Daily stressors, trauma exposure, and mental health among stateless Rohingya refugees in Bangladesh

Social-ecological factors associated with trajectories of adolescent sexual and reproductive health stigma: longitudinal cohort findings with urban refugee youth in Kampala

Background Stigma towards sexually active young people presents profound barriers to uptake of sexual and reproductive health (SRH) services, including HIV testing and contraception. Yet, few studies have examined adolescent SRH stigma trajectories over time. To address this knowledge gap, we examined associations between social-ecological factors and trajectories of adolescent SRH stigma among urban refugee youth in Kampala, Uganda. Methods This longitudinal cohort study with refugee youth in Kampala collected data on adolescent SRH stigma at four time-points between 2022 and 2024. We used latent class growth analyses to examine distinct trajectories of adolescent SRH stigma, and examined baseline social-ecological and socio-demographic factors associated with class membership using multivariable logistic regression. Results Among the participants (n =164 with n =668 observations; mean age 19.9 years, standard deviation2.5 years; 52.8% cisgender women), we categorised two distinct adolescent SRH stigma trajectories: consistently high (n =496; 74.2%) and sustained low (n =172; 25.8%). In multivariable analyses, living in Uganda ≥1year at baseline assessment (1-5years: adjusted odds ratio [aOR]5.28, confidence interval [CI]2.29-12.19, P P 10years: aOR3.89, CI1.56-9.68, P P P P P Conclusions Social-ecological and socio-demographic factors were associated with consistently high levels of adolescent SRH stigma over 2years. Multi-level strategies can meaningfully engage youth in developing stigma reduction strategies for SRH service delivery.

A qualitative study of cultural concepts of distress among Rohingya refugees in Cox's Bazar, Bangladesh

BACKGROUND

Rohingya refugees residing in Bangladesh have been exposed to profound trauma in addition to ongoing daily stressors of living in the refugee camps. Accurate assessments of mental health burden and their impact among this population require culturally sensitive tools that remain lacking in this context. The purpose of this study was to characterize salient cultural concepts of distress (CCDs), their causes, consequences, and approaches to treatment, among Rohingya refugees living in Cox's Bazar, Bangladesh, to help inform future measurement and intervention design.

METHODS

Between December 2020 and March 2022, 106 free-listing interviews and 10 key informant interviews were conducted with community members to identify and better understand common CCDs. Rohingya research staff analyzed the interview transcripts by tabulating the frequency of unique CCDs in the free-listing interviews and the unique attributed causes, signs, consequences, and treatment strategies for each CCD in the key informant interviews.

RESULTS

In total, five CCDs were identified: tenshon (tension), bishi sinta (excessive thinking), feshar (pressure), gum zai nofara (unable to sleep), and shoit-shoit lagon (feeling restless and/or trapped). Although the five CCDs had overlapping symptoms, they also had unique presentation, consequences, and preferred strategies for treatment that may impact service-seeking behavior. Three out of the five CCDs were considered life-threatening, if severe and left untreated.

CONCLUSION

The five CCDs identified are culturally salient ways of experiencing and communicating distress within this community but are not adequately captured in existing mental health assessments for this population. This may negatively impact programmatic efforts among the group.

Practical challenges for mental health services among Rohingya refugee in Bangladesh

Rohingya Muslims have been forcefully displaced from their mother land, Rakhaine State, Myanmar to Bangladesh, a country with about 170 million population with a treatment gap of more than 90% for standard mental health care. Due to the experienced trauma and displacement, high prevalence of depression, anxiety and post-traumatic tress disorders has been identified among Rohingya refugees in addition to the enduring mental health burden of Bangladesh. Very little has been known regarding the practical challenges of mental health services among Rohingya refugees in Bangladesh. In this commentary, we aimed to highlight the practical challenges for mental health services in Rohingya camps in Bangladesh along with our speculative ways forward based on available evidence, work experience, and informal communications. We highlighted the available mental health services, several major challenges including awareness, perception and belief towards mental health, language and cultural barriers, dearth of skilled service providers, inadequate services for severe mental illness, dearth of mental health services for children, inadequate provision of supervision and 'Care for Caregivers' program, and privacy and confidentiality of the clients. Although significant improvements have been made in the mental health field in the emergency crisis sector in Cox's Bazar over the past years, concentrated efforts are urgently required to actualize proposed solutions in this paper.

Psychosocial impacts of Baby Friendly Spaces for Rohingya refugee mothers in Bangladesh: A pragmatic cluster-randomized controlled trial

Background

This study evaluated the effectiveness of Baby Friendly Spaces (BFS), a psychosocial support program for Rohingya refugee mothers of malnourished young children in Bangladesh. Because BFS was already being implemented, we examined the benefit of enhancing implementation supports.

Methods

In matched pairs, 10 sites were randomized to provide BFS treatment as usual (BFS-TAU) or to receive enhanced implementation support (BFS-IE). 600 mothers were enrolled and reported on maternal distress, functional impairment, subjective well-being and coping at baseline and 8-week follow-up. Data were analyzed using multilevel linear regression models to account for clustering; sensitivity analyses adjusted for the small number of clusters.

Results

Significant within-group improvements in BFSIE were observed for distres (-.48, p = .014), functional impairment (-.30, p = .002) and subjective well-being (.92, p = .011); improvements in BFS-TAU were smaller and not statistically significant. Between-group comparisons favored BFS-IE for distress (β = -.30, p = .058) and well-being (β = .58, p = .038). Sensitivity adjustments produced p-values above .05 for all between-group comparisons.

Discussion

Feasible adjustments to implementation can improve program delivery to increase impact on maternal distress and well-being. Although results should be interpreted with caution, study design limitations are common in pragmatic, field-based research.

Prevalence and associated factors of common mental disorders among internally displaced people by armed conflict in Cabo Delgado, Mozambique: a cross-sectional community-based study

Background

Humanitarian emergencies are a major global health challenge with the potential to have a profound impact on people's mental and psychological health. Displacement is a traumatic event that disrupts families and affects physical and psychological health at all ages. A person may endure or witness a traumatic incident, such as being exposed to war, and, as a result, develop post-traumatic stress disorder (PTSD). There is a lack of information about post-traumatic stress disorder, depression, and anxiety disorder in low and middle-income countries in humanitarian emergency contexts such as Mozambique. This study aimed to assess the prevalence of PTSD, depression, and anxiety, and associated factors among armed conflict survivors in Cabo Delgado, north region of Mozambique in 2023.

Methods

A community-based cross-sectional study was conducted between January and April 2023 among 750 participants, who were selected by convenience. A face-to-face interview used the Primary Care Post-Traumatic Stress Disorder Checklist (PC-PTSD-5) to evaluate PTSD, the Generalized Anxiety Disorder Scale (GAD-7) to evaluate anxiety and the Patient Health Questionnaire - Mozambique (PHQ-9 MZ) to evaluate depression. The association between PTSD and demographic and psychosocial characteristics was analyzed using bivariate and multivariable binary logistic regression. We used a 5% significance level.

Results

The three mental disorders assessed were highly prevalent in our sample with 74.3% PTSD, 63.8% depression, and 40.0% anxiety. The chance of developing PTSD was higher in females (AOR = 2.30, 95% CI 1.50-3.51), in patients with depression symptoms (AOR = 8.27, 95% CI = 4.97-13.74) and anxiety symptoms (AOR = 1.45, 95% CI = 0.84-2.50).

Conclusion

This study reported that the prevalence of PTSD, depression, and anxiety were high. Patients having depressive symptoms, anxiety symptoms, and being female are more at risk of developing PTSD. There is a need to integrate screening for common mental disorders in the context of humanitarian emergencies and its adapted integration of psychosocial interventions.

Coping strategies of unaccompanied refugee minors shortly after arrival in Belgium

Unaccompanied refugee minors (URMs) are a group in an especially vulnerable situation with heightened psychological suffering due to both stressful life events and current daily stressors. Research has shown that certain coping strategies such as avoidance can be adaptive in the face of ongoing stress. We conceptualize social support as an essential coping resource that these strategies tap into. Since the interrelations between these factors are often not clear in the literature, this study strives to identify and link URMs' coping strategies, the respective coping resources and the various stressors they target, shortly after arrival in a high-income country. Seventy-nine URMs from various backgrounds were recruited in two first-phase reception centers in Belgium. In addition to self-report questionnaires to assess stressful life events and current daily stressors, we conducted semi-structured interviews, with cultural mediators if required. Thematic analysis was applied to the participants' accounts and resulted in the identification of four coping strategies: avoidance and distraction, continuity and coherence, selective reliance, and positive appraisal and acceptance. The relation between these coping strategies, the various coping resources used, and the specific stressors at which they aim are discussed. We conclude that avoidant coping and contact with the ethnic community, particularly the peer group, are fundamental strategies for successful coping. Practitioners need to support URMs in their coping efforts by providing and facilitating appropriate coping resources.

