P183 Arterial stiffness was inversely associated with left ventricular diastolic function in indigenous Papuan populations

Background

Age-related increase in systolic pressure is known to be absent in indigenous Papuan populations, partially because of their life-long low-sodium and high-potassium diets.

Purpose

The aim of this study was to investigate the age-related change in left ventricular (LV) systolic and diastolic function and the relationship with arterial hemodynamics among the indigenous Papuan highland people. 

Methods

Indices of arterial hemodynamics were measured using oscillometric brachial cuff-based sphygmomanometer (Mobil-O-Graph). Brachial-ankle pulse wave velocity (baPWV) was measured using a semiautomatic device (form ABI/baPWV). LV systolic and diastolic function was evaluated by 2-dimensional echocardiography and tissue-Doppler imaging using Vivid iq.

Results

A total of 81 native Papuans (median age 42 years, 47% women) were enrolled in this study. None of the subjects took any medicines, particularly antihypertensive drugs. All participants presented in sinus rhythm. With ageing, LV mass index remained unchanged, and LV ejection fraction increased, but mildly reduced (40–50%) in 3 participants. Transmitral E-wave velocity slightly decrease but the change was not significant. Transmitral A-wave velocity markedly increased (ρ=0.60, P < 0.001) and E/A ratio decreased with age (ρ=-0.52, P < 0.001). Age-related change of E-wave deceleration time was not significant. Septal e′ (ρ=-0.60, P < 0.001) and lateral e′ decreased (ρ=-0.53, P < 0.001) and average E/e′ increased with age (ρ=0.44, P < 0.001). Left atrial volume index did not change significantly with age. In multivariate regression analysis, baPWV was independently associated with E/e" ratio both before and after adjustment for age, sex, body mass index, mean arterial pressure, and heart rate; however, indices of wave reflection including augmentation index and reflection magnitude were not associated with E/e′. Only age and heart rate were inversely associated with E/A ratio. 

Conclusion

LV systolic function was preserved in indigenous Papuan populations; however, LV diastolic function decreased with ageing. Age-related arterial stiffening, not wave reflection, was inversely related to LV diastolic function.

Defining a combined constellation of complicated bereavement and PTSD and the psychosocial correlates associated with the pattern amongst refugees from West Papua

BACKGROUND

Refugees are at risk of experiencing a combined constellation of complicated bereavement and posttraumatic stress disorder (PTSD) symptoms following exposure to complex traumas associated with personal threat and loss. Features of identity confusion are central to both complicated bereavement and PTSD and these characteristics may be particularly prominent amongst refugees from traditional cultures displaced from their homelands, families, and kinship groups. We investigate whether a combined pattern of complicated bereavement and PTSD can be identified amongst West Papuan refugees participating in an epidemiological survey (n = 486, response rate: 85.8%) in a remote town in Papua New Guinea.

METHODS

Latent class analysis was applied to derive subpopulations of refugees based on symptoms of complicated bereavement and PTSD. Associations were examined between classes and traumatic loss events, post-migration living difficulties (PMLDs), and psychosocial support systems.

RESULTS

The four classes identified comprised a complicated bereavement class (11%), a combined posttraumatic bereavement class (10%), a PTSD class (11%), and a low symptom class (67%). Symptoms of identity confusion were prominent in the posttraumatic bereavement class. Compared with the low symptom class, the combined posttraumatic bereavement class reported greater exposure to traumatic loss events (OR 2.43, 95% CI 1.11-5.34), PMLDs (OR 2.24, 95% CI 1.01-4.6), disruptions to interpersonal bonds and networks (OR 3.3, 95% CI 1.47-7.38), and erosion of roles and identities (OR 2.18, 95% CI 1.11-4.27).

CONCLUSIONS

Refugees appear to manifest a combined pattern of complicated bereavement and PTSD symptoms in which identity confusion is a prominent feature. This response appears to reflect the combined impact of high levels of exposure to traumatic losses, PMLDs, and disruption of relevant psychosocial systems.

The structure and psychosocial correlates of complicated bereavement amongst refugees from West Papua

PURPOSE

Refugees may be at risk of experiencing a complicated form of bereavement. As yet, however, the nosological status of this putative category across cultures remains in question. We apply qualitative and quantitative methods to investigate the manifestations, prevalence, factorial structure and psychosocial correlates of complicated bereavement amongst refugees from West Papua, a population with no past exposure to western concepts of grief or to formal mental health services.

