Exploring Predictors of Preterm Birth: A Comparative Study of Turkish and Syrian Refugee Women

OBJECTIVE

This study is designed to explore associated sociodemographic, birth-related and household characteristics with preterm birth (< 37 weeks) among Turkish and Syrian refugee women.

METHODS

The data utilized in this study were obtained from the Turkey Demographic and Health Survey (TDHS) conducted in 2018. Various statistical analyses, including descriptive statistics, independent sample t-tests, and Chi-square tests, were employed to examine the differences in study variables between Turkish and Syrian refugee women. Furthermore, logistic regression analysis was conducted to identify the associated factors with preterm birth among Turkish and Syrian refugee women, allowing for comparative analysis.

RESULTS

The key findings of this study revealed significant differences in sociodemographic (p < 0.05), birth-related (p < 0.05), and household characteristics (p < 0.05) that are associated with preterm birth among Turkish and Syrian refugee women. Also, nationality (OR: 3.427; 95% CI 2.770-4.241), delivery by c-section (OR: 1.630; 95% CI 1.370-1.939), educational status (OR: 0.674; 95% CI 0.547-0.832), place of delivery (OR: 0.806; 95% CI 0.666-0.975), and number of household members (OR: 1.206; 95% CI 1.013-1.437) were found to be important factors associated with preterm birth risk.

CONCLUSIONS

The key findings of this study contribute to the identification of women's factors in preterm birth. By understanding the factors that contribute to preterm birth among both Syrian refugee and Turkish women, appropriate interventions can be developed to improve maternal and child health outcomes.

Suicidality Among Syrian Refugee Children in Jordan

History of adverse events in childhood is one of the strongest predictors of developing negative mental health outcomes with suicidality being the most devastating consequence. Syrian refugee children are at very high risk of developing mental illness, however, the prevalence and significance of suicidal thoughts among this population remains undocumented. A total of 339 Syrian refugee children and adolescents aged 10 to 17 years and their parents living in Jordan were surveyed to assess resilience, depression and suicidality. Demographics and parental depression were correlated with child suicidality. Multivariate logistic regression analyses were used to determine the predictors of suicidality within this population. A total of 94 (27.7%) children reported suicidal statements. In the multivariate analyses we found that younger children were more likely to state suicidal ideation than older children. Of the children who stated suicidal ideation, 49 were in primary school, 19 in pre-secondary and 26 in upper-secondary school. In the multivariate analyses, mild (OR 2.633 (95% CI 1.283, 5.709)) and high (OR 6.987 (95% CI 3.532, 14.614)) depression levels among the surveyed children were predictive of suicidality. Experiencing bullying was also predictive of suicidality (OR 2.181 (95% CI 1.179, 4.035)) when compared to those who did not report any bullying. We report high rates of suicidal ideation among Syrian refugee children, especially in children with exposure to pre-existing depression or bullying. Prevention through raising awareness, education and early detection of depression are needed to address suicidality in this and other vulnerable populations of children.

Investigating the aftermath of the Türkiye 2023 earthquake: exploring post-disaster uncertainty among Syrian migrants using social network analysis with public health approach

Objectives

On February 6th, 2023, a doublet earthquake struck Türkiye, impacting more than 15 million people including migrants, and resulting in over 50,000 deaths. The Syrian migrants experience multiple uncertainties in their daily lives which are further compounded by multifaceted challenges of the post-disaster environment. Social media was used intensively and with impunity in this environment and thereby provides a window into the explicit and implicit dynamics of daily life after a disaster. We aimed to explore how a post-disaster environment potentially generates new uncertainties or exacerbating pre-existing ones for migrants through social media analysis with an indirect perspective, in the context of 2023-Earthquake in Türkiye and Syrian migrants.

Methods

Social network analysis was used to analyze Twitter-data with the hashtags 'Syrian' and 'earthquake' during a 10-day period beginning on March 22nd, 2023. We calculated network metrics, including degree-values and betweenness-centrality and clustered the network to understand groups. We analyzed a combination of 27 tweets with summative content analysis using a text analysis tool, to identify the most frequently used words. We identified the main points of each tweet and assessed these as possible contributors to post-disaster uncertainty among migrants by using inductive reasoning.

Results

There were 1918 Twitter users, 274 tweets, 124 replies and 1726 mentions. Discussions about Syrian migrants and earthquakes were established across various groups (ngroups(edges > 15) = 16). Certain users had a greater influence on the overall network. The nine most frequently used words were included under uncertainty-related category (nmost_frequently_used_words = 20); 'aid, vote, house, citizen, Afghan, illegal, children, border, and leave'. Nine main points were identified as possible post-disaster uncertainties among migrants.