A mixed methods systematic review of mental health self-care strategies for Arabic-speaking refugees and migrants

BACKGROUND

Self-care strategies can improve mental health and wellbeing, however, the evidence on preferred strategies among Arabic-speaking refugees and migrants is unclear. This mixed methods systematic review aimed to identify and synthesise the global research on mental health self-care strategies used by these populations.

METHODS

English and Arabic language studies reporting on positive mental health self-care strategies to address symptoms of posttraumatic stress disorder, generalised anxiety and depression in the target populations were identified by systematically searching eight electronic databases and grey literature. Studies were deemed eligible if they were published from 2000 onwards and included Arabic-speaking migrants, refugees or asylum seekers aged 12 years and above. A narrative synthesis of study characteristics and relevant key findings was undertaken. The review protocol was registered on PROSPERO (registration number CRD42021265456).

RESULTS

Fifty-nine records reporting 57 studies were identified, the majority appearing after 2019. There were 37 intervention studies that incorporated a self-care component and 20 observational studies that reported on self-generated self-care practices. Across both study types, four broad groups of mental health self-care were identified-social, psychological, religious/spiritual, and other (e.g., expressive arts and exercise). Psychological strategies were the most reported self-care practice overall and featured in all intervention studies. Religious/spiritual and social strategies were more common in the observational studies. Intervention studies in diverse settings reported statistical improvements on a range of outcome measures. Observational studies reported a range of individual and community benefits. Linguistic, cultural and religious considerations, inherent in the observational studies, were variably addressed in the individual and group interventions.

CONCLUSION

Overall, study participants experienced self-care as helpful although some encountered challenges in practicing their preferred strategies. Further research on mental health self-care strategies among Arabic-speaking refugees and migrants is needed in Western resettlement countries to guide mental health service delivery and primary healthcare initiatives for new arrivals and in transit countries.

Much room for change: access to surgical care for stateless individuals in Pakistan

BACKGROUND

As developing countries take steps towards providing universal essential surgery, ensuring the equitable distribution of such care for underrepresented populations is a vital function of the global surgery community. Unfortunately, in the context of the global "stateless", there remains much room for improvement.

KEY ISSUES

Inherent structural deficiencies, such as lack of adequate population data on stateless communities, absent health coverage policies for stateless individuals, and minimal patient-reported qualitative data on barriers to surgical service delivery prevent stateless individuals from receiving the care they require - even when healthcare infrastructure to provide such care exists. The authors therefore propose more research and targeted interventions to address the systemic issues that prevent stateless individuals from accessing surgical care.

CONCLUSION

It is essential to address the aforementioned barriers in order to improve stateless populations' access to surgical care. Rigorous empirical and qualitative research provides an important avenue through which these structural issues may be addressed.

A film-based intervention to reduce child maltreatment among migrant and displaced families from Myanmar: Protocol of a pragmatic cluster randomized controlled trial

BACKGROUND

Child maltreatment is a global public health crisis with negative consequences for physical and mental health. Children in low- and middle-income countries (LMIC)-particularly those affected by poverty, armed conflict, and forced migration-may be at increased risk of maltreatment due to heightened parental distress and disruptions to social support networks. Parenting interventions have been shown to reduce the risk of child maltreatment as well as improve a range of caregiver and child outcomes, yet large-scale implementation remains limited in low-resource displacement settings. This study will examine the impact of an entertainment-education narrative film intervention on reducing physical and emotional abuse and increasing positive parenting among migrant and displaced families from Myanmar living in Thailand.

METHOD

The study is a pragmatic, superiority cluster randomized controlled trial with approximately 40 communities randomized to the intervention or treatment as usual arms in a 1:1 ratio. Participating families in the intervention arm will be invited to attend a community screening of the film intervention and a post-screening discussion, as well as receive a poster depicting key messages from the film. Primary outcomes are changes in physical abuse, emotional abuse, and positive parenting behaviour. Secondary outcomes include caregiver knowledge of positive parenting, caregiver attitudes towards harsh punishment, caregiver psychological distress, and family functioning. Outcomes will be assessed at 3 time points: baseline, 4 weeks post-intervention, and 4-month follow up. A mixed methods process evaluation will be embedded within the trial to assess intervention delivery, acceptability, perceived impacts, and potential mechanisms of change.

DISCUSSION

To our knowledge, this study will be the first randomized controlled trial evaluation of a film-based intervention to reduce child maltreatment among migrant and displaced families in a LMIC. An integrated knowledge translation approach will inform uptake of study findings and application to potential scale up pending evaluation results.

TRIAL REGISTRATION

The study was prospectively registered with the Thai Clinical Trials Registry on 22 February 2023 (TCTR20230222005).

Effect of daily stressors and collective efficacy on post-traumatic stress symptoms among internally displaced persons in post-war northern Sri Lanka

BACKGROUND

Daily stressors have been shown to mediate the relationship of war trauma and trauma-related distress among refugees and internally displaced persons exposed to war and conflict.

AIMS

To examine the extent to which the relationship between war-related trauma and mental distress was mediated by daily stressors and collective efficacy among internally displaced communities a decade after exposure to war.

METHOD

In a cross-sectional study, we recruited a random sample of residents in villages severely affected by conflict in five districts in the Northern Province of Sri Lanka. Measures of war trauma, daily stressors, collective efficacy and post-traumatic stress symptoms (PTSS) were examined. Statistical analyses of the mediating and moderating effects of daily stressors were conducted using regression based methods.

RESULTS

Daily stressors mediated the association of war trauma and PTSS, as both paths of the indirect effect, war trauma to daily stressors and daily stressors to PTSS, were significant. The predictive effect of war trauma on PTSS was positive and significant at moderate and high levels of daily stressors but not at low levels. Higher levels of neighbourhood informal social control, a component of collective efficacy, function as a protective factor to reduce effects of war trauma and daily stressors on mental distress in this population.

CONCLUSIONS

Daily stressors are an important mediator in the well-established relationship between war exposure and traumatic stress among internally displaced persons, even a decade after the conflict. Mental health and psychosocial support programmes that aim to address mental distress among war-affected communities could reduce daily stressors and enhance collective efficacy in this context.

A conceptual study on the relationship between daily stressors, stressful life events, and mental health in refugees using network analysis

Introduction

There is growing recognition that daily stressors, such as social and material deficiencies, can be highly detrimental to the mental health of refugees. These stressors are in addition to stressful life events, which have been widely studied in the context of migration and forced displacement. Despite increasing evidence for an ecological model, there is still no consensus regarding the conceptualization of these highly influential factors. In particular, the demarcation of daily stressors from stressful life events and the categorization of daily stressors require further examination in order to develop usable and accurate tools for researchers, design effective interventions for practitioners and assist politicians in designing meaningful policies.

Methods

To address these challenges, we used data from a sample of 392 unaccompanied young refugees from diverse backgrounds and employed network analysis to examine the relationships between daily stressors, stressful life events, and symptoms of depression, anxiety, and post-traumatic stress.

Results

Our findings highlight the significant relationship between daily stressors and mental health, particularly depression. Meaningful clusters of daily stressors include material stressors, social stressors, and social exclusion stressors.

Conclusion

Our results demonstrate the importance of considering daily stressors in the mental health of refugees and suggest that using a network approach offers a viable way to study these complex interrelationships. These findings have implications for researchers, practitioners, and policymakers in understanding and addressing the mental health needs of refugees.

Persistence of the association between mental health and resource access: A longitudinal reciprocal model in a diverse refugee sample

Stress associated with resource deprivation is an active social determinant of mental health. However, mixed findings around the strength of this association and its persistence over time obscure optimal interventions to improve mental health in forcibly displaced populations. A reciprocal model was analyzed between resource access and measures of depression, anxiety and posttraumatic stress (PTSD) symptoms at three different assessments conducted 6 months apart (Time [T] 1, T2, and T3). Participants included resettled refugees (N = 290) from three geocultural regions (i.e., Afghanistan, the Great Lakes Region of Africa, and Iraq/Syria). The results showed that although limited resource access at T1 was related to depressive and anxiety symptoms, B = 0.26, SE = 0.16, p = .023, r2 = 0.55; posttraumatic stress disorder (PTSD) symptoms, B = 0.20, SE = 0.10, p < .001, r2 = .56; and culturally specific depression and anxiety at T2, B = 0.22, SE = 0.16, p < .001, r2 = 0.65, these were not reciprocally related to resource access at T3. The results help clarify the strength and direction of effects between resource deprivation and depression, anxiety , and PTSD sympotms over time. Although resource deprivation is predictive of depression, anxiety, and PTSD symptoms among recently resettled refugees, the effect may not persist in the long term. These findings have critical implications, including the urgency of ensuring initial access to resources for resettled refugees to stave off the development of depression, anxiety and PTSD symptoms, as delaying immediate resource access may result in the development of chronic, hard-to-treat mental health disorders.

