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Jahan N, Velasco M, Vranceanu AM, Alegría M, Saadi A. Clinician perspectives on characteristics and care of traumatic brain injury among asylum seekers and refugees. Disabil Rehabil 2024:1-10. [PMID: 38831593 DOI: 10.1080/09638288.2024.2356014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 05/10/2024] [Indexed: 06/05/2024]
Abstract
PURPOSE Traumatic brain injury (TBI) disproportionately affects asylum-seekers and refugees (ASR), although underdiagnosed and undertreated. Our study assesses clinicians' perspectives on characteristics and management of TBI among ASR, with the hope of improving TBI management in this population. MATERIALS AND METHODS We conducted six focus groups of 16 clinicians across two academic medical centers in Boston, Massachusetts, United States. Clinicians in our sample included primary care clinicians, nurse practitioners, social workers, psychologists, neurologists, psychiatrists, and neuropsychologists. We analyzed the qualitative data following a hybrid inductive-deductive thematic analytic approach. RESULTS Clinicians characterized TBI among ASR as mostly mild and remote, involving head strikes, perpetrated predominantly by interpersonal violence and strangulation-related brain injury, and involving symptom overlap with mental health diagnoses, challenging diagnosis. Clinicians also described inadequate screening, the importance of connecting the physical and psychological symptoms of the brain injury rather than viewing them as distinct, and addressing diagnosis-related stigma and shame. Finally, they discussed lack of TBI-specific knowledge among providers and patients alike, and resource limitations affecting the continuum of care for this population. CONCLUSION Integrating clinicians' perspectives in caring for this population allows us to best meet their needs, including in TBI recovery.
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Affiliation(s)
- Nusrath Jahan
- Tufts University School of Medicine, Boston, MA, USA
| | - Margarita Velasco
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Ana-Maria Vranceanu
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Margarita Alegría
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Altaf Saadi
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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Saadi A, Prabhu M, Snyder SA, Daboul L, Mateen F. Neurological Care of Refugees and Other Forcibly Displaced Persons. Semin Neurol 2024; 44:217-224. [PMID: 38499195 PMCID: PMC11177780 DOI: 10.1055/s-0044-1782495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/20/2024]
Abstract
There are more than 100 million forcibly displaced persons (FDPs) in the world today, including a high number of people who experience neurologic symptoms and presentations. This review summarizes the conceptual frameworks for understanding neurological health risks and conditions across the migration journey (premigration, migration journey, and postmigration) and life span, including special attention to pediatric FDPs. The interaction with psychiatric illness is discussed, as well as the available published data on neurologic presentations in FDPs in the medical literature. A social determinant of health lens is used to provide ways in which forcible displacement can influence brain health and neurological outcomes. Priorities and future needs for the neurological care of refugees and other FDPs are suggested.
