Integrating mental health into primary health care in Rohingya refugee settings in Bangladesh: experiences of UNHCR

Challenges in substance use treatment as perceived by professionals and Arabic-speaking refugees in Germany

BACKGROUND

Substance use (SU) and substance use disorders (SUDs) have been recently documented among forcibly displaced populations as a coping mechanism to migration and postmigration stressors. Although the literature exploring substance use among refugees has grown recently, little is known about SU among Arabic-speaking refugees and, more specifically, on the challenges and experiences in regards to SU treatment. This study investigates this topic from the perspectives of Arabic-speaking refugees and professionals in Germany.

METHODS

Design and participants To expand our knowledge on this topic, a qualitative approach was employed by conducting in-depth and semi-structured interviews among 26 participants (13 refugees and 13 professionals) in Germany during 2020-2021. Purposive sampling was used to recruit Arabic-speaking refugees in two rehabilitation centers in Berlin. Data and analysis Interviews were conducted with 26 participants of which 13 were refugees and 13 professionals. Refugees were interviewed individually in the rehabilitation centers, they ranged from 21 to 52 years of age, and their average time in Germany was 6.3 years. An open-ended survey was conducted among the professionals via the SoSci-survey platform, and they ranged from 22 to 66 years of age, with an average of 5 to 9 years of work experience. Data were analyzed using thematic analysis.

RESULTS

Three themes resulted from the thematic analysis: (1) The treatment is facilitated by institutional and emotional support; (2) The affected refugees struggle with complex contextual barriers to access SUD treatment; and (3) Individual and community preventive strategies are needed.

CONCLUSIONS

This study provides insight into the support and challenges of accessing effective SU treatment and prevention among Arabic-speaking refugees in Germany. Collaborative efforts by the community, professionals, and policymakers are needed to facilitate access to effective treatment and implement culturally and linguistically sensitive approaches for the treatment and prevention of SU among refugees.

Health disparities among Burmese diaspora: an integrative review

Tens of thousands of displaced Burmese ethnic minorities have endured various adversities for over six decades but are largely underserved. This study aimed to illuminate the health impacts of their misfortunes and unmet areas of concern. Using a holistic lens, we conducted an integrative review of 47 papers spanning the years 2004 to 2022 from diverse data sources. The results revealed widespread multimorbidity, triggered mainly by displacement. The diaspora's problematic health conditions were worse than their host country's general population. There was a strong indication that the diaspora's unfortunate health trajectory is determined early in life. Ongoing human rights violations and grossly inadequate health care interventions deepened pre-existing health conditions. Noteworthy emerging treatment initiatives, including integrative health care, were underutilized. The persisting health and intervention needs among the diaspora warrant advanced studies to facilitate much-needed resource mobilization and collaboration among stakeholders to promote health equity.

Funding

There was no financial support for this manuscript.

Ten years of tracking mental health in refugee primary health care settings: an updated analysis of data from UNHCR's Health Information System (2009-2018)

BACKGROUND

This study examines mental, neurological, and substance use (MNS) service usage within refugee camp primary health care facilities in low- and middle-income countries (LMICs) by analyzing surveillance data from the United Nations High Commissioner for Refugees Health Information System (HIS). Such information is crucial for efforts to strengthen MNS services in primary health care settings for refugees in LMICs.

METHODS

Data on 744,036 MNS visits were collected from 175 refugee camps across 24 countries between 2009 and 2018. The HIS documented primary health care visits for seven MNS categories: epilepsy/seizures, alcohol/substance use disorders, mental retardation/intellectual disability, psychotic disorders, severe emotional disorders, medically unexplained somatic complaints, and other psychological complaints. Combined data were stratified by 2-year period, country, sex, and age group. These data were then integrated with camp population data to generate MNS service utilization rates, calculated as MNS visits per 1000 persons per month.

RESULTS

MNS service utilization rates remained broadly consistent throughout the 10-year period, with rates across all camps hovering around 2-3 visits per 1000 persons per month. The largest proportion of MNS visits were attributable to epilepsy/seizures (44.4%) and psychotic disorders (21.8%). There were wide variations in MNS service utilization rates and few consistent patterns over time at the country level. Across the 10 years, females had higher MNS service utilization rates than males, and rates were lower among children under five compared to those five and older.