Modeling the predictors of mobile health adoption by Rohingya Refugees in Bangladesh: An extension of UTAUT2 using combined SEM-Neural network approach

While the healthcare facilities for the people is questionable in Bangladesh, Rohingya refugees is a burning issue for both Bangladesh and global community. Integrating Rohingya refugees into the framework of mHealth could be beneficial for both Bangladesh and Rohingya refugees in general, and in specific situation like COVID-19 outbreak. However, no research has been found on what motivates Rohingya refugees to accept mHealth in Bangladesh. Drawing on the UTAUT2 model, this study investigates the predictors of acceptance of mHealth services technologies among Rohingya refugees. The study also seeks to clarify the roles of mHealth developers, the Bangladesh government, and non-governmental organizations working with the 1.1 million Rohingya refugees in Bangladesh. Quantitative data were collected from refugee camps with the permission of the Refugee Relief and Repatriation Commissioner (RRRC). The data were analyzed in two stages using a mixed approach that combines PLS-SEM and Artificial Neural Network (ANN). This study revealed that Effort expectancy (EE, with t = 5.629, β = 0.313) and facilitating conditions (FC with t = 4.442, β = 0.269) in PLS-SEM, and FC (with 100 percent importance) and Health consciousness (HC, with 94.88 percent importance) in ANN analysis were found to be the most substantial predictors of mHealth adoption. The study also revealed that EE and FC are more important for low education group, while PE and Situational Constraint (SC) are more important for the high education group of refugees. In addition to providing insights for mHealth developers, this study particularly focuses on the role of government institutions and non-governmental social workers in working with the subjects to increase FC and HC among Rohingya refugees and bring them under mHealth services.

Reflections on the multi-sectoral response to COVID-19 in Bangladesh’s Rohingya refugee camps

While the COVID-19 pandemic continues to impact people globally, refugees comprise a vulnerable population, particularly those living in densely populated areas. In Bangladesh, Cox’s Bazar is currently home to almost a million Rohingya refugees. Because of the lack of healthcare, sanitation and water, as well as overcrowding, refugees were at high risk of becoming ill during the early phases of the COVID-19 pandemic in 2020. Moreover, superstitions and lack of trust in the healthcare system threaten to put the community at further risk. To prevent tragic consequences, national and international attention and action are required to strengthen the health system for Rohingya refugees. The community will require surveillance and testing, infection prevention and control measures, adequate food supplies, and access to improved healthcare services. This paper calls for a multi-sectoral approach to developing an action plan and implementation strategy to minimize the impact of COVID-19 on this vulnerable population.

Prevalence and determinants of self-reported functional status among older adults residing in the largest refugee camp of the world

BACKGROUND

The older adults of refugee camps might be vulnerable to exhibiting limited functional abilities because of the limited resources available to create a supportive environment for older population in the camps. This study aims to explore the prevalence and determinants of self-reported functional status among the older adults residing in the Rohingya refugee camp in Bangladesh.

METHODS

This cross-sectional study was conducted on 864 older adults aged 60 years and above living in five selected sub-camps of Rohingya refugee camp in Cox's Bazar, Bangladesh. Data were collected through face-to-face interviews of the participants between November-December 2021. Functional status was measured using the Barthel Index. Information on participants' sociodemographic characteristics, self-reported chronic diseases and lifestyle characteristics were also collected. A multiple logistic regression model was used to assess the factors associated with self-reported functional abilities among the participants.

RESULTS

The overall percentage of people having limited self-reported functional ability was 26.5% (male: 22.6% and female: 31.5%) with inability most found in grooming (33.2%), bathing (31.8%), stair using (13.2%) and mobility (10.7%). In the final adjusted model, having age of 80 years or more (aOR = 2.01,95% CI: 1.08,3.75), being female (aOR = 1.44, 95% CI: 1.04,2.0), having low memory or concentration (aOR = 1.83, 95% CI: 1.30,2.56), loneliness (aOR = 2.89, 95% CI:1.74,4.80) and living with aid alone (aOR = 2.89, 95% CI: 1.74,4.80) were found to be associated with self-reported limited functional ability.

CONCLUSION

The findings of this study highlight the need for attention from policymakers and public health practitioners on addressing functional limitations among older adults residing in the Rohingya refugee camp. Our findings emphasize the need for the development of comprehensive interventions that can address the wider unmet needs (e.g., ensuring family/caregiver support, engaging in social and physical activities, providing nutritional support packages, etc.) to improve the health and well-being of older Rohingya adults.

Participation in Everyday Occupations Among Rohingya Refugees in Bangladeshi Refugee Camps

IMPORTANCE

Bangladesh hosts a large number of Rohingya refugees from Myanmar. Living in refugee camps, the Rohingya refugees face challenges in everyday occupations because of violence, limited opportunities, and corporal punishment by the community.

OBJECTIVE

To explore how Rohingya refugees experience participation in everyday occupations while living in temporary refugee camps in Bangladesh.

DESIGN

Phenomenological study to describe, understand, and interpret the meanings of life experiences in particularly adverse conditions.

SETTING

Rohingya refugee camps in Bangladesh.

PARTICIPANTS

Fifteen purposively selected participants from the camps.

OUTCOMES AND MEASURES

In-depth semistructured interview, as well as participant and environmental observations. Researchers used line-by-line data analysis to capture quotations and patterns using interpretive phenomenological analysis, which included establishment of initial codes, interpretation, determining selected codes, and categorization.

RESULTS

The research identified four major themes-(1) mental stress, sleep disturbances, and daily occupations; (2) adjustment to inconsistent daily activities; (3) complex relationships and limited social roles that decreased occupational engagement; and (4) involvement in precarious occupations that exacerbated severe health risks-and four subthemes-(1) fragmented family relationships, (2) formation of new relationships to perform social roles, (3) inconvenient and inaccessible living conditions, and (4) continuation of unlawful work to survive.

CONCLUSIONS AND RELEVANCE

Rohingya refugees should receive comprehensive health and rehabilitative care because of their perilous mental health conditions, precarious occupations, and lack of trustworthy relationships with family and neighbors. What This Article Adds: Rohingya refugees experience imbalanced, deprived, and maladapted occupations in refugee camps. Suggestions to improve their lived experience with further peer support programs may help them participate in occupation-based rehabilitation services to facilitate their social integration.

Financing of health services for undocumented immigrants in Iran: common challenges and potential solutions

INTRODUCTION

Iran is host to one of the largest urban refugee populations worldwide, about two million of whom are undocumented immigrants (UIs). UIs are not eligible to enroll in the Iranian health insurance scheme and have to pay out-of-pocket to access most health services. This increases the likelihood that they will delay or defer seeking care, or incur substantial costs if they do seek care, resulting in worse health outcomes. This study aims to improve understanding of the financial barriers that UIs face in utilizing health services and provide policy options to ensure financial protection to enhance progress towards UHC in Iran.

METHODS

This qualitative study was conducted in 2022. A triangulation approach, including interviews with key informants and comparing them with other informative sources to find out the complementary findings, was applied to increase data confirmability. Both purposive and snowball sampling approaches were used to select seventeen participants. The data analysis process was done based on the thematic content analysis approach.

RESULTS

The findings were explained under two main themes: the financial challenges in accessing health services and the policy solutions to remove these financial barriers, with 12 subthemes. High out-of-pocket payments, high service prices for UIs, fragmented financial support, limited funding capacity, not freeing all PHC services, fear of deportation, and delayed referral are some of the barriers that UIs face in accessing health care. UIs can get insurance coverage by using innovative ways to get money, like peer financing and regional health insurance, and by using tools that make it easier, like monthly premiums without policies that cover the whole family.

CONCLUSION

The formation of a health insurance program for UIs in the current Iranian health insurance mechanism can significantly reduce management costs and, at the same time, facilitate risk pooling. Strengthening the governance of health care financing for UIs in the form of network governance may accelerate the inclusion of UIs in the UHC agenda in Iran. Specifically, it is necessary to enhance the role of developed and rich regional and international countries in financing health services for UIs.

Self-perceived mental health and factors associated with the mental health of Hong Kong's asylum-seekers and refugees - A mixed methods study

Rationale

The 21st century has seen vast flows of displaced people. In the year 2020 alone, an estimated 11.2 million were forcibly displaced as a result of persecution, conflict or generalized violence. The torment and fear of war, persecution and threat to life, whether in the home country, during the process of fleeing, or in the post-migration host country, can be extremely traumatic to these marginalized populations. Hong Kong is not a signatory to the 1951 UN Refugee Convention, but the territory has signed the 1967 UN(CAT) which requires the former colony to allow people who flee for their lives to have their cases processed in Hong Kong. Currently there are around 14,000 cases in Hong Kong, some of whom have been in Hong Kong for more than a decade, waiting for their claims to be processed, living on meagre government subsidies and with no right to work.

