized refugees.

Predictors of asylum seekers' mental health course in the early stages of resettlement: Results of a longitudinal study

OBJECTIVE

Asylum seekers who have experienced persecution, war and torture show high prevalence rates of stress-related mental disorders. After arrival in the host country, the early stages of resettlement seem to be a particularly vulnerable phase characterized by social instability. This longitudinal study aimed to explore predictors of the asylum seekers' course of mental health during the transition phase from a state registration and reception center to municipal shelters.

METHODS

We used hierarchical regression analysis to assess the symptom course of posttraumatic stress disorder (PTSD), depression, anxiety and panic disorders as well as well-being in n = 84 asylum seekers. The follow-up assessment took place three to five months after baseline assessment. The following blocks of possible predictors were included in the statistical models: (1) sociodemographic variables, (2) cultural background related variables, (3) psychometric measures of emotion regulation and sense of coherence and (4) time range to follow-up.

RESULTS

Language proficiency, origin, religion and gender were stronger predictors of the asylum seekers' mental health course in the early stages of resettlement than emotion regulation and sense of coherence.

CONCLUSIONS

Sociodemographic and cultural background related variables, like language proficiency have a high psychosocial relevance for asylum seekers in the early phase of the asylum process. Therefore, language courses should be implemented progressively. Psychotherapy for asylum seekers should always be performed with awareness for cultural specific perspectives and acculturative adjustment processes.

Predictors of Asylum Seekers' Health Care Utilization in the Early Phase of Resettlement

BACKGROUND

Asylum seekers display high prevalence rates of posttraumatic stress disorder, depression, anxiety, and panic disorder due to pre-, peri-, and post-migration stressors. In contrast to the high mental health burden, health care utilization among asylum seekers in the early phase of resettlement is low. However, the early stages after migration are a particularly vulnerable phase in which psychosocial support measures are needed to prevent mental disorders from becoming chronic.

OBJECTIVE

To identify predictors of asylum seekers' health care utilization in the early stages of resettlement.

METHODS

Using hierarchical logistic regression analysis, the variance explanation of the (1) general utilization of health care services as well as the individual utilization of (2) outpatient psychiatrists, (3) counselling centers, and (4) general practitioners was analyzed in n = 65 asylum seekers. A structured interview on health care utilization took place between three to five months after assessment of possible predictors. We defined the following three groups of predictors a) the sociodemographic variables gender, age, number of children, religion, language proficiency, b) the psychological variables sense of coherence and emotion regulation as well as c) the asylum seekers' psychiatric diagnoses.

RESULTS

Individual sociodemographic factors, such as gender, age, and number of children as well as the emotion regulation strategy of expressive suppression and sense of coherence were shown to be predictive for the utilization of health care services among asylum seekers.

CONCLUSIONS

Low-threshold, culture-sensitive treatment offers for asylum seekers should be established in the early phase after migration. General practitioners should be a central hub for further referrals to disorder-specific treatments.

Effects of introducing a walk-in clinic on ambulatory care sensitive hospitalisations among asylum seekers in Germany: a single-centre pre-post intervention study using medical records

OBJECTIVE

Measuring the effect of introducing a walk-in clinic on ambulatory care sensitive (ACS) hospitalisations among asylum seekers in a large state reception- and registration centre.

DESIGN AND SETTING

Pre-post intervention study using anonymous account data from a university hospital functioning as referral facility for a state reception- and registration centre in the third largest German federal state.

PARTICIPANTS

We included all asylum seekers residing in the reception centre and admitted to the referral hospital between 2015 to 2017.

INTERVENTIONS

Establishment of an interdisciplinary walk-in clinic in the reception centre (02/2016).

MAIN OUTCOME MEASURES

International lists for ACS conditions for both adults and children were adapted and used to calculate the prevalence of ACS conditions among the population (primary outcome measure). The impact of the intervention on the outcome was analysed using a segmented Poisson regression to calculate incidence-rate ratios with respective 95% CIs, adjusted for age, sex and admission.

RESULTS

The prevalence of ACS hospitalisations changed over time, as did the effect of age, sex and quarter of admission. Introducing the walk-in clinic reduced the prevalence of ACS hospitalisations among asylum seekers compared with the period before establishment of the clinic (incidence-rate ratios (IRR)=0.80 (0.65 to 1.00), p=0.054), but the effect was attenuated after adjustment for time trends. The average difference in prevalence of ACS hospitalisations compared with the period before establishment of the clinic, corrected for pre-existing time trends, age and sex of asylum seekers was IRR=1.03 ((0.69 to 1.55), p=0.876).

CONCLUSIONS

A walk-in clinic in reception centres may be effective to reduce ACS hospitalisations, but our study could not prove evidence for a measurable effect after full adjustment for time trends. Further research, ideally with parallel control groups, is required to establish evidence for the effectiveness of walk-in clinics in reception centres on reducing ACS hospitalisations.