CONCLUSIONS

Despite increased efforts to integrate MNS services into refugee primary health care settings over the past 10 years, there does not appear to be an increase in overall service utilization rates for MNS disorders within these settings. Healthcare service utilization rates are particularly low for common mental disorders such as depression, anxiety, post-traumatic stress disorder, and substance use. This may be related to different health-seeking behaviors for these disorders and because psychological services are often offered outside of formal health settings and consequently do not report to the HIS. Sustained and equitable investment to improve identification and holistic management of MNS disorders in refugee settings should remain a priority.

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.

Priorities for addressing substance use disorder in humanitarian settings

Background

Populations affected by humanitarian emergencies are vulnerable to substance (alcohol and other drug) use disorders, yet treatment and prevention services are scarce. Delivering substance use disorder treatment services in humanitarian settings is hampered by limited guidance around the preparation, implementation, and evaluation of substance use disorder treatment programs. This study aims to identify and prioritize key gaps and opportunities for addressing substance use disorder in humanitarian settings.

Methods

UNODC convened a consultation meeting (n = 110) in coordination with UNHCR and WHO and administered an online survey (n = 34) to, thirteen program administrators and policymakers, eleven service providers, nine researchers, and one person with lived experience to explore best practices and challenges to addressing substance use disorder in diverse populations and contexts. Participants presented best practices for addressing substance use disorder, identified and ranked challenges and opportunities for improving the delivery of substance use disorder treatment interventions, and provided recommendations for guidelines that would facilitate the delivery of substance use disorder treatment services in humanitarian emergencies.

Results

Participants agreed on key principles for delivering substance use disorder treatment in humanitarian settings that centered on community engagement and building trust, integrated service delivery models, reducing stigma, considering culture and context in service delivery, and an ethical ‘do no harm’ approach. Specific gaps in knowledge that precluded the delivery of appropriate substance use disorder treatment include limited knowledge of the burden and patterns of substance use in humanitarian settings, the effectiveness of substance use disorder treatment services in humanitarian settings, and strategies for adapting and implementing interventions for a given population and humanitarian context. Participants emphasized the need to strengthen awareness and commitment related to the burden of substance use disorder treatment interventions among communities, practitioners, and policymakers in humanitarian settings.

Conclusions

Results from this consultation process highlight existing gaps in knowledge related to the epidemiology and treatment of substance use disorders in humanitarian emergencies. Epidemiological, intervention, and implementation research as well as operational guidance are needed to fill these gaps and improve access to substance use treatment services in humanitarian settings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13031-021-00407-z.

Epilepsy and psychogenic non-epileptic seizures in forcibly displaced people: A scoping review

With a growing number of forcibly displaced people (FDP) globally, the focus on their medical needs has necessarily increased. Studies about the prevalence and incidence of epilepsy and psychogenic non-epileptic seizures (PNES) in this population are, though, sparse. This Review highlights the importance of exploring and managing both conditions in these vulnerable people to promote global health. We performed an exhaustive review of 10 databases, as well as a manual search of relevant websites related to global health and refugee-related organizations. We analyzed data related to the prevalence and incidence of epilepsy and PNES; health visits; costs of medical care and challenges faced by healthcare workers in relation to FDP with these conditions. Fifty six papers met our inclusion criteria. Of these, 53 reported directly or indirectly on the prevalence of epilepsy and its costs in FDP. Two articles reported on the prevalence of PNES in forcibly displaced people. The reported prevalence of epilepsy in FDP varied from 0.2% to 39.13%, being highest in people with pre-existing neurological or psychiatric comorbidities. Only one study reported on the incidence of epilepsy in internally displaced children. Data from the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) have identified a tendency to higher incidence of epilepsy in children following wars. While within displaced women without a history of sexual violence the rate of PNES was 16.7%, in FDP women with such a history the rate of PNES was 43.7% (p=0.02). The healthcare costs for epilepsy can be high, with recurrent health visits related to seizures being the most common cause of health encounters in refugee camps. Increasing awareness and further studies of multicultural aspects to improve shared understanding of seizure phenomenon in vulnerable displaced populations would seem crucial.