Objectives

The paper examines the mental health of asylum-seekers and refugees in Hong Kong and the factors associating with their mental health.

Method

A sequential mixed methods approach was conducted among asylum-seekers and refugees in Hong Kong between October 2019 and mid-2020. It comprised a pilot quantitative survey conducted with 47 participants, and follow-up qualitative interviews with 16 of the 47 participants. Survey results were analyzed using statistical measures while the qualitative in-depth interviews were thematically analyzed to identify emergent patterns and categories.

Results

Results from the quantitative data identify 52.2% of the asylum-seekers taking part as having symptomatic anxiety, 55.3% as having symptomatic depression and 54.3% as having overall problems. Qualitative results show that asylum-seekers and refugees cited lack of work and poverty as key factors affecting their mental health and well-being. Fear of being sent home was expressed by respondents who were married or having children for the fear of being separated from each other.

Associations among past trauma, post-displacement stressors, and mental health outcomes in Rohingya refugees in Bangladesh: A secondary cross-sectional analysis

Objective

The Rohingya endured intense trauma in Myanmar and continue to experience trauma related to displacement in Bangladesh. We aimed to evaluate the association of post-displacement stressors with mental health outcomes, adjusting for previously experienced trauma, in the Rohingya refugee population in Cox's Bazar, Bangladesh.

Methods

We analyzed data from the Cox's Bazar Panel Survey, a cross sectional survey consisting of 5,020 household interviews and 9,386 individual interviews completed in 2019. Using logistic regression, we tested the association between post-displacement stressors such as current exposure to crime and conflict and two mental health outcomes: depression and post-traumatic stress disorder (PTSD). In adjusted analyses, we controlled for past trauma, employment status, receiving an income, food security, and access to healthcare and stratified by gender.

Results

The prevalence of depressive symptoms was 30.0% (n = 1,357) and PTSD 4.9% (n = 218). Most (87.1%, n = 3,938) reported experiencing at least one traumatic event. Multiple post-displacement stressors, such as current exposure to crime and conflict (for men: OR = 2.23, 95% CI = 1.52-3.28, p < 0.001; for women: OR = 1.92, 95% CI = 1.44-2.56, p < 0.001), were associated with higher odds of depressive symptoms in multivariable models. Trauma (OR = 4.98, 95% CI = 2.20-11.31, p < 0.001) was associated with increased odds of PTSD. Living in a household that received income was associated with decreased odds of PTSD (OR = 0.74, 95% CI = 0.55-1.00, p = 0.05).

Conclusion

Prevalence of depressive symptoms was high among Rohingya refugees living in Cox's Bazar. Adjusting for past trauma and other risk factors, exposure to post-displacement stressors was associated with increased odds of depressive symptoms. There is a need to address social determinants of health that continue to shape mental health post-displacement and increase mental healthcare access for displaced Rohingya.

A house is not a home: a network model perspective on the dynamics between subjective quality of living conditions, social support, and mental health of refugees and asylum seekers

BACKGROUND

Providing adequate living conditions for forcibly displaced people represents a significant challenge for host countries such as Germany. This study explores refugee mental health's reciprocal, dynamic relationship with post-migration living conditions and social support.

METHODS

The study sample included 325 Arabic- or Farsi-speaking asylum seekers and refugees residing in Germany since 2014 and seeking mental health treatment. Associations between reported symptoms of post-traumatic stress and depression and the subjective quality of living conditions and perceived social support were analyzed using a two-level approach including multiple linear regression and network analyses.

RESULTS

Post-migration quality of living conditions and perceived social support were significantly associated with negative mental health outcomes on both levels. In the network, both post-migration factors were negatively connected with overlapping symptoms of psychiatric disorders, representing potential target symptoms for psychological treatment.

CONCLUSION

Post-migration quality of living conditions and social support are important factors for refugee mental health and should be targeted by various actors fostering mental well-being and integration.

Community based sociotherapy for depressive symptomatology of Congolese refugees in Rwanda and Uganda (CoSTAR): a protocol for a cluster randomised controlled trial

Background: Conflict in the Democratic Republic of Congo has led to large numbers of refugees fleeing to Uganda and Rwanda. Refugees experience elevated levels of adverse events and daily stressors, which are associated with common mental health difficulties such as depression. The current cluster randomised controlled trial aims to investigate whether an adapted form of Community-based Sociotherapy (aCBS) is effective and cost-effective in reducing depressive symptomatology experienced by Congolese refugees in Uganda and Rwanda.Methods: A two-arm, single-blind cluster randomised controlled trial (cRCT) will be conducted in Kyangwali settlement, Uganda and Gihembe camp, Rwanda. Sixty-four clusters will be recruited and randomly assigned to either aCBS or Enhanced Care As Usual (ECAU). aCBS, a 15-session group-based intervention, will be facilitated by two people drawn from the refugee communities. The primary outcome measure will be self-reported levels of depressive symptomatology (PHQ-9) at 18-weeks post-randomisation. Secondary outcomes will include levels of mental health difficulties, subjective wellbeing, post-displacement stress, perceived social support, social capital, quality of life, and PTSD symptoms at 18-week and 32-week post-randomisation. Cost effectiveness of aCBS will be measured in terms of health care costs (cost per Disability Adjusted Life Year, DALY) compared to ECAU. A process evaluation will be undertaken to investigate the implementation of aCBS.Conclusion: This cRCT will be the first investigating aCBS for mental health difficulties experienced by refugees and will contribute to knowledge about the use of psychosocial interventions for refugees at a time when levels of forced migration are at a record high.Trial registration: ISRCTN.org identifier: ISRCTN20474555.

Biological Psychiatry in Displaced Populations: What We Know, and What We Need to Begin to Learn

Conflict and climate change continue to displace millions of people, who experience unique trauma and stressors as they resettle in host countries. Both children and adults who are forcibly displaced, or choose to migrate, experience posttraumatic stress disorder, anxiety, depression, and other mental health conditions at higher rates than the general population. This may be attributed to severe, cumulative stress and trauma (largely interpersonal traumas); discrimination and harassment in host countries; and structural barriers to accessing and addressing mental health concerns, including clinician availability, language barriers, cultural differences, geographic accessibility, health care access, and stigma. Despite high exposure to and clinical impact of such experiences, and despite representing 1% of the world population, forcibly displaced people are underrepresented in neuroscientific research. The availability of such literature and research findings is significant in understanding the unique genetic and cultural aspects of trauma- and stress-related mental health, advocacy, reducing stigma, informing prevention, and treatment. The present work aimed to explore how the field of neuroscience can address mental health equity for individuals who have been uprooted in relation to land, with a focus on refugee populations. We offer practical suggestions on how to improve research in this area and narrow the gap in knowledge.

Mental disorders and lack of social support among refugees and Ugandan nationals screening for HIV at health centers in Nakivale refugee settlement in southwestern Uganda

Background

Exposure to potentially traumatic events and daily stressors in humanitarian settings puts refugees and asylum seekers (henceforth collectively referred to as refugees) at increased risk for mental disorders. Little is known about how mental disorder prevalence compares between refugees and national populations who live in the same settings and are exposed to many of the same daily challenges. We aimed to compare the proportions of refugees and Ugandan nationals screening positive for mental disorders in a Ugandan refugee settlement to inform targeted health interventions. Given displacement’s disruptive effect on social networks and the importance of social support for mental health, we also aimed to assess social support.

Methods

Refugees and Ugandan nationals voluntarily testing for HIV at health centers in Nakivale Refugee Settlement were screened for post-traumatic stress disorder (PTSD CheckList-6 – Civilian Version [PCL-6]), depression (Patient Health Questionnaire-9 [PHQ-9]), anxiety (General Anxiety Disorder-7 [GAD-7]), and lack of social support (Brief Social Support Scale [BS6]). The association between refugee versus Ugandan national status and the four outcomes was assessed using log-binomial regression.

Results

Screening surveys were completed by 5,513 participants, including 3,622 refugees and 1,891 Ugandan nationals. A positive screen for PTSD, depression, anxiety and lack of social support was found for 2,388 (44%), 1,337 (25%), 1,241 (23%) and 631 (12%) participants, respectively. Refugee status was associated with a higher prevalence of a positive screen for PTSD (prevalence ratio (PR)=1.15; 95% confidence interval (CI)=1.08-1.23), depression (PR=1.22; 95% CI=1.11-1.36), anxiety (PR=1.28; 95% CI=1.14-1.42), and lack of social support (PR=1.50; 95% CI=1.27-1.78). When adjusted for the other outcomes, the higher prevalence of a positive screen for PTSD, anxiety and lack of social support for refugees remained statistically significant.

Conclusions

Elevated symptoms of mental disorders are found among refugees and Ugandan nationals testing for HIV in Nakivale Refugee Settlement. The significant association between refugee status and PTSD, anxiety and lack of social support symptoms highlights the distinct needs of this population. To determine the prevalence of mental disorders in these populations, comprehensive assessment, including psychological and neuropsychological testing, is needed.