METHODS

Qualitative methods (focus groups and informant interviews) were used to identify cultural expressions of complicated bereavement derived from international classification systems, that is, DSM 5 persistent complex bereavement disorder (PCBD) and ICD-11 prolonged grief disorder (PGD) in developing a structured interview applied by trained field workers. Participants were adult West Papuan refugees and their offspring recruited from households (n = 486, response 85.8%) across nine villages in a remote town in Papua New Guinea.

RESULTS

The qualitative data obtained from focus groups (n = 20) and informant interviews (n = 4) with local psychiatrists supported the cultural validity of complicated bereavement. 16% (n = 78) of the sample met criteria for PCBD based on DSM-5 criteria and 103 (21%) met criteria for PGD based on ICD-11 criteria. Confirmatory factor analysis yielded a six-factor model of complicated bereavement with a moderately good fit to the data. The model included dimensions of anger/negative appraisal (AN), avoidance/giving up, estrangement from others, and confusion and diminished identity. In contrast, the DSM-5 three-factor model and the ICD-11 two-factor model each yielded a poor fit. Cumulative traumatic losses (β = 0.16, P = 0.03), duration since displacement [(β = 0.10, P = 0.02)] and postmigration living difficulties (β = 0.20, P = 0.01) were associated with an aggregated index of complicated bereavement, supporting the concurrent validity of the structure identified.

CONCLUSIONS

Culture and exposure to persecution and displacement may contribute to the content and configuration of the complicated bereavement reaction, an issue that requires recognition in international classification systems and clinical practice.

Developing a measure of adaptive stress arising from the psychosocial disruptions experienced by refugees based on a sample of displaced persons from West Papua

OBJECTIVES

We report the testing and refinement of the Adaptive Stress Index (ASI), a psychosocial assessment tool designed to measure the longer terms stressors of adapting to the psychosocial disruptions experienced by refugees.

METHODS

The ASI is based on a theoretical model, the Adaptation and Development After Persecution and Trauma (ADAPT), which postulates that five psychosocial domains are disrupted by conflict and displacement, namely, safety and security, attachment, access to justice, roles and identities, and existential meaning. We used confirmatory factor analysis (CFA) and item response theory (IRT) to shorten and refine the measure based on data obtained from 487 refugees participating in a household survey in Papua New Guinea (response rate: 85.8%).

RESULTS

CFA allowed the exclusion of low loading items (<0.5) and locally dependent items. A good fit was found for single models representing each of the five ASI domains. A graded response IRT model identified items with the highest discrimination and information content in each of the five derived scales.

CONCLUSIONS

The analysis produced a shortened and refined ASI for use amongst refugee populations. The study offers a guide to adapting measures of stress for application to diverse populations exposed to mass conflict and refugee displacement.

The Relationship of Complex Post-traumatic Stress Disorder and Post-traumatic Stress Disorder in a Culturally Distinct, Conflict-Affected Population: A Study among West Papuan Refugees Displaced to Papua New Guinea

BACKGROUND

Controversy continues about the validity of the construct of complex post-traumatic stress disorder (C-PTSD). In particular, questions remain whether C-PTSD can be differentiated from post-traumatic stress disorder (PTSD) and, secondarily, other common mental disorders. The examination of these issues needs to be expanded to populations of diverse cultural backgrounds exposed to prolonged persecution. We undertake such an inquiry among a community sample of West Papuan refugees exposed to extensive persecution and trauma.

METHODS

We interviewed over 300 West Papuan refugees using the Refugee-Mental Health Assessment Package to record symptoms of PTSD, C-PTSD, major depressive disorder (MDD), and complex grief (CG). We used first- and second-order confirmatory factor analysis (CFA) to test aspects of the convergent and discriminant validity of C-PTSD.

RESULTS

The CFA analysis supported both a one-factor and two-factor model of PTSD and C-PTSD. Nested model comparison tests provide support for the parsimonious one-factor model solution. A second-order CFA model of PTSD and C-PTSD produced a poor fit. The modified three-factor multi-disorder solution combining a traumatic stress (TS) factor (amalgamating PTSD and C-PTSD), MDD, and CG yielded a good fit only after removing three CG domains (estrangement, yearning, and behavioral change), a model that produced large standardized residuals (>0.20).

CONCLUSION

The most parsimonious model yielded a single TS factor combining symptom domains of C-PTSD and PTSD in this culturally distinct community exposed to extensive persecution and conflict-related trauma. There may be grounds for expanding the scope of psychological treatments for refugees to encompass this wider TS response. Our findings are consistent with theoretical frameworks focusing on the wider TS reaction of refugees exposed to human rights-related traumas of mass conflict, persecution, and displacement.