A Naturalistic Evaluation of Group Integrative Adapt Therapy (IAT-G) with Rohingya Refugees During the Emergency Phase of a Mass Humanitarian Crisis in Cox's Bazar, Bangladesh

Background: Studies of scalable psychological interventions in humanitarian setting are usually carried out when the acute emergency has stabilized. We report the first evaluation of an evidence-based group psychological intervention, Group Integrative Adapt Therapy (IAT-G), during the emergency phase of a mass humanitarian crisis amongst Rohingya refugees in Cox's Bazar, Bangladesh. Methods: We did a pragmatic naturalistic evaluation (2018-2020) of a seven-session group intervention with adult Rohingya refugees with elevated symptoms of depression (≥10 on the Patient Health Questionnaire) and/or posttraumatic stress disorder, PTSD, (≥3 on the Posttraumatic Stress Disorder-8), and functional impairment (≥17 on WHO Disability Assessment Schedule or WHODAS-brief). Screening was done across the most densely populated campsites. Blind assessments were completed at baseline, posttreatment, and at 3-month follow-up using culturally adapted measures of depression, anxiety, posttraumatic stress symptoms, complicated bereavement, adaptive stress associated with disrupted psychosocial support systems, functional impairment, and resilience. Findings: 383 persons were screened and of the 144 persons who met inclusion criteria all participated in the group intervention. Compared to baseline scores, IAT-G participants recorded significantly lower mean scores on key outcome indices (mental health symptoms, adaptive stress, and functional impairment) at posttreatment and 3-month follow-up (all pairwise tests significant Ps<.05). From baseline to 3-month follow-up, score changes were greatest for functional impairment (d = 2.24), anxiety (d = 2.15) and depression (d = 1.9), followed by PTSD symptoms (d = 1.17). Interpretation: A group-based intervention designed specifically to reflect the refugee experience and adapted to the language and culture, showed positive outcomes in the context of a pragmatic, naturalistic trial implemented in a mass humanitarian emergency. Funding: United Nations High Commissioner for Refugees; National Health and Medical Research Council Australia.

Predisplacement Abuse and Postdisplacement Factors Associated With Mental Health Symptoms After Forced Migration Among Rohingya Refugees in Bangladesh

IMPORTANCE

At the end of August 2017, violence and persecution in Myanmar's Rakhine state forced nearly 1 million Rohingyas to flee to Bangladesh for their lives and seek shelter. Many refugees, after their traumatic experiences leaving Myanmar, experience mental health problems.

OBJECTIVES

To identify the prevalence of posttraumatic stress symptoms (PTSSs) among displaced Rohingya adults and investigate the association of predisplacement abuse and postdisplacement factors with PTSSs.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional analysis from a household survey of 1184 Rohingya adults aged 18 years or older was conducted in 8 refugee camps within Cox's Bazar, Bangladesh, from September 17, 2019, to January 11, 2020.

MAIN OUTCOMES AND MEASURES

The Impact of Event Scale-Revised was used to assess PTSSs. The possible range of scores was 0 to 88; moderate PTSSs were classified using a score cutoff of 33 to 38 and severe PTSSs were classified using a score cutoff of 39 and above. Adjusted prevalence ratios (aPRs) were estimated using a multivariable logistic regression model adjusted for potential confounders.

RESULTS

Of 1184 participants (625 men [52.8%]; mean [SD] age, 35.1 [13.4] years), 552 (46.6%) had severe PTSSs, and 274 (23.1%) had moderate PTSSs. In Bangladesh, refugees are not legally permitted to work in refugees camps, but 276 of 1165 respondents (23.7%) had temporary paid jobs. Moreover, 113 of the 276 working participants (40.9%) and 430 of the 889 nonworking participants (48.4%) reported severe PTSSs. A total of 496 respondents (41.9%) reported inadequate humanitarian aid for their families, and among them, 281 (56.7%) reported severe PTSSs. A total of 136 of 1177 respondents (11.6%) experienced both physical and sexual abuse in Myanmar, and 87 (64.0%) of them had severe PTSSs. The multivariable analysis showed a reduced risk of PTSSs with appropriate humanitarian assistance (aPR, 0.50; CI, 0.38-0.65). Experiencing both physical and sexual abuse before displacement had a significant association with PTSSs (aPR, 2.09; CI, 1.41-3.07). Opportunities for paid employment in refugee camps also reduced the risks of PTSSs (aPR, 0.69; CI, 0.52-0.91).

CONCLUSIONS AND RELEVANCE

The high prevalence of self-reported severe PTSSs in Rohingya refugees suggests that the trauma of displacement and the violent consequences of military crackdowns still exist. In the Rohingya camp settings of Bangladesh, employment opportunity and sufficient humanitarian aid hold promise as potential interventions to reduce the high prevalence of severe PTSSs. Mental health symptoms were more prevalent in adults who experienced physical abuse or physical and sexual abuse before displacement.