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Affiliation(s)
- Altaf Saadi
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Meha Prabhu
- Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | - Sara A. Snyder
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Lynn Daboul
- Mass General Brigham Neurology Residency Program, Boston, MA
| | - Farrah Mateen
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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Milewski A, Weinstein E, Lurie J, Lee A, Taki F, Pilato T, Jedlicka C, Kaur G. Reported Methods, Distributions, and Frequencies of Torture Globally: A Systematic Review and Meta-Analysis. JAMA Netw Open 2023; 6:e2336629. [PMID: 37787994 PMCID: PMC10548313 DOI: 10.1001/jamanetworkopen.2023.36629] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 08/24/2023] [Indexed: 10/04/2023] Open
Abstract
Importance Despite its prohibition by the United Nations Convention against Torture and other international treaties, torture has been perpetrated against countless individuals worldwide, and health care practitioners globally are increasingly encountering refugee torture survivors in their clinical practices. The methods, geographic distribution, and frequency of torture globally are not well described, which limits health care practitioners' ability to adequately diagnose and treat the sequelae of torture. Objective To rank the commonness of torture methods and identify the regions of the world with which they are associated. Data Sources For this systematic review and meta-analysis, Ovid MEDLINE, Ovid Embase, Web of Science, and The Cochrane Library were searched from inception to July 2021. Study Selection Included studies were peer-reviewed articles in English, contained an independent sample population of individuals who experienced torture, and outlined the type(s) of torture experienced. Excluded studies were not peer reviewed, lacked an independent sample population, or did not specify torture methods. Articles were chosen for inclusion by 2 independent and blinded reviewers, and a third, independent reviewer resolved discrepancies. Overall, 266 articles-15.3% of the 1739 studies initially identified for full review-met the inclusion criteria. Data Extraction and Synthesis Data abstraction and quality assessment followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Data were extracted by 2 independent and blinded reviewers into predefined templates, and a third, independent reviewer resolved discrepancies. The risk of bias was evaluated using the Downs and Black Checklist. Main Outcomes and Measures Torture methods were ranked by their average frequencies, numbers of reporting studies, and numbers of countries wherein the methods occurred. Results A total of 9937 titles and abstracts were screened, and 266 studies encompassing 103 604 individuals (13 350 men, 5610 women, and 84 644 unspecified) were analyzed. Torture was reported for 105 countries; 21 methods accounted for 84% of all reported methods and 10 methods accounted for 78% of all physical tortures. The top 3 methods were beating or blunt-force trauma (reported in 208 studies and 59 countries; average frequency, 62.4%; 95% CI, 57.7%-67.1%), electrical torture (reported in 114 studies and 28 countries; average frequency, 17.2%; 95% CI, 15.0%-19.4%), and starvation or dehydration (reported in 65 studies in 26 countries; average frequency, 12.7%; 95% CI, 10.2%-15.2%). According to the Downs and Black appraisal tool, 50 studies were rated as good or excellent and 216 as fair or poor. Conclusions and Relevance The findings of this study suggest that torture remains widespread. Although innumerable torture methods exist, a limited number account for the vast majority of reported tortures. So that targeted therapies may be developed, additional investigation is needed to better elucidate the sequelae associated with the most common torture methods, described here.
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Affiliation(s)
- Andrew Milewski
- Department of Anesthesiology, NewYork-Presbyterian Hospital/Weill Cornell Medicine, New York
| | - Eliana Weinstein
- Department of Anesthesiology, NewYork-Presbyterian Hospital/Weill Cornell Medicine, New York
| | - Jacob Lurie
- Department of Anesthesiology, NewYork-Presbyterian Hospital/Weill Cornell Medicine, New York
| | - Annabel Lee
- Weill Cornell Medicine Medical College, New York, New York
| | - Faten Taki
- Department of Anesthesiology, NewYork-Presbyterian Hospital/Weill Cornell Medicine, New York
| | - Tara Pilato
- Samuel J. Wood Library, Weill Cornell Medicine, New York, New York
| | - Caroline Jedlicka
- Kingsborough Community College, City University of New York, Brooklyn
| | - Gunisha Kaur
- Department of Anesthesiology, NewYork-Presbyterian Hospital/Weill Cornell Medicine, New York