Factorial structure of complicated grief: associations with loss-related traumatic events and psychosocial impacts of mass conflict amongst West Papuan refugees

INTRODUCTION

Definitions of complicated grief vary across diagnostic systems, being represented as persistent complex bereavement (PCB) in DSM-5 and prolonged grief disorder (PGD) in the proposed revision of the ICD system. A past study in a high-income country has identified a six-factor structure for complicated grief, but there are no data testing this or any other model across cultures. The present study reports findings from a survey amongst West Papuan refugees (n = 230, response rate = 92 %) residing in Port Moresby, Papua New Guinea.

MATERIALS AND METHODS

We applied culturally adapted measures of conflict-related traumatic event (TEs) (drawing specifically on domains of conflict and loss), symptoms of complicated grief adapted and modified to the culture, and a multidimensional psychosocial index of the broader effects of conflict and displacement.

RESULTS

Confirmatory factor analysis yielded a single higher order construct of complicated grief comprising six factors of yearning/preoccupation; shock/disbelief; anger/negative appraisal; behavioural change; estrangement from others/impairment; and a novel dimension of confusion/diminished identity. In contrast, our analysis failed to support DSM or ICD models of PCB or PGD. A Multiple Indicators Multiple Causes (MIMIC) model revealed that traumatic loss and the sense of injustice each were associated with the unitary construct of complicated grief and its subdomains of yearning/preoccupation; shock/disbelief; anger/negative appraisal (exclusive to injustice); and estrangement from others/social impairment (exclusive to TE domain of conflict and loss).

CONCLUSIONS

Conflict and loss associated with feelings of injustice may be especially pathogenic in generating the anger/negative appraisal component of complicated grief amongst refugees.

Associations of adult separation anxiety disorder with conflict-related trauma, ongoing adversity, and the psychosocial disruptions of mass conflict among West Papuan refugees

Refugees commonly experience traumatic events that threaten the self and close others, suggesting the possibility that they may experience overlapping symptoms of posttraumatic stress disorder (PTSD) and separation anxiety disorder (SAD). We examine this possibility among West Papua refugees (n = 230) displaced to Port Moresby, Papua New Guinea. We also examine associations between the combined PTSD-SAD construct and indices of past trauma exposure, ongoing adversity, and the psychosocial disruptions caused by mass conflict and displacement. We applied culturally adapted interview modules to assess symptoms of PTSD, SAD, traumatic events (TEs), ongoing adversity, and 5 psychosocial dimensions. Latent class analysis identified a PTSD class (23%), a posttraumatic (PT) SAD class (22%), and a low-symptom class (55%). Compared with the low-symptom class, both the PTSD and PT-SAD classes endorsed higher levels of exposure to all domains of TEs (conflict-related trauma, witnessing murder, childhood related adversities, traumatic losses, and health stress) and ongoing adversity (access to health care, displacement/separation, safety in the community, and access to basic needs), but the 2 comorbid groups did not differ on these indices. The PT-SAD class alone scored higher than the low-symptom reference class in relation to disruptions to the psychosocial domains (safety/security, bonds/network, access to justice, roles/identities, existential meaning) and higher than the PTSD class on safety/security, justice and roles/identities. Our findings suggest that the PT-SAD pattern may represent a response to the most severe forms of psychosocial disruptions of mass conflict among refugees. A focus on separation anxiety may enhance psychotherapies designed to treat PTSD in refugees. (PsycINFO Database Record

Pathways from conflict-related trauma and ongoing adversity to posttraumatic stress disorder symptoms amongst West Papuan refugees: The mediating role of anxiety and panic-like symptoms

BACKGROUND

Although the relationship involving exposure to traumatic events (TEs), conditions of adversity, and posttraumatic stress disorder (PTSD) is well established in the refugee field, the psychological factors mediating the relevant pathways are not as clearly delineated. In the present path analysis, we examined a model in which anxiety and panic-like symptoms mediated the path between conflict-related TEs, ongoing adversity, and PTS symptoms amongst 230 refugees from West Papua.

METHODS

Culturally adapted measures were applied to assess TE exposure, ongoing adversity, anxiety, panic-like, PTS, and depressive symptoms.