Conclusion

The post-disaster environment has the potential to exacerbate existing uncertainties, such as being an undocumented migrant, concerns about deportation and housing, being or having a child, inequality of rights between being a citizen and non-citizen, being in minority within minority, political climate of the host nation and access to education or to generate new ones such equitable distribution of aid, which can lead to poor health outcomes. Recognizing the possible post-disaster uncertainties among migrants and addressing probable underlying factors might help to build more resilient and healthy communities.

The impact of family income and parental factors on children's resilience and mental well-being

Although there is robust evidence on the intergenerational transmission of trauma-related distress, much less is known about the relation of family income and parental resilience on the resilience and mental well-being of traumatized children. We aimed to determine the association between parental resilience and perceived financial stability, and the resilience and depression of their children among Syrian refugees in Jordan. We carried out a survey of 363 parent-child dyads from a refugee clinic in Northern Jordan. Measures of resilience, trauma, symptoms of mental illnesses, and demographics were reported by the mother and child. We evaluated the associations between parental resilience and their children's mental health. Resilience was highest among parents who reported that their income met their financial needs, (65.77 [standard deviation (SD) 15.96]), and lower for those who reported less income or who stated that their income met their needs only fairly well (62.77 [SD 17.56]). Resilience was lowest for those who reported that that income met their needs poorly (48.02 [SD 23.24]). Parent resilience was positively correlated with child resilience (β = 0.076 [95% confidence interval 0.035-0.12], p < 0.001). Depression and resilience of parents were most closely correlated with the depression and resilience scores of their children, among parents who reported the highest financial stability. Income plays a modifying role in the parent-child resilience and depression associations, with this association being least pronounced within those families who were financially less secure. These findings can help develop interventions to target parental transgenerational impacts according to income status.

Culturally Adapting a Digital Intervention to Reduce Suicidal Ideation for Syrian Asylum Seekers and Refugees in the United Kingdom: Protocol for a Qualitative Study

BACKGROUND

The conflict in Syria has produced the largest forced displacement crisis since the Second World War. As a result, Syrians have experienced various stressors across the migratory process, putting them at an increased risk of developing mental health issues, including, crucially, suicidal ideation (SI). Despite their high rates of SI across Europe, there remain various barriers to accessing treatment. One way to increase access is the use of culturally adapted digital interventions, which have already shown potential for other minority populations. To culturally adapt the intervention, further research is needed to better understand Syrian asylum seekers' and refugees' cultural conceptualizations, coping strategies, and help-seeking behavior for SI. To do so, this study will use a unique cultural adaptation framework to intervene at points of lived experience with the migratory process where Syrian culture and signs of psychopathology converge. Likewise, co-design events will be used to adapt points of experience with the intervention where Syrian culture and the intervention conflict. As the first cultural adaption of a digital SI intervention for Syrian asylum seekers and refugees, this study will hopefully encourage further development of culturally sensitive interventions for the largest refugee population in the United Kingdom and the world.

OBJECTIVE

The objective of the study is to increase access to mental health treatment for Syrian asylum seekers and refugees in the United Kingdom by culturally adapting a digital intervention to reduce SI.

METHODS

The study will use experience-based co-design, an action research method, to culturally adapt a digital intervention to reduce SI for Syrian asylum seekers and refugees in the United Kingdom. This will involve conducting 20-30 interviews to understand their lived experiences with the migratory process, cultural conceptualizations of mental health and SI, coping strategies, mental health help-seeking behavior, and perceptions of digital mental health interventions. In addition, 3 co-design events with 6 participants in each will be held to collaboratively adapt the intervention. Touchpoints and themes extracted from each phase will be prioritized by a community panel before adapting the intervention.

RESULTS

The study began in November 2022 and will continue until the last co-design event in August 2023. The results of the study will then be published by December 2023.

CONCLUSIONS

Access to treatment for some of the most severe mental health issues is still limited for Syrian asylum seekers and refugees in the United Kingdom. Cultural adaptations of digital interventions developed for general populations have the potential to increase access to treatment for this population. Specifically, adapting the intervention for Syrian asylum seekers' and refugees' experiences with SI in relation to their lived experience with the migratory process may enable greater recruitment and adherence for users of various cultural and ethnic subgroups and levels of SI.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/47627.