Past trauma, resettlement stress, and mental health of older Bhutanese with a refugee life experience

OBJECTIVES

Older displaced persons often receive limited attention from aid organizations, policy-makers and service providers in countries of resettlement. The objective of this study is to identify the relationship between experiencing traumatic events and stressors prior to resettlement, current resettlement stressors, social support, and mental health of older Bhutanese with a refugee life experience.

METHOD

Study participants were 190 older Bhutanese with a refugee life experience living in a metropolitan area in New England (US) and Ontario (Canada). We used structural equation modeling to determine the association between traumatic and stressful events in Bhutan and Nepal, current resettlement stressors, and symptoms of anxiety and depression, as measured by the GAD-7 and PHQ-9. We assessed the role of social support as an effect modifier in the relationship between these variables.

RESULTS

Surviving torture was associated with anxiety (p=.006), and experiencing threats to physical wellbeing in Nepal was associated with both anxiety (p=.003) and depression (p=.002). The relationship between physical threats in Nepal and current mental health were partially mediated by resettlement stressors. Social support moderated the relationship between trauma, stress, and mental health.

CONCLUSION

Both past traumas and current resettlement stressors contribute to the current psychosocial functioning of older Bhutanese with a refugee life experience. Based on our findings, social support is critical in promoting mental health in this population.

Disrupted daily routines mediate the socioeconomic gradient of depression amid public health crises: A repeated cross-sectional study

OBJECTIVE

There is a socioeconomic gradient to depression risks, with more pronounced inequality amid macroenvironmental potential traumatic events. Between mid-2019 and mid-2020, the Hong Kong population experienced drastic societal changes, including the escalating civil unrest and the COVID-19 pandemic. We examined the change of the socioeconomic gradient in depression and the potential intermediary role of daily routine disruptions.

METHOD

We conducted repeated territory-wide telephone surveys in July 2019 and July 2020 with 1112 and 2034 population-representative Cantonese-speaking Hong Kong citizens above 15 years old, respectively. Stratified by year, we examined the association between socioeconomic indicators (education attainment, household income, employment status and marital status) and probable depression (nine-item Patient Health Questionnaire [PHQ-9] ⩾ 10) using logistic regression. Differences in the socioeconomic gradient between 2019 and 2020 were tested. Finally, we performed a path analysis to test for the mediating role of daily routine disruptions.

RESULTS

Logistic regression showed that higher education attainment in 2019 and being married in 2020 were protective against probable depression. Interaction analysis showed that the inverse association of higher education attainment with probable depression attenuated in 2020 but that of being married increased. Path analysis showed that the mediated effects through daily routine disruptions accounted for 95.9% of the socioeconomic gradient of probable depression in 2020, compared with 13.1% in 2019.

CONCLUSION

From July 2019 to July 2020, the mediating role of daily routine disruptions in the socioeconomic gradient of depression in Hong Kong increased. It is thus implied that infection control measures should consider the relevant potential mental health impacts accordingly.

Effect of Reading Activities on Children's Mental Health under the Environment of Artificial Intelligence and Deep Learning

The illustrations in picture books are lovely and emotional; pictures and text work together to express a theme and weave into one another to create a seamless and comprehensive visual image in picture books. Reading helps children improve for life and is an unending source of wealth in one's life. Picture book reading has a positive effect on children's psychological well-being since it allows them to develop different intelligences and their spiritual worlds in addition to reading stories and learning facts. This thesis investigates, against the backdrop of artificial intelligence (AI) and deep learning, the impact of reading activities on children's psychological health. Deep learning and AI are the tools used where students can engage in a more in-depth conversation with the article and comprehend the author's mindset and background after completing the basic reading. This can help students' analytical, thinking, writing, and other application skills, as well as give them the opportunity to learn from and build upon their first reading accumulation. Research has shown that this method produces impressive results, and it is suited for widespread use because its reasonable strength has improved by 17.24% when compared to the conventional method.

Assessing equity of access and affordability of care among South Sudanese refugees and host communities in two districts in Uganda: a cross-sectional survey

Background

The vast majority of refugees are hosted in low and middle income countries (LMICs), which are already struggling to finance and achieve universal health coverage for their own populations. While there is mounting evidence of barriers to health care access facing refugees, there is more limited evidence on equity in access to and affordability of care across refugee and host populations. The objective of this study was to examine equity in terms of health needs, service utilisation, and health care payments both within and between South Sudanese refugees and hosts communities (Ugandan nationals), in two districts of Uganda.

Methods

Participants were recruited from host and refugee villages from Arua and Kiryandongo districts. Twenty host villages and 20 refugee villages were randomly selected from each district, and 30 households were sampled from each village, with a target sample size of 2400 households. The survey measured condition incidence, health care seeking and health care expenditure outcomes related to acute and chronic illness and maternal care. Equity was assessed descriptively in relation to household consumption expenditure quintiles, and using concentration indices and Kakwani indices (for expenditure outcomes). We also measured the incidence of catastrophic health expenditure- payments for healthcare and impoverishment effects of expenditure across wealth quintiles.

Results

There was higher health need for acute and chronic conditions in wealthier groups, while maternal care need was greater among poorer groups for refugees and hosts. Service coverage for acute, chronic and antenatal care was similar among hosts and refugee communities. However, lower levels of delivery care access for hosts remain. Although maternal care services are now largely affordable in Uganda among the studied communities, and service access is generally pro-poor, the costs of acute and chronic care can be substantial and regressive and are largely responsible for catastrophic expenditures, with service access benefiting wealthier groups.

Conclusions

Efforts are needed to enhance access among the poorest for acute and chronic care and reduce associated out-of-pocket payments and their impoverishing effects. Further research examining cost drivers and potential financing arrangements to offset these will be important.

Chronic pain, mental health and functional impairment in adult refugees from Syria resettled in Norway: a cross-sectional study

BACKGROUND

Limited research exists on pain and especially the co-occurrence of pain and mental ill health in general refugee populations. The present study aimed to approximate the prevalence of chronic pain (CP) among adult refugees from Syria resettled in Norway; investigate the association between CP and mental ill health; and explore how CP and mental ill health associate with both perceived general health and functional impairment. Gender as potential effect modifier in these associations was also examined.

METHODS

Cross-sectional, postal survey questionnaire.

INCLUSION CRITERIA

≥ 18 years old; refugee from Syria; and arrived in Norway between 2015 and 2017. Study sample was randomly drawn from full population registries, and n = 902 participated (participation rate ≈10%). CP was measured with 10 items on pain lasting for ≥ 3 consecutive months last year. Symptoms of anxiety, depression and PTSD were measured with the HSCL and HTQ scales, respectively. Ordered and binomial logistic regressions were used in analyses. Gender was tested as effect modifier with Wald test for interaction.

RESULTS

In the sample overall, the proportion of participants who reported severe CP was 43.1%. There was strong evidence that anxiety, depression and PTSD were associated with higher levels of CP. In fully adjusted regression models, including both CP and mental health variables, CP was strongly associated with poor perceived general health whereas mental health showed much weaker associations. The association between mental health (anxiety and PTSD) and functional impairment was highly gender specific, with strong associations in men but not in women. CP was strongly associated with functional impairment with no difference across gender.

CONCLUSION

The study shows a high burden of CP in a general population of adult refugees from Syria with likely substantial adverse consequences for daily functioning. The strong association between CP and mental ill health suggests personnel working with refugees' health should be attuned to their co-occurrence as both problems may need to be addressed for either to be effectively mitigated. A clear mismatch exists between the burden on health caused by pain in general refugee populations and the amount of available evidence to guide mitigating strategies.

TRIAL REGISTRATION

NCT03742128.

Coping resources mediate the prospective associations between disrupted daily routines and persistent psychiatric symptoms: A population-based cohort study

This study examined the mediating effects of coping resources in the prospective associations between daily routine disruptions in the acute phase of COVID-19 and persistent probable anxiety and depression. A prospective, population-representative cohort of 1318 Hong Kong Chinese respondents completed a baseline survey between February and July 2020 (T1) and a 1-year follow-up survey between March and August 2021 (T2). Respondents reported demographics and disruptions to primary and secondary daily routines at T1, coping resources (i.e., self-efficacy and meaning making) at T2, and anxiety and depressive symptoms at T1 and T2. We found that 8.1% and 10.0% of respondents reached cutoff scores for probable anxiety and depression respectively at both T1 and T2. Logistic regression showed that T1 daily routine disruptions were positively associated with heightened risk of persistent probable anxiety and depression amid COVID-19. Path analysis showed that 15.3% and 13.1% of the associations of daily routine disruptions with persistent probable anxiety and depression were explained by coping resources, respectively, while the direct routine-outcome associations remained significant. Daily routine disruptions predict higher odds of persistent probable anxiety and depression directly and partially through reducing coping resources. Sustainment of regular daily routines should be advocated and fostered to enhance coping resources and reduce the risk of poorer adjustment among the affected populations amid public health crises.