RESULTS

Our model identified two pathways leading from conflict-related exposure to PTS symptoms, one a direct path, the other mediated by a sequence of ongoing adversity, anxiety and panic-like symptoms. Older refugees from West Papua had higher levels of anxiety and panic-like symptoms than the younger adult generation born in PNG.

CONCLUSIONS

Our findings suggest that a focus on reducing anxiety and panic together with addressing social deprivations and threats may improve anxiety and panic amongst refugees, ultimately improving outcomes for PTS symptoms.

Pathways involving traumatic losses, worry about family, adult separation anxiety and posttraumatic stress symptoms amongst refugees from West Papua

There is some evidence that adult separation anxiety disorder (ASAD) symptoms are closely associated with posttraumatic stress disorder (PTSD) amongst refugees exposed to traumatic events (TEs), but the pathways involved remain to be elucidated. A recent study suggests that separation anxiety disorder precedes and predicts onset of PTSD. We examined a path model testing whether ASAD symptoms and worry about family mediated the path from traumatic losses to PTSD symptoms amongst 230 refugees from West Papua. Culturally adapted measures were applied to assess TE exposure and symptoms of ASAD and PTSD. A structural equation model indicated that ASAD symptoms played an important role in mediating the effects of traumatic losses and worry about family in the pathway to PTSD symptoms. Although based on cross-sectional data, our findings suggest that ASAD symptoms may play a role in the path from traumatic losses to PTSD amongst refugees. We propose an evolutionary model in which the ASAD and PTSD reactions represent complementary survival responses designed to protect the individual and close attachments from external threats.

The structure of post-traumatic stress disorder and complex post-traumatic stress disorder amongst West Papuan refugees

BACKGROUND

The validity of applying the construct of post-traumatic stress disorder (PTSD) across cultures has been the subject of contention. Although PTSD symptoms have been identified across multiple cultures, questions remain whether the constellation represents a coherent construct with an interpretable factor structure across diverse populations, especially those naïve to western notions of mental disorder. An important additional question is whether a constellation of Complex-PTSD (C-PTSD) can be identified and if so, whether there are distinctions between that disorder and core PTSD in patterns of antecedent traumatic events. Our study amongst West Papuan refugees in Papua New Guinea (PNG) aimed to examine the factorial structure of PTSD based on the DSM-IV, DSM-5, ICD-10 and ICD-11 definitions, and C-PTSD according to proposed ICD-11 criteria. We also investigated domains of traumatic events (TEs) and broader psychosocial effects of conflict (sense of safety and injustice) associated with the factorial structures identified.

METHODS

Culturally adapted measures were applied to assess exposure to conflict-related traumatic events (TEs), refugees' sense of safety and justice, and symptoms of PTSD and C-PTSD amongst 230 West Papuan refugees residing in Port Morseby, PNG.

RESULTS

Confirmatory factor analysis (CFA) supported a unitary construct of both ICD-10 and ICD-11 PTSD, comprising the conventional symptom subdomains of intrusion, avoidance, and hyperarousal. In contrast, CFA did not identify a unitary construct underlying C-PTSD. The interaction of witnessing murders and sense of injustice was associated with both the intrusion and avoidance domains of PTSD, but not with the unique symptom clusters characterizing C-PTSD.

CONCLUSIONS

Our findings support the ICD PTSD construct and its three-factor structure in this transcultural refugee population. Traumatic experiences of witnessing murder associated with a sense of injustice were specifically related to the intrusion and avoidance domains of PTSD. The unitary nature of C-PTSD across cultures remains in question.

Associations of Conflict-Related Trauma and Ongoing Stressors with the Mental Health and Functioning of West Papuan Refugees in Port Moresby, Papua New Guinea (PNG)