Evaluation of bio-psycho-social and socio-cultural problems of Syrian elderly living in Turkey

BACKGROUND

Older persons are among the vulnerable groups most affected by war and migration due to physical weakness, illness, social environment, and cultural adaptation difficulties.

AIMS

The aim of this study is to determine the economic, biopsychosocial, and socio-cultural problems of the older Syrians living in Turkey.

METHODS

Convergent mixed design was used within the scope of the research. For the qualitative phase of the research, 19 older persons migrants were interviewed. A semi-structured interview form was used to collect data in the interviews. For the quantitative phase of the research, 432 participants were reached. In order to collect data, Geriatric Depression Scale (GDS-15) and Socio-cultural Adaptation Scale (SCAS-R) were used together with the demographic information form.

RESULTS

The mean age of the participants was 66.2 ± 7.10 (Min: 60; Max: 91), the majority (87%) between the ages of 60 to 74 and 53.2% were male. The mean SCAS-R score of the older Syrians was 2.48 ± 0.88 (Min: 1; Max: 5) and the mean GDS-15 was 2.63 ± 3.84 (Min: 0; Max: 15). About 22.7% of older Syrian participants had mild or severe depressive symptoms. Experienced traumatic events, changing economic situation, and family relationships affected both physical and mental health of the older persons. The socio-cultural adaptation of the older persons was affected by language, temporary protection, and exposure to exclusion. The Older Syrians, who lacked information on social services, were experiencing problems with nutrition, clothing, bill payment, and rent due to economic problems. However, they mostly did not want to return to Syria because their living order in Syria was deteriorating and they were afraid.

CONCLUSION

Syrian elderly immigrants living in Turkey have biopsychosocial, economic, and cultural problems. National and international support programs and policies should be developed for elderly Syrian refugees who are expected to live in Turkey unless a safe living environment is provided.

Associations among migration risk factors, cultural identity conflict, and psychological symptoms among Syrian emerging adults with refugee backgrounds in the Netherlands

OBJECTIVES

In the present study, we examined relations between premigration, perimigration, and postmigration risk factors (i.e., potentially traumatic events [PTEs], postmigration living problems [PMLPs], stressful life events) and psychological symptoms (i.e., anxiety/depression, posttraumatic stress) in Syrian emerging adults with refugee backgrounds; we also tested cultural identity conflict as a possible mediator of these relations. We expected that greater exposure to migration risk factors was associated with more psychological symptoms and that higher cultural identity conflict would contribute to these associations.

METHODS

We used data from the first wave of Karakter, a longitudinal study of 158 Syrians with refugee backgrounds (69.0% men, age range 18-35). Participants completed a questionnaire assessing PTEs, PMLPs, stressful life events, cultural identity conflict, and symptoms of anxiety/depression and posttraumatic stress.

RESULTS

Correlational analyses indicated that more PTEs and stressful life events were related to higher levels of cultural identity conflict and more psychological symptoms. Furthermore, greater cultural identity conflict was associated with more psychological symptoms. We did not observe indirect effects of cultural identity conflict in the mediation analyses.

CONCLUSIONS

Results suggest that postmigration stressors and cultural identity conflict are associated with psychological symptoms among Syrian emerging adults who have resettled in the Netherlands.

A qualitative study of a mental health awareness intervention for Jordanian and resettled Syrian refugees in host communities

BACKGROUND

Mental health disorders significantly contribute to the global burden of disease, however, prevention and treatment programs are often inaccessible in low- and middle-income countries.

AIMS

The goal of this qualitative evaluation was to examine participants experiences of the healthy community clinic (HCC-MH), an integrated mental health awareness intervention delivered in primary care clinics to Jordanians and resettled Syrians in a border community in Jordan.

METHODS

Four focus group discussions (FGDs) with Jordanians and Syrians (N = 21) who participated in the HCC-MH were conducted. FGDs examined knowledge, acceptability, and applicability of the intervention. Open coding and the constant comparison method were used to identify themes that emerged from the FGDs.

RESULTS

Six central themes emerged from the data including : (1) awareness; (2) behavior changes; (3) reduction in stigma; (4) connecting physical and mental health; (5) relationships; and (6) coping. Notably, female participants stated participation in the intervention fostered awareness of their own emotional needs, which led to positive lifestyle and behavior changes. Participants also described how the information provided in the intervention normalized emotional distress and aided understanding of the interconnection between physical and mental health. The amplification of healthy coping strategies to reduce stress and distress was also a prominent theme.