What do we mean by individual capacity strengthening for primary health care in low- and middle-income countries? A systematic scoping review to improve conceptual clarity

BACKGROUND

Capacity strengthening of primary health care workers is widely used as a means to strengthen health service delivery, particularly in low- and middle-income countries. Despite the widespread recognition of the importance of capacity strengthening to improve access to quality health care, how the term 'capacity strengthening' is both used and measured varies substantially across the literature. This scoping review sought to identify the most common domains of individual capacity strengthening, as well as their most common forms of measurement, to generate a better understanding of what is meant by the term 'capacity strengthening' for primary health care workers.

METHODS

Six electronic databases were searched for studies published between January 2000 and October 2020. A total of 4474 articles were screened at title and abstract phase and 323 full-text articles were reviewed. 55 articles were ultimately identified for inclusion, covering various geographic settings and health topics.

RESULTS

Capacity strengthening is predominantly conceptualised in relation to knowledge and skills, as either sole domains of capacity, or used in combination with other domains including self-efficacy, practices, ability, and competencies. Capacity strengthening is primarily measured using pre- and post-tests, practical evaluations, and observation. These occur along study-specific indicators, though some pre-existing, validated tools are also used.

CONCLUSION

The concept of capacity strengthening for primary health care workers reflected across a number of relevant frameworks and theories differs from what is commonly seen in practice. A framework of individual capacity strengthening across intra-personal, inter-personal, and technical domains is proposed, as an initial step towards building a common consensus of individual capacity strengthening for future work.

Educational and Training Interventions Aimed at Healthcare Workers in the Detection and Management of People With Mental Health Conditions in South and South-East Asia: A Systematic Review

Background: To bridge significant mental health treatment gaps, it is essential that the healthcare workforce is able to detect and manage mental health conditions. We aim to synthesise evidence of effective educational and training interventions aimed at healthcare workers to increase their ability to detect and manage mental health conditions in South and South-East Asia. Methods: Systematic review of six electronic academic databases from January 2000 to August 2020 was performed. All primary research studies were eligible if conducted among healthcare workers in South and South-East Asia and reported education and training interventions to improve detection and management of mental health conditions. Quality of studies were assessed using Modified Cochrane Collaboration, ROBINS-I, and Mixed Methods Appraisal Tools and data synthesised by narrative synthesis. Results are reported according to Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. A review protocol was registered with the PROSPERO database (CRD42020203955). Findings: We included 48 of 3,654 screened articles. Thirty-six reported improvements in knowledge and skills in the detection and management of mental health conditions. Training was predominantly delivered to community and primary care health workers to identify and manage common mental health disorders. Commonly used training included the World Health Organization's mhGAP guidelines (n = 9) and Cognitive Behavioural Therapy (n = 8) and were successfully tailored and delivered to healthcare workers. Digitally delivered training was found to be acceptable and effective. Only one study analysed cost effectiveness. Few targeted severe mental illnesses and upskilling mental health specialists or offered long-term follow-up or supervision. We found 21 studies were appraised as low/moderate and 19 as high/critical risk of bias. Interpretation: In low resource country settings, upskilling and capacity building of primary care and community healthcare workers can lead to better detection and management of people with mental health disorders and help reduce the treatment gap. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/, identifier CRD42020203955.

Psychosocial mechanisms of change in symptoms of Persistent Complex Bereavement Disorder amongst refugees from Myanmar over the course of Integrative Adapt Therapy

Background: The ability to adapt to the psychosocial disruptions associated with the refugee experience may influence the course of complicated grief reactions. Objective: We examine these relationships amongst Myanmar refugees relocated to Malaysia who participated in a six-week course of Integrative Adapt Therapy (IAT). Method: Participants (n = 170) included Rohingya, Chin, and Kachin refugees relocated to Malaysia. At baseline and six-week post-treatment, we applied culturally adapted measures to assess symptoms of Prolonged Complex Bereavement Disorder (PCBD) and adaptive capacity to psychosocial disruptions, based on the Adaptive Stress Index (ASI). The ASI comprises five sub-scales of safety/security (ASI-1); bonds and networks (ASI-2); injustice (ASI-3); roles and identity (ASI-4); and existential meaning (ASI-5). Results: Multilevel linear models indicated that the relationship between baseline and posttreatment PCBD symptoms was mediated by the ASI scale scores. Further, ASI scale scores assessed posttreatment mediated the relationship between baseline and posttreatment PCBD symptoms. Mediation of PCBD change was greatest for the ASI II scale representing disrupted bonds and networks. Conclusion: Our findings are consistent with the informing model of IAT in demonstrating that changes in adaptive capacity, and especially in dealing with disrupted bonds and networks, may mediate the process of symptom improvement over the course of therapy.