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Saadi A, Williams J, Parvez A, Alegría M, Vranceanu AMM. Head Trauma in Refugees and Asylum Seekers: A Systematic Review. Neurology 2023; 100:e2155-e2169. [PMID: 37019660 PMCID: PMC10238158 DOI: 10.1212/wnl.0000000000207261] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 02/21/2023] [Indexed: 04/07/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Refugees and asylum seekers are at risk of head trauma. They endure blows to the head due to exigent circumstances necessitating resettlement (e.g., torture, war, interpersonal violence) and during their dangerous journeys to refuge. Our objective was to assess the global prevalence of head trauma in refugees and asylum seekers and describe its clinical characteristics in this population. METHODS The protocol was registered in the PROSPERO International Prospective Register of Systematic Reviews (CRD42020173534). PubMed/MEDLINE, PsycInfo, Web of Science, Embase, and Google Scholar databases were searched for relevant studies. We included all studies in English that comprised refugees or asylum seekers of any age and examined the prevalence or characteristics of head trauma. We excluded studies that were not peer-reviewed original research. Information was recorded on the prevalence of head trauma, method of ascertaining head trauma, severity, mechanism of injury, other trauma exposures, and comorbidities. Descriptive analyses and narrative syntheses were performed. RESULTS A total of 22 studies were included, of which 13 with 6,038 refugees and asylum seekers reported head trauma prevalence. Prevalence estimates ranged from 9% to 78%. Heterogeneity among studies precluded meta-analysis. Most studies were US based (n = 9, 41%), followed by the Middle East (n = 5, 23%). Most refugees or asylum seekers were from the Middle East (n = 9, 41%), with those from Latin America least represented (n = 3, 14%). Studies disproportionately involved younger (pooled mean age = 29 years) adult samples composed of men. Recruitment settings were predominantly hospitals/clinics (n = 14, 64%), followed by refugee camps (n = 3, 14%). The most common mechanism of injury was direct impact through a beating or blow to the head. Studies varied greatly in how head trauma was defined and ascertained; no study used a validated traumatic brain injury (TBI)-specific screening tool. Similarly, TBI severity was not uniformly assessed, although hospital-based samples captured more moderate-to-severe head injuries. Mental health comorbidities were more frequently documented rather than physical health ones. Only 2 studies included a comparison with local populations. DISCUSSION Refugees and asylum seekers are vulnerable to head trauma, but studies using systematic approaches to screening are lacking. Increased attention to head trauma in displaced populations will allow for optimizing equitable care for this growing vulnerable population.
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Affiliation(s)
- Altaf Saadi
- From the Department of Neurology (A.S.), Massachusetts General Hospital; Harvard Medical School (A.S., M.A., A.-M.M.V.), Boston, MA; University of Connecticut School of Medicine (J.W.), Farmington; University College London Medical School (A.P.), United Kingdom; and Disparities Research Unit (M.A.), Department of Medicine, and Center for Health Outcomes and Interdisciplinary Research (A.-M.M.V.), Massachusetts General Hospital, Boston.
| | - Jasmin Williams
- From the Department of Neurology (A.S.), Massachusetts General Hospital; Harvard Medical School (A.S., M.A., A.-M.M.V.), Boston, MA; University of Connecticut School of Medicine (J.W.), Farmington; University College London Medical School (A.P.), United Kingdom; and Disparities Research Unit (M.A.), Department of Medicine, and Center for Health Outcomes and Interdisciplinary Research (A.-M.M.V.), Massachusetts General Hospital, Boston
| | - Ameerah Parvez
- From the Department of Neurology (A.S.), Massachusetts General Hospital; Harvard Medical School (A.S., M.A., A.-M.M.V.), Boston, MA; University of Connecticut School of Medicine (J.W.), Farmington; University College London Medical School (A.P.), United Kingdom; and Disparities Research Unit (M.A.), Department of Medicine, and Center for Health Outcomes and Interdisciplinary Research (A.-M.M.V.), Massachusetts General Hospital, Boston
| | - Margarita Alegría
- From the Department of Neurology (A.S.), Massachusetts General Hospital; Harvard Medical School (A.S., M.A., A.-M.M.V.), Boston, MA; University of Connecticut School of Medicine (J.W.), Farmington; University College London Medical School (A.P.), United Kingdom; and Disparities Research Unit (M.A.), Department of Medicine, and Center for Health Outcomes and Interdisciplinary Research (A.-M.M.V.), Massachusetts General Hospital, Boston
| | - Ana-Maria M Vranceanu