Factors Contributing to Violence Against Children: Insights From a Multi-informant Study Among Family-Triads From Three East-African Refugee Camps

Parental violence poses a considerable, yet mitigable risk for the mental health and well-being of refugee children living in resource-poor refugee camps. However, little is known about potential risk factors for parental violence in these settings. Using an ecological systems perspective and a multi-informant approach, we investigated ontogenic (parental childhood experiences of violence), microsystem (parents' and children's psychopathology) and exosystem (families' monthly household income) risk factors for child-directed parental violence in a sample of 226 Burundian families living in refugee camps in Tanzania. Data were collected through individual structured clinical interviews with mothers, fathers, and children. In the child-report path model [χ² (6) = 7.752, p = .257, comparative fit index (CFI) = 0.99, root mean square error of approximation (RMSEA) = 0.036 (p = .562)], children's posttraumatic stress disorder (PTSD) symptoms, externalizing symptoms and paternal PTSD symptoms were positively associated with violence by both parents. Maternal psychosocial impairment was positively associated with child-reported paternal violence. In the parent-report path model [χ² (6) = 7.789, p = .254, CFI = 0.97, RMSEA = 0.036 (p = .535)], children's externalizing problems as well as a lower monthly household income were positively related to maternal violence. Each parent's childhood victimization was positively linked to their use of violence against children. Maternal psychosocial impairment and paternal alcohol abuse were positively associated with paternal violence. Child and paternal psychopathology, maternal psychosocial impairment, parents' childhood victimization, and families' socioeconomic status may be important targets for prevention and intervention approaches aiming to reduce parental violence against refugee children living in camps.

Barriers to male condom use in Rohingya refugee camps in Bangladesh: A qualitative study

Background

Rohingya people are often called the most persecuted minority in the world. Currently, almost 800,000 Rohingya refugees live in temporary shelters in Cox's Bazar, Bangladesh. More than one-quarter of them are women and girls of reproductive age who are at increased risk of unplanned pregnancies, unsafe abortions and related complications. However, the use of contraception remains inadequate, and particularly use of condoms and male participation is scarce. This study examines the barriers to condom use as a contraceptive method among married Rohingya couples.

Methods

We conducted in-depth qualitative interviews of married Rohingya men and women and thematically analysed the data.

Findings

Depo Provera injections and pills are the dominant forms of contraception. Men's participation in family planning and contraceptive use is rare, and so is the use of condoms. Participants identified several barriers to condom use, including contraception being the responsibility of the women, socio-cultural issues, the stigma attached to condoms, unfamiliarity with condoms, the limitations of condoms, and issues of security in conjugal life. Health workers do not promote condoms in the same way as other contraceptive methods.

Interpretation

Condom use and men's participation in contraception use are rare in Rohingya camps. The involvement of family planning workers who are males may help to promote the use of condoms and increase the method-mix options of contraceptives.

Funding

La Trobe University, Melbourne, Australia.

Intimate Partner Abuse Among Rohingya Women and Its Relationship With Their Abilities to Reject Husbands' Advances to Unwanted Sex

Currently, around a million Rohingya refugees live in Cox's Bazar, Bangladesh. Displacement from homelands and restrictions on movement in the refugee camps may exacerbate intimate partner abuse (IPA) against refugee women and their abilities to reject husbands' advances to unwanted sex. This study examines Rohingya refugee women's attitudes toward and experience of intimate partner abuse (IPA) and their impact on the abilities to reject husbands' advances to unwanted sex. A survey was conducted among Rohingya refugee women in Cox's Bazar, Bangladesh. Women's attitudes toward IPA, and experience of IPA were the exposure variables. Women's abilities to say "no" to husbands' advances to unwanted sexual intercourse was the outcome variable. Multivariable logistic regression models were used to examine the relationships. Participants' median age was 22 years (range: 13-41). Most women perceived hitting/beatings by their husbands in certain situations as justifiable, 72% had experienced such abuse and 56.5% had to engage in unwanted sexual intercourse with their husbands. Women with increasing leniency towards hitting/beatings and those who had experienced such abuse were less likely to be able to say "no" to husbands' advances to unwanted sexual intercourse. Rohingya women's attitudes toward and experience of IPA are associated with their abilities to say "no" to husbands' advances to unwanted sex. Intervention is needed to denormalize the current practice of IPA, create awareness against IPA, and ensure formal education for girls.

Health Beliefs and Barriers to Healthcare of Rohingya Refugees

In recent years, over 1,000 Rohingya families have been resettled to Milwaukee, Wisconsin from areas where they faced trauma and health disparities. To better understand their health beliefs and barriers to healthcare, we conducted a qualitative study with ten community health workers and stakeholders serving the Milwaukee Rohingya community. Interviews were transcribed, coded, and analyzed. Themes included: 1) health is defined as being able to meet basic needs of the family/community; 2) prior and existing mistrust and fear of systems of authority impact healthcare seeking behavior; 3) past-trauma negatively impacts physical and mental health; 4) religion and spirituality influence beliefs about illness, recovery, and wellbeing; 5) linguistic, cultural, and educational barriers impact access, quality of care, and understanding of disease. These results begin to address the significant gap in our knowledge of the health beliefs and needs of the local Rohingya community and underscore the need for tailored interventions.

Long-term effectiveness of Self-Help Plus in refugees and asylum seekers resettled in Western Europe: 12-month outcomes of a randomised controlled trial

AIMS

As refugees and asylum seekers are at high risk of developing mental disorders, we assessed the effectiveness of Self-Help Plus (SH + ), a psychological intervention developed by the World Health Organization, in reducing the risk of developing any mental disorders at 12-month follow-up in refugees and asylum seekers resettled in Western Europe.

METHODS

Refugees and asylum seekers with psychological distress (General Health Questionnaire-12 ⩾ 3) but without a mental disorder according to the Mini International Neuropsychiatric Interview (M.I.N.I.) were randomised to either SH + or enhanced treatment as usual (ETAU). The frequency of mental disorders at 12 months was measured with the M.I.N.I., while secondary outcomes included self-identified problems, psychological symptoms and other outcomes.

RESULTS

Of 459 participants randomly assigned to SH + or ETAU, 246 accepted to be interviewed at 12 months. No difference in the frequency of any mental disorders was found (relative risk [RR] = 0.841; 95% confidence interval [CI] 0.389-1.819; p-value = 0.659). In the per protocol (PP) population, that is in participants attending at least three group-based sessions, SH + almost halved the frequency of mental disorders at 12 months compared to ETAU, however so few participants and events contributed to this analysis that it yielded a non-significant result (RR = 0.528; 95% CI 0.180-1.544; p-value = 0.230). SH + was associated with improvements at 12 months in psychological distress (p-value = 0.004), depressive symptoms (p-value = 0.011) and wellbeing (p-value = 0.001).

CONCLUSIONS

The present study failed to show any long-term preventative effect of SH + in refugees and asylum seekers resettled in Western European countries. Analysis of the PP population and of secondary outcomes provided signals of a potential effect of SH + in the long-term, which would suggest the value of exploring the effects of booster sessions and strategies to increase SH + adherence.

‘We are inferior, we have no rights’: Statelessness and mental health among ethnic minorities in Northern Thailand

Research has shown that asylum seekers, refugees, and internally displaced persons, including stateless persons, are at increased risk of poor mental health. Yet, only a few studies explicitly focus on stateless persons. This article examines the association between legal status and mental health among Akha, Lahu and Tai-Yai people in Northern Thailand. A convergent parallel mixed-methods design was adopted and primary data were collected in June 2020 by face-to-face, semi-structured interviews with persons who do not hold a nationality (n = 108). A distinction was made between registered (nationalityless) and unregistered (stateless) persons since only the former have a legal status in Thailand. The correlates of mental health were analyzed using descriptive statistics and logistic regression. Qualitative thematic analysis was employed to gain deeper insights into the relationship between legal status, ethnicity and mental health. The quantitative results weakly suggest that stateless persons are more likely to have poorer mental health than nationalityless persons, who are recognized as habitually resident in Thailand and are recorded in the country's civil registry. The qualitative results, however, show that the legal status afforded to nationalityless persons is considered important as it gives rise to hope and increases livelihood opportunities. Yet, respondents also pointed out that it is not comparable to citizenship. The odds of having poorer mental health are significantly higher for Lahu and Tai-Yai respondents. The importance of ethnicity is confirmed by the qualitative results. These further indicate that citizenship problems and ethnicity are deeply interrelated. Stigma, discrimination, and lack of social support are key risk factors identified by respondents. Disaggregating data to better understand the heterogeneity of persons without nationality could play a key role in accelerating efforts to resolve protracted citizenship problems and close ethnic gaps.