Documentation is limited in relation to the mental health of the people of West Papua, a territory that has been exposed to decades-long political persecution. We examined associations of traumatic events (TEs) and current stressors with mental disorder and functioning, amongst 230 West Papuan refugees residing in six settlements in Port Morseby, Papua New Guinea (PNG). We used culturally adapted modules to assess exposure to TEs and mental disorders. Current stressors and functioning were assessed using modifications of measures developed by the World Health Organization (WHO). 129 of 230 respondents (56%) reported exposure to at least one traumatic event (TE), including: political upheaval (36.5%), witnessing or hearing about family members tortured and murdered (33.9%), and not being able to access medical care for family members (33%). One fifth of respondents (47, 20.4%) experienced exposure to high levels of TEs (16 to 23). 211 (91.7%) endorsed at least one or more ongoing stressors, including: exposure to illicit substance use in the community (91.7%), problems with safety and the protection of women (89.6%), no access to legal rights and citizenship (88.3%), and lack of adequate shelter and facilities (85.2%). A quarter (26.9%) met criteria for one or more current mental disorder, and 69.1% reported functional impairment ranging from mild to extreme. Mental disorder was associated with being male (adjusted odds ratio=2.00; 95% CI=1.01-3.97), and exposure to the highest category of ongoing stressors (AOR=2.89; 95% CI=1.08-7.72). The TE count showed a dose-response pattern in its relationship with functional impairment, the greatest risk (AOR=11.47; 95% CI=2.11-62.37) being for those experiencing the highest level of TE exposure (16-23 events). West Papuans living in settlements in Port Moresby reported a range of TEs, ongoing stressors and associated mental disorders characteristic of populations exposed to mass conflict and persecution, prolonged displacement, and ongoing conditions of extreme hardship.

Human rights trauma and the mental health of West Papuan refugees resettled in Australia

OBJECTIVES

To document the extent and nature of human rights violations and other traumatic events reported by West Papuan refugees resettled in Australia and to assess trauma-related psychological disorders, distress and disability.

DESIGN AND SETTING

Australian-based sample, mixed-methods design with 44 participants, conducted in Australia between October 2007 and November 2010 in communities in North Queensland and Melbourne.

PARTICIPANTS

West Papuan refugees aged 18 years and over (88% response rate).

MAIN OUTCOME MEASURES

Post-traumatic stress disorder (PTSD) symptoms (Harvard Trauma Questionnaire) and premigration potentially traumatic events (PTEs), psychological distress (Kessler Psychological Distress Scale [K10]), post-migration living difficulties, days out of role.

RESULTS

Of the 44 West Papuan refugees, 40 reported one or more PTE, including inability to access medical care for family (40), lack of food and water (39) and lack of access to medical treatment (38). The most frequent postmigration stressors were separation from and worries about family members remaining in West Papua (43) and being unable to return home in an emergency because of ongoing conflict (41). Twenty-six participants reached a lower threshold for PTSD symptoms of 2.0, and 13 reached the clinical threshold of 2.5. Fourteen reported severe psychological distress.

CONCLUSIONS

West Papuan refugees resettled in Australia report a wide range of premigration PTEs including human rights violations, as well as symptoms of PTSD and distress. The data add to concerns about the state of human rights and mental health among West Papuans.

Dua sakit (double sick): trauma and the settlement experiences of West Papuan refugees living in North Queensland

There is mounting evidence of systematic abuses, including torture, rape and extrajudicial killings directed against independence activists as well as the civilian population in Indonesian occupied West Papua. Refugees from West Papua have sought safety in neighbouring Australia, experiencing hazardous journeys during their flight. We report early observations from a mental health study among West Papuan refugees living in North Queensland, Australia. The project includes qualitative methods aimed at gathering histories of trauma and human rights violations as well as standard mental health assessments and indices of acculturation and resettlement stresses. We consider the emerging data from the vantage point of the Adaptation and Development After Persecution and Trauma model that identifies five psychosocial domains that require repair following exposure to gross human rights violations and refugee trauma. The model emphasizes the inter-relatedness of key challenges, the compounding of adversity, and the bivalent effects of complex experiences, with both positive and negative elements shaping the adaptive trajectory of displaced persons. Refugee groups have their own approaches to conceptualizing the complexity of their problems, with the term dua sakit representing the expression used by West Papuans to identify the multiple challenges they face. The study highlights the importance of assessing each refugee group within its unique social and cultural context, taking into account such diverse factors as geographical location, employment, and ongoing conflict in the homeland in designing appropriate interventions.

Health and human security in West Papua

Recent publications have highlighted the impact of human rights violations, poverty and extraction of natural resources on the health status of the indigenous people of West Papua. However, the Australian medical literature has so far remained silent on this issue. Long-standing allegations of violence being perpetrated against Papuan civil society are supported by accounts given by West Papuan refugees involved in an Australian-based study. Health data collected by Médecins du Monde and other sources provide an insight into the poor health and lack of health care in the province, with high rates of infant mortality and morbidity, maternal mortality, and HIV/AIDS. Extraction of natural resources is causing major disruptions to the traditional livelihoods of indigenous Papuans, as a result of environmental degradation, mass displacement and an influx of migrant workers. Australian health professionals are urged to assist in remediating this dire situation, in keeping with our tradition of contributing to the health care of societies in our region.