- From the Department of Neurology (A.S.), Massachusetts General Hospital; Harvard Medical School (A.S., M.A., A.-M.M.V.), Boston, MA; University of Connecticut School of Medicine (J.W.), Farmington; University College London Medical School (A.P.), United Kingdom; and Disparities Research Unit (M.A.), Department of Medicine, and Center for Health Outcomes and Interdisciplinary Research (A.-M.M.V.), Massachusetts General Hospital, Boston
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Mirzaei S, Preitler B, Wenzel T. Localizing a metabolic focus during a functional seizure with fluorodeoxyglucose positron emission tomography-computed tomography. World J Nucl Med 2021; 20:96-98. [PMID: 33850496 PMCID: PMC8034789 DOI: 10.4103/wjnm.wjnm_22_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 04/02/2020] [Accepted: 04/04/2020] [Indexed: 11/04/2022] Open
Abstract
Traumatic brain injuries can lead to long-term mental seizures that are difficult to differentiate from dissociative psychogenic symptoms, respectively, psychogenic nonepileptic seizures. Recent articles have drawn attention to the need of differentiation of psychological and brain trauma-related symptoms in survivors of violence. This case study reflects a diagnostic step in a 20-year-male who reported to have been subjected to torture, including blunt force to the head 2 years before examination. He suffers from episodical headaches followed by mental bouts of aggression and restlessness. We performed a brain 18F-fluorodeoxyglucose positron emission tomography (PET)-computed tomography to identify a cerebral correlate of the psychogenic seizures. The examination yielded a hypermetabolic focus in the frontal superior parasagittal region. Psychogenic seizures can frequently be observed as culture-specific "idioms of distress" and can challenge diagnostic evaluation, especially in the victims of violence with an additional history of blunt brain trauma. The advances in molecular imaging such as PET can be expected to play a crucial role in forensic and clinical assessment in the increasing number of such patients.
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Affiliation(s)
- Siroos Mirzaei
- Institute of Nuclear Medicine with PET-Center, Wilhelminenspital, Vienna, Austria.,Hemayat, Organisation for Support of Victims of Torture and War, Vienna, Austria
| | - Barbara Preitler
- Hemayat, Organisation for Support of Victims of Torture and War, Vienna, Austria
| | - Thomas Wenzel
- Department of Psychiatry, Medical University of Vienna, Vienna, Austria.,World Psychiatric Association Section of Psychological Aspects of Torture and Persecution, Geneva, Switzerland
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Traumatic brain injury and forensic evaluations: Three case studies of U.S. asylum-seekers. J Forensic Leg Med 2021; 79:102139. [PMID: 33740607 DOI: 10.1016/j.jflm.2021.102139] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 02/05/2021] [Accepted: 02/15/2021] [Indexed: 11/20/2022]
Abstract
Traumatic brain injuries are common among refugees and asylum-seekers and can result from a range of etiologies, including intimate partner violence, gang violence, war-related trauma, and torture. Regardless of the cause, these injuries often result in a host of neuropsychiatric and other symptoms that may complicate individuals' subsequent health outcomes. For asylum-seekers, documenting prior head trauma is essential to the legal process, since traumatic brain injuries and their subsequent effects on memory and cognition may affect the ability to provide thorough testimony. Using three case vignettes, we explore how to approach the forensic evaluation of asylum-seekers with a history of traumatic brain injury, illustrating the range of etiologies and sequelae of traumatic brain injury in this complex population.
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Akgungor S, Alaei K, Chao WF, Harrington A, Alaei A. Correlation between human rights promotion and health protection: a cross country analysis. INTERNATIONAL JOURNAL OF HUMAN RIGHTS IN HEALTHCARE 2019. [DOI: 10.1108/ijhrh-07-2018-0050] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
The purpose of this paper is to explore the correlation among health outcomes, and civil and political rights (CPR) and also economic, social and cultural rights.
Design/methodology/approach
The study uses cross-sectional data from 161 countries. The authors use health outcomes and human rights variables in the model. In order to combine dimensions of human rights, this paper uses factor analysis and obtains proxy variables that measure economic, social and cultural rights and CPR. The two proxy variables are used as independent variables to explain variations in health in a regression model. The paper then classifies countries by cluster analysis and explores the patterns of different components of human rights and health outcomes across country clusters.