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Legal recognition and ethnicity affect the mental health of persons without nationality.

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Stigma, discrimination, and lack of social support are key risk factors.

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Disaggregated data are essential for identifying and addressing existing gaps.

Gendered Citizenship, Inequality, and Well-Being: The Experience of Cross-National Families in Qatar during the Gulf Cooperation Council Crisis (2017-2021)

This study explores the impact of gendered citizenship on the well-being of cross-national families following the political blockade imposed on Qatar in 2017. More specifically, it examines how these families, women, and children face challenges related to their lives, well-being, and rights. Twenty-three face-to-face interviews were conducted with Qatari and non-Qatari women and men married to non-Qatari spouses residing in Qatar. The study's findings revealed that Qatari women with non-Qatari husbands did not enjoy the benefits of full citizenship, further undermining their psychological well-being and their socioeconomic and legal rights. Additionally, children born before or during the blockade have become stateless and undocumented, which jeopardizes their mental and physical well-being and the prospects of their parents' economic advancement. This study contributes to the conceptualization of and debate on gender citizenship rules and policies, which can exclude these women and children and deny them the recognition and rights they deserve. Since ensuring full citizenship rights is crucial for people's well-being, increasing gender equality and reforming Qatar's existing citizenship policies would benefit both groups and provide social justice for all.

Refugee and Asylum Seeker Women's Experiences with Healthcare and Social Environment in Malaysia

The internal conflict in Rakhine State, Myanmar over the last few decades has forced Rohingyas to flee to other countries, including Malaysia. However, the non-recognition of the status of refugees in Malaysia keeps Rohingyas as "people without documents" and without adequate protection, access to healthcare services, education, and employment. Women among these groups face different challenges and are at risk of numerous physical and mental health issues. Thus, this research attempted to understand the experiences of Rohingya women in Malaysia, particularly in accessing public hospitals. Focus group discussions and key-informant interview techniques were used to collect data. The transcripts were then analysed using the thematic analysis method. The research found that Rohingya women experience numerous challenges despite being on safer ground in Malaysia. Their experiences of marriage and domestic violence, access to public hospitals, financial barriers to healthcare services, and the services provided by medical social workers in the country to refugees and asylum seekers are presented. Non-recognition of the status of refugees in the country is one of the primary barriers to the allocation and provision of resources for refugees and asylum seekers. Due to structural barriers, medical social workers are unable to provide their services to this population. This article provides recommendations for social workers in Malaysia on how to overcome these challenges and work more effectively with refugees and asylum seekers.

Translating, contextually adapting, and pilot testing of psychosocial and mental health assessment instruments for Congolese refugees in Rwanda and Uganda

Background

Forcibly displaced people are at elevated risk of experiencing circumstances that can adversely impact on mental health. Culturally and contextually relevant tools to assess their mental health and psychosocial needs are essential to inform the development of appropriate interventions and investigate the effectiveness of such interventions.

Methods

We conducted two related studies: (1) to translate and contextually adapt the Patient Health Questionnaire (PHQ-9), a measure of depressive symptomatology, along with assessment instruments measuring levels of daily stress (Checklist for Daily & Environmental Stressors; CDES), social capital (Shortened and Adapted Social Capital Assessment Tool; SASCAT) and perceived social support (Multidimensional Scale of Perceived Social Support; MSPSS) for use with Congolese refugees; (2) to conduct pilot testing of the assessment instruments (including cognitive interviewing about participants’ views of completing them) and a validation of the adapted PHQ-9 using a ‘known group’ approach by recruiting Congolese refugees from refugee settings in Rwanda (n = 100) and Uganda (n = 100).

Results

Study 1 resulted in the translation and adaptation of the assessment instruments. No substantive adaptations were made to the SASCAT or MSPSS, while notable linguistic and contextual adaptations were made in both sites to the CDES and the PHQ-9. The cognitive interviewing conducted in Study 2 indicated that the adapted assessment instruments were generally well received by members of the refugee communities. Participants recruited on the basis that local informants adjudged them to have high levels of depressive symptoms had significantly higher PHQ-9 scores (M = 11.02; SD = 5.84) compared to those in the group adjudged to have low levels of depressive symptoms (M = 5.66; SD = 5.04). In both sites, the adapted versions of the PHQ-9 demonstrated concurrent validity via significant positive correlations with levels of daily stressors. Each of the four adapted assessment instruments demonstrated at least adequate levels of internal consistency in both sites.

Conclusions

The adapted versions of the PHQ-9, CDES, SASCAT and MSPSS are appropriate for use amongst Congolese refugees in Rwanda and Uganda. We recommend further application of the approaches used in the current studies for contextually adapting other assessment instruments in humanitarian settings.

Climate Risks and Truncated Opportunities: How Do Environmental Challenges Intersect with Economic and Social Disadvantages for Rohingya Adolescents in Bangladesh?

Integration of environmental, economic, and social approaches to development is crucial to achieve the United Nations Sustainable Development Goals. Global evidence reflects that this integration is often imbalanced, with development policies and programs in many low- and middle-income countries placing greater emphasis on economic needs than environmental vulnerabilities. Drawing on qualitative research undertaken in mid-2021, this article explores how limited integration of environmental, economic, and social aspects has affected the development of Rohingya refugee adolescents who were forcibly displaced from Myanmar to the Cox’s Bazar district of Bangladesh. Cox’s Bazar is one of the most climate-vulnerable areas in Bangladesh and is subject to extreme rainfall, landslides, and flash floods. The article highlights the ways in which Rohingya adolescents are highly vulnerable to both the direct and indirect consequences of these environmental conditions due to poverty, and inadequate housing infrastructure and water, sanitation, and hygiene facilities. It discusses the ways in which these environmental challenges intersect with socioeconomic disadvantage, especially limited education, skills development, and livelihood opportunities for young people, which are in turn compounded by limited voice and agency, and a dearth of security and protection measures. For some Rohingya adolescent girls and boys, the findings suggests that these multi-dimensional vulnerabilities place them at risk of exploitation by traffickers, smugglers, extremist groups, and criminals. The article concludes by highlighting the importance of explicitly integrating environmental aspects into policy and programs that support Rohingya adolescents to develop their full capabilities, and encouraging their meaningful participation in policy dialogues and accountability processes.

Effectiveness of a WHO self-help psychological intervention for preventing mental disorders among Syrian refugees in Turkey: a randomized controlled trial

Refugees are at high risk of developing mental disorders. There is no evidence from randomized controlled trials (RCTs) that psychological interventions can prevent the onset of mental disorders in this group. We assessed the effectiveness of a self-help psychological intervention developed by the World Health Organization, called Self-Help Plus, in preventing the development of mental disorders among Syrian refugees experiencing psychological distress in Turkey. A two-arm, assessor-masked RCT was conducted in two Turkish areas. Eligible participants were adult Syrian refugees experiencing psychological distress (General Health Questionnaire ≥3), but without a diagnosis of mental disorder. They were randomly assigned either to the Self-Help Plus arm (consisting of Self-Help Plus combined with Enhanced Care as Usual, ECAU) or to ECAU only in a 1:1 ratio. Self-Help Plus was delivered in a group format by two facilitators over five sessions. The primary outcome measure was the presence of any mental disorder assessed by the Mini International Neuropsychiatric Interview at six-month follow-up. Secondary outcome measures were the presence of mental disorders at post-intervention, and psychological distress, symptoms of post-traumatic stress disorder and depression, personally identified psychological outcomes, functional impairment, subjective well-being, and quality of life at post-intervention and six-month follow-up. Between October 1, 2018 and November 30, 2019, 1,186 refugees were assessed for inclusion. Five hundred forty-four people were ineligible, and 642 participants were enrolled and randomly assigned to either Self-Help Plus (N=322) or ECAU (N=320). Self-Help Plus participants were significantly less likely to have any mental disorders at six-month follow-up compared to the ECAU group (21.69% vs. 40.73%; Cramer's V = 0.205, p<0.001, risk ratio: 0.533, 95% CI: 0.408-0.696). Analysis of secondary outcomes suggested that Self-Help Plus was not effective immediately post-intervention, but was associated with beneficial effects at six-month follow-up in terms of symptoms of depression, personally identified psychological outcomes, and quality of life. This is the first prevention RCT ever conducted among refugees experiencing psychological distress but without a mental disorder. Self-Help Plus was found to be an effective strategy for preventing the onset of mental disorders. Based on these findings, this low-intensity self-help psychological intervention could be scaled up as a public health strategy to prevent mental disorders in refugee populations exposed to ongoing adversities.