Asylum seekers' mental health and treatment utilization in a three months follow-up study after transfer from a state registration-and reception-center in Germany

Even though asylum seekers show a high prevalence of trauma-related disorders and comorbid psychological stress symptoms, little is known about how their mental health develops during the asylum process and what options of care are provided. We aimed to investigate the mental health and treatment utilization of asylum seekers after they were transferred from a state registration- and reception-center to municipal shelters in Germany. N = 228 asylum seekers with on-going asylum procedure were recruited in the psychosocial walk-in clinic located in a state registration- and reception-center. We firstly captured symptoms of posttraumatic stress, depression, anxiety disorders, quality of life, as well as alcohol or drug abuse. Subsequently we performed a follow-up after three months to evaluate a potential shift in symptoms and determining rates of access to treatment. In the pre-post psychometric assessment, there were statistically significant changes in depression (PHQ-2), panic (PHQ-PD) and psychosocial well-being scores (WHO-5). However, all these scores still remained within a clinical relevant range, respectively. Traumatic stress (PC-PTSD-5) and general anxiety scores (GAD-2) did not change significantly. Although N = 44 (66%) of the interviewed patients had been referred to psychotherapy initially, none (0%) of them had received outpatient psychotherapeutic treatment after three months. Our results emphasize a strong need for low-threshold, cultural adapted psychotherapeutic treatment for asylum seekers.

Stabilizing Techniques and Guided Imagery for Traumatized Male Refugees in a German State Registration and Reception Center: A Qualitative Study on a Psychotherapeutic Group Intervention

Refugees have an increased risk of developing mental health problems. Due to the unstable setting in refugee state registration and reception centers, recommended trauma-focused treatment approaches are often not applicable. For this purpose, we devised a suitable therapeutic approach to treat traumatized refugees in a German state registration and reception center: Group therapy, focusing on stabilizing techniques and guided imagery according to Reddemann (2017). From May 2017 to April 2018, we conducted semi-structured interviews with n = 30 traumatized refugees to assess their experiences with the stabilizing techniques and guided imagery in group sessions and self-practice. Participants mainly reported that they had more pleasant feelings, felt increasingly relaxed, and could better handle recurrent thoughts. Additionally, the participants noticed that their psychosocial functioning had improved. The main difficulties that participants encountered were feeling stressed, having difficulties staying focused, or concentrating on the techniques. During self-practice, the participants found it most challenging that they did not have any verbal guidance, were often distracted by the surroundings in the accommodation, and had recurrent thoughts about post-migratory stressors, such as insecurity concerning the future or the application for asylum. Our results show that stabilizing techniques and guided imagery according to Reddemann (2017) are a suitable approach to treat traumatized refugees living in volatile conditions.

Medical Clerkship in a State Registration and Reception Center for Forced Migrants in Germany: Students' Experiences, Teachable Moments, and Psychological Burden

Aspects of global health are becoming increasingly relevant for doctors of future generations. However, medical curricula rarely include courses which focus on global health or forced migration. Furthermore, it remains unclear whether students are at risk to develop psychological strain, after being confronted with highly burdened or even traumatized asylum seekers. This is a prospective study using a mixed-methods approach. We included n = 22 medical students performing a medical clerkship in a state registration and reception center for refugees. By applying (1) qualitative interviews, (2) reflective diaries, and (3) psychometric questionnaires, we examined the students’ experiences, teachable moments, and potential psychological burdens. In the interviews, the students emphasized the importance of cultural sensitivity during their clerkship. However, they also reported cognitive changes concerning their views of themselves and the world in general; this could indicate vicarious traumatization. The reflective diaries displayed high learning achievements. According to the psychometric questionnaires, the assignment in the reception center had not caused any significant psychological strain for the students. By completing their medical clerkship in a reception center, students were able to improve their medical, organizational, and interactional knowledge and skills. Furthermore, they reported that they had broadened their personal and cultural horizons.

Psychotherapeutic Group Intervention for Traumatized Male Refugees Using Imaginative Stabilization Techniques-A Pilot Study in a German Reception Center

Background: Due to persecution, human rights violations and armed conflicts, the prevalence of post-traumatic stress disorder (PTSD) is high in refugee populations. Previous studies indicate that trauma-focused treatments are highly effective in treating PTSD in refugees. However, these approaches rely on the stability of the therapeutic setting, treatment continuity, and safe housing. Although early treatment of PTSD is recommended, these requirements are not met in reception centers. Therefore, we conducted a pilot study to examine the effect of imaginative stabilization techniques derived from psychodynamic psychotraumatology therapy for the early stabilization of traumatized refugees in a reception center. Methods: From May 2017 to April 2018, 86 imaginative stabilization group therapy sessions have taken place. A sample of 43 out of 46 traumatized refugees completed self-report questionnaires assessing PTSD, depression, and anxiety symptoms prior to attending open imaginative stabilization group therapy sessions. Furthermore, participants filled in self-report questionnaires on distress and emotional state (valence/arousal/dominance) before and after each session. After having participated in four consecutive sessions, a sub-group of 17 participants completed a follow-up assessment of PTSD, depression, and anxiety symptoms. Follow-up interviews were conducted with 25 participants 2 weeks after their last session attendance to explore self-practice habits post intervention. Results: The pre-post-intervention comparison of scores indicated a significant reduction of distress (z = -3.35, p < 0.001, r = -0.51) and an improvement of affective reports for valence (z = -4.79, p < 0.001, r = -0.82) and dominance (z = -3.89, p < 0.001, r = -0.59), whereas arousal scores were not affected. We found a significant reduction of anxiety symptoms (z = -2.04, p < 0.05, r = -0.49), whereas PTSD and depression scores remained unchanged. Follow-up interviews revealed that 80% of the participants continued to practice the imaginative stabilization techniques after redistribution to other accommodation. Conclusion: The results indicate that imaginative stabilization techniques are a promising and feasible approach to treat refugees in unstable reception center settings. In regular imaginative stabilization group therapy sessions, we were able to reduce the participants' distress and anxiety symptoms while strengthening their internal resources and increasing their emotional stability.