Findings
The regression model demonstrates that the economic, social and cultural rights variables explain variations in all health outcomes. The relationship between CPR and health is weaker than that of the economic, social and cultural rights. Cluster analysis further reveals that despite the country’s commitment to CPR, those that highly respect economic, social and cultural rights lead to superior health outcomes. The more respect a country has for economic, social and cultural rights, the better the health outcomes for the citizens of that country.
Practical implications
National policies should consider equal emphasis on all dimensions of human rights for further improvements in health.
Originality/value
The sole promotion of CPR such as democracy and empowerment, absence of adequate support of economic, social and cultural rights such as rights to housing, education, food and work can only contribute partially to health.
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Mental Health of Refugees and Torture Survivors: A Critical Review of Prevalence, Predictors, and Integrated Care. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16132309. [PMID: 31261840 PMCID: PMC6651013 DOI: 10.3390/ijerph16132309] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 06/27/2019] [Accepted: 06/27/2019] [Indexed: 11/17/2022]
Abstract
Civilian war trauma and torture rank among the most traumatic life experiences; exposure to such experiences is pervasive in nations experiencing both internal and external conflict. This has led to a high volume of refugees resettling throughout the world with mental health needs that primary care physicians may not be screening for and prepared to effectively address. In this article, we review the literature on demographics, predictors, mental health outcomes of torture, and integrated care for the mental health needs of refugees. We searched PubMed and PSYCINFO databases for original research articles on refugees and mental health published in the English language between 2010 and present. Nine percent of 720 adults in conflict areas in Nepal, with predominance of literate married males, met the threshold for Post-Traumatic Stress Disorder (PTSD), 27.5% for depression, and 22.9% for anxiety. While, PTSD rate has been documented as high as 88.3% among torture survivors from Middle East (ME), Central Africa (CA), South Asia (SA), Southeast Europe (SE). Depression was recorded as high as 94.7% among 131 African torture survivors and anxiety as high as 91% among 55 South African torture survivors. Torture severity, post-migration difficulties, and wait time to receive clinical services were significantly associated with higher rate of mental health symptoms. Mental health screening is not a standard component of initial physical exams for refugees, yet these individuals have had high trauma exposure that should inform clinical care. Integrated care models are lacking but would greatly benefit this community to prevent progression to greater severity of mental health symptoms.
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Integrated behavioral health care for Karen refugees: a qualitative exploration of active ingredients. INTERNATIONAL JOURNAL OF MIGRATION HEALTH AND SOCIAL CARE 2018. [DOI: 10.1108/ijmhsc-10-2017-0043] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
The purpose of this paper is to explore the “active ingredients” of integrated behavioral health care (IBHC) from the perspective of Karen refugee participants in an IBHC intervention.
Design/methodology/approach
This paper is based on in-depth, semi-structured interviews with participants (n=40) who have received an IBHC intervention for one year. These qualitative data are supplemented by descriptive quantitative data from those same participants.
Findings
This research suggested that IBHC increased awareness and access to behavioral health services, and that IBHC may be especially amenable to treating complex health conditions. The research also found that IBHC provided a point of regular contact for patients who had limited time with their primary care providers, which helped to enhance access to and engagement with health care.
Practical implications
IBHC has the potential to meet the complex needs of Karen resettled refugees living in an urban setting in the USA.
Originality/value
IBHC is a promising approach to help meet the mental health needs of refugees in the USA. There are, however, gaps in knowledge about the “active ingredients” of IBHC. This paper helps fill these gaps by studying how IBHC works from the perspective of a group of Karen refugees; these are critical perspectives, missing in the literature, which must be heard in order to better address the complex conditions and needs of resettled refugees.
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Affiliation(s)
- Jacob I. McPherson
- Department of Rehabilitation Sciences, University at Buffalo, Buffalo, NY, USA
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