An Integrative Adapt Therapy for common mental health symptoms and adaptive stress amongst Rohingya, Chin, and Kachin refugees living in Malaysia: A randomized controlled trial

BACKGROUND

This randomised controlled trial (RCT) aims to compare 6-week posttreatment outcomes of an Integrative Adapt Therapy (IAT) to a Cognitive Behavioural Therapy (CBT) on common mental health symptoms and adaptive capacity amongst refugees from Myanmar. IAT is grounded on psychotherapeutic elements specific to the refugee experience.

METHODS AND FINDINGS

We conducted a single-blind RCT (October 2017 -May 2019) with Chin (39.3%), Kachin (15.7%), and Rohingya (45%) refugees living in Kuala Lumpur, Malaysia. The trial included 170 participants receiving six 45-minute weekly sessions of IAT (97.6% retention, 4 lost to follow-up) and 161 receiving a multicomponent CBT also involving six 45-minute weekly sessions (96.8% retention, 5 lost to follow-up). Participants (mean age: 30.8 years, SD = 9.6) had experienced and/or witnessed an average 10.1 types (SD = 5.9, range = 1-27) of traumatic events. We applied a single-blind design in which independent assessors of pre- and posttreatment indices were masked in relation to participants' treatment allocation status. Primary outcomes were symptom scores of Post Traumatic Stress Disorder (PTSD), Complex PTSD (CPTSD), Major Depressive Disorder (MDD), the 5 scales of the Adaptive Stress Index (ASI), and a measure of resilience (the Connor-Davidson Resilience Scale [CDRS]). Compared to CBT, an intention-to-treat analysis (n = 331) at 6-week posttreatment follow-up demonstrated greater reductions in the IAT arm for all common mental disorder (CMD) symptoms and ASI domains except for ASI-3 (injustice), as well as increases in the resilience scores. Adjusted average treatment effects assessing the differences in posttreatment scores between IAT and CBT (with baseline scores as covariates) were -0.08 (95% CI: -0.14 to -0.02, p = 0.012) for PTSD, -0.07 (95% CI: -0.14 to -0.01) for CPTSD, -0.07 for MDD (95% CI: -0.13 to -0.01, p = 0.025), 0.16 for CDRS (95% CI: 0.06-0.026, p ≤ 0.001), -0.12 (95% CI: -0.20 to -0.03, p ≤ 0.001) for ASI-1 (safety/security), -0.10 for ASI-2 (traumatic losses; 95% CI: -0.18 to -0.02, p = 0.02), -0.03 for ASI-3 (injustice; (95% CI: -0.11 to 0.06, p = 0.513), -0.12 for ASI-4 (role/identity disruptions; 95% CI: -0.21 to -0.04, p ≤ 0.001), and -0.18 for ASI-5 (existential meaning; 95% CI: -0.19 to -0.05, p ≤ 0.001). Compared to CBT, the IAT group had larger effect sizes for all indices (except for resilience) including PTSD (IAT, d = 0.93 versus CBT, d = 0.87), CPTSD (d = 1.27 versus d = 1.02), MDD (d = 1.4 versus d = 1.11), ASI-1 (d = 1.1 versus d = 0.85), ASI-2 (d = 0.81 versus d = 0.66), ASI-3 (d = 0.49 versus d = 0.42), ASI-4 (d = 0.86 versus d = 0.67), and ASI-5 (d = 0.72 versus d = 0.53). No adverse events were recorded for either therapy. Limitations include a possible allegiance effect (the authors inadvertently conveying disproportionate enthusiasm for IAT in training and supervision), cross-over effects (counsellors applying elements of one therapy in delivering the other), and the brief period of follow-up.

CONCLUSIONS

Compared to CBT, IAT showed superiority in improving mental health symptoms and adaptative stress from baseline to 6-week posttreatment. The differences in scores between IAT and CBT were modest and future studies conducted by independent research teams need to confirm the findings.

TRIAL REGISTRATION

The study is registered under Australian New Zealand Clinical Trials Registry (ANZCTR) (http://www.anzctr.org.au/). The trial registration number is: ACTRN12617001452381.