Course and predictors of posttraumatic stress and depression longitudinal symptom profiles in refugees: A latent transition model

Exposure to potentially traumatic events and post-migration living difficulties (PMLDs) may explain the high rates of posttraumatic stress disorder (PTSD) and depression in resettled refugees. Latent class analyses (LCAs) in refugees have identified subgroups that differ in symptom profiles of PTSD and comorbid symptoms. However, knowledge on longitudinal symptom profiles in refugees is sparse. Examining longitudinal PTSD and depression symptom profiles could provide information on risk factors underlying worsening of symptoms post-resettlement. Self-rated PTSD (Posttraumatic Diagnostic Scale) and depression (Patient Health Questionnaire-9) symptoms were assessed among 613 refugees who had resettled in Australia up to two years previously (W1) and at 6 months follow-up (W2). PTSD and depression symptom profiles were identified using LCAs for W1 and W2 separately. Latent transition analysis was used to examine (predictors of) changes in symptom profiles, including gender, age, trauma exposure, and PMLDs. Four classes were identified that were consistent across timepoints: a No symptoms (W1 61%; W2 68%), Low PTSD/Moderate depression (W1 16%; W2 10%), Moderate PTSD/depression (W1 16%; W2 14%), and High symptoms class (W1 7%; W2 7%). Higher levels of problems with PMLDs, including being discrimination and family separation, predicted movements out of the No symptom class at W1 to classes with psychopathology at W2. To conclude, most participants did not develop PTSD or depression symptoms. The risk of developing these symptoms seems higher when problems with interpersonal PMLDs increased, pointing to the need for considering these stressors when addressing the mental health needs in this population.

The 'good life', personal appearance, and mental health of Congolese refugees in Rwanda and Uganda

RATIONALE

Research into mental health and wellbeing recognises the role of positive mental health to enable people to lead healthy and emotionally fulfilling lives. Mental health difficulties continue to be associated with high levels of disability worldwide, and refugees fleeing conflict are known to suffer from poor mental health for years after their forced migration.

METHOD

Informed by Sen's Capability Approach and as part of a wider research project, we used semi-structured interviews to engage with 60 men and women in two refugee communities in Uganda and Rwanda to explore their aspirations and what a 'good life' meant to them.

FINDINGS

While aspects of what constituted a good life were gendered, both men and women struggled to achieve their aspirations within their communities. Following the basic needs of food and shelter, the complex needs of being dressed well and being clean were consistently associated with be able to achieve a 'good life' by women and men across age groups. Looking good and being clean were highly valued and associated with gaining the respect of others, achieving good relationships with neighbours, and avoiding conflict. Participants identified personal appearance and related social status as critical precursors to their successful engagement with other gendered dimensions of social and economic life in their communities, such as finding employment and being well regarded in their religious communities.

CONCLUSIONS

Our findings suggest that without the means to present a good appearance, people living in refugee communities may experience feelings of shame and isolation and are unable to gain self-respect and the respect of others needed to achieve the positive mental and physical health they associate with leading 'a good life'.

The mental health impact of multiple deprivations under protracted conflict: A multi-level study in the occupied Palestinian territory

Building on the literatures examining the impacts of deprivation and war and conflict on mental health, in this study, we investigate the impact of different forms of deprivation on mental health within a context of prolonged conflict in the occupied Palestinian territory(oPt). We expand the operationalization go deprivation while accounting for more acute exposures to conflict and political violence and spatial variations. We use multilevel modelling of data from the Socio-Economic & Food Security Survey 2014 conducted by the Palestinian Central Bureau of Statistics, which included a sample size of 7827 households in the West Bank(WB) and Gaza Strip(GS). We conduct the analysis for the combined sample, as for the WB and GS separately. We use a General Health Questionnaire-12 (GHQ12) score as our main outcome measure of poor health. We used various measures of deprivation including subjective deprivation, material deprivation, food deprivation, and political deprivation. In addition to the different measures of deprivation, we included acute political, health, and economic shocks in our analysis along with background socio-demographic characteristics. The results indicate significant variance at the locality level. We find a significant association between poor mental health and subjective, economic, political, and food deprivation; health, economic, and political stressors; age, and being a woman. Post-secondary education and wealth have a significant inverse association with poor mental health. Subjective deprivation is the strongest predictor of GHQ12 score in the models whereby people who feel very deprived have GHQ12 scores that are almost 4-points higher than people who do not feel deprived. Economic conditions, particularly subjective measures, are significant predictors of mental health status. Our findings confirm that political and social factors are determinants of health. Feeling deprived is an important determinant of mental health. The community effect suggests that spatial characteristics are influencing mental health, and warrant further investigation.

The Rohingya refugees: a conceptual framework of their psychosocial adversities, cultural idioms of distress and social suffering

Rohingya refugees, a group of religious and ethnic minorities, primarily reside in the South Asian nations. With decades of displacement, forced migration, limited freedom of movement, violence and oppression, they have been termed by the United Nations (UN) as the 'most persecuted minority group' in world history. Literature shows an increased prevalence of psychiatric disorders such as depression, anxiety, post-traumatic stress, insomnia, etc., in this population. However, beyond 'medicalisation', the psychosocial challenges of the Rohingyas need to be understood through the lens of 'social suffering', which results from a complex interplay of multiple social, political, environmental and geographical factors. Lack of essential living amenities, poverty, unemployment, overcrowding, compromised social identity, and persistent traumatic stressors lead to inequality, restricted healthcare access, human rights deprivation and social injustice in this group. Even though the United Nations High Commission for Refugees (UNHCR) has taken a renewed interest in Rohingya re-establishment with well-researched standards of care, there are several pragmatic challenges in their implementation and inclusion in policies. This paper reviews these multi-dimensional psychosocial challenges of the Rohingyas by synthesising various intersecting conceptual models including minority stress, health-stigma-discrimination framework, refugee ecological model and capability approach. Furthermore, it highlights multidisciplinary interventions to mitigate these adversities, improve their living situation and eventually foster healing via means which are culturally relevant and contextually appropriate. These interventions need to involve various stakeholders from a human rights and dignity based lens, including the voices of the Rohingyas and supported by more research in this area.

Balanced time perspective as a facilitator of immigrants' psychological adaptation: A study among Ukrainian immigrants in Poland

The perception of time plays a fundamental role in the organisation of basic psychological processes, and as such may also influence migrants' psychological wellbeing. This paper investigates the relationship between the perception of time and immigrants' psychological adaptation (i.e., affective aspects of migration) based on a sample of 238 Ukrainians residing in Poland. To assess time perception, we drew primarily from time perspective theory, which defines time perspective as a measure of the degree to which individuals non-consciously construe the past, the present, and the future. Psychological adaptation was assessed, focusing on participants' basic psychological needs satisfaction, their satisfaction with life, and their psychological condition. We observed a relatively strong negative relationship between negative past and fatalistic present time perspectives and psychological adaptation. Additionally, we found that a more balanced and less negative temporal profile was related to significantly better psychological adaptation of immigrants. We discuss these results in light of the cultural validity of time perspective theory, the destructive impact of negative time perspective on migrants' psychological wellbeing, and the potential applications of time perspective-based therapy in integration interventions for immigrants.

Recognizing and Breaking the Cycle of Trauma and Violence Among Resettled Refugees

Purpose of Review

The number of refugees across the globe continues to grow, leaving a large proportion of the global population in a vulnerable state of health. However, the number of robust clinical interventions has not kept apace. This paper provides a general review of literature on the trauma and violence that refugees face, the impact on health outcomes, and some of the promising models for clinical intervention.

Recent Findings

Refugees experience a cycle of trauma, violence, and distress that begins before migration and continues during migration and after resettlement. It has been challenging to develop robust clinical interventions due to the cumulative and cyclic effects of trauma, as well as the unique experiences of trauma that each refugee community and each refugee individual faces.

Summary

Trauma-informed care is a critical component of health care. Developing stronger guidelines for trauma-informed care will help clinicians better provide inclusive and equitable care for refugee patients.

Statelessness, forced migration and the security dilemma along borders: an investigation of the foreign policy stance of Bangladesh on the Rohingya influx

Statelessness not only triggers crises within the boundaries of a state, but these crises often spread along borders. The Rohingya refugee crisis, resulting from systematic state atrocities towards a stateless community, has resulted in a massive wave of forced migration to neighbouring Bangladesh. Subsequently, the large number of refugees is exerting enormous pressure on the economy of this developing nation. The crisis can be understood from the perspectives of both human concerns and Bangladesh’s traditional security concerns. Furthermore, the COVID-19 pandemic is bringing additional challenges. This study investigates and examines the nature of the dilemma faced by the Bangladesh government in its foreign policy strategy over the Rohingya refugee crisis. It is argued that Bangladesh is facing dual challenges from the national and human security perspectives, and that the regional interests of major players, such as India, China, Russia and Japan, are determining the country’s policy stance. It is also argued that the plight of the Rohingya people through their statelessness has become less decisive in the major powers’ diplomatic calculations. The findings suggest that Bangladesh should accentuate its efforts to internationalise the issue and engage in a vigilant balancing between the major players for the repatriation of refugees, while, at the same time, exerting bilateral pressure on Myanmar.