CONCLUSIONS

Findings are discussed within the cultural and contextual setting of the study, and implications for mental health awareness interventions in complex settings are provided.

Gender differences in Syrian refugees in Jordan: Psychological, self-esteem, family function, marital satisfaction, and life satisfaction

AIM

The current study examined gender differences in mental health, self-esteem, family function, marital satisfaction, and life satisfaction between men and women living in a refugee camp for Syrian refugees in Jordan.

METHOD

A snowball method used by local female and male students trained to collect data according to culturally competent methods. The following research instruments were deployed: Symptoms Checklist-SCL90, Self-esteem Scale, the McMaster Family Assessment Device, Marital Satisfaction Scale, and life Satisfaction Scale.

RESULTS

A sample of 290 adults (196 women and 94 men) living in a refugee camp in Jordan participated in the study. Findings revealed that marital satisfaction, self-esteem, and life satisfaction were significantly different between males and females, indicating less subjective well-being for women. Many of the mental health symptoms in this study were more common for women than men; particularly noteworthy were somatization, obsessive compulsive behavior, interpersonal sensitivity, depression, hostility, psychoticism, and higher scores on the Global Severity Index (GSI).

CONCLUSION

While some stressors are not gender-specific, there are unique factors that women face which place them at increased risk of mental health problems. Implications for practice include a greater understanding of the challenges and resilience mechanisms that are related to gender and culture.

Nutritional and health status of adult Syrian refugees in the early years of asylum in Germany: a cross-sectional pilot study

BACKGROUND

Migration is usually accompanied by changes in the social, cultural, and religious environment, socioeconomic status, and housing conditions, all of which affect nutritional health. In a cross-sectional study, we assessed the dietary intake as well as nutritional and health situation in a population of Syrian refugees who have resided in Germany for at least six months up to four years since 2015. The primary aim of this pilot study was to evaluate the nutritional and health status in comparison to reference values.

METHODS

Between December 2018 and March 2020, 114 adult Syrian refugees were included in the study. The subjects filled out questionnaires on sociodemographic variables, exercise, and nutrition behavior (three-day nutrition record). After a fasting blood draw, the subjects were examined for anthropometric parameters (height, weight, body mass index, waist circumference, waist-hip ratio, and body composition via a bioelectrical impedance analyzer). Various blood markers including iron status, hematological parameters, Vitamin D status, lipid metabolism, glucose metabolism, and total homocysteine (tHcy) were measured.

RESULTS

About half of the participants (71 male, 43 female) had lived in Germany for less than three years. Over 60% of men and 30% of women were overweight (BMI 25-30 kg/m2) or obese (BMI > 30 kg/m2), while 79% of men and 74% of women observed an elevated body fat mass. The evaluation of the three-day nutrition records revealed an unfavorable supply situation for numerous critical nutrients. More than half of the women (53.5%) had depleted iron stores (serum ferritin < 15 µg/l). The 25-OH-Vitamin D blood levels showed a high prevalence of Vitamin D insufficiency (25-49.9 nmol/l: 38% of men and 21% of women) and deficiency (< 25 nmol/l: 44% of men and 70% of women). 83% of men and 67% of women showed tHcy levels in plasma > 10 nmol/l. Fasting insulin levels and the HOMA-IR index indicate a risk for insulin resistance. Hyperlipidemia was prevalent, especially in males with 24% showing hypertriglyceridemia (> 150 mg/dl) and LDL-hypercholesterolemia (> 130 mg/dl).

CONCLUSIONS

The nutritional and health status of the cohort of Syrian refugees in Germany examined in this study is unsatisfactory, and many of the investigated refugees are at risk for developing cardiovascular disease and type 2 diabetes mellitus. Further studies are required to investigate the nutritional and health situation of refugees. This is obligatory to find ways to avoid malnutrition with all its associated health, sociodemographic, and economic consequences.

The Understanding and Impact of COVID-19 and Pandemic Policies on Syrian and Other Arabic-Speaking Refugees in Tampa, Florida

Background  Vulnerable communities around the world, such as Syrian refugees, faced increased social and financial strain due to coronavirus disease 2019 (COVID-19). We evaluated the underlying issues and inequities of Arabic-speaking refugees during the pandemic. Methods  Data were collected from Arabic-speaking refugees ( N  = 20) in July 2020, using an online 97-item questionnaire, in short response and multiple-choice formats. Results  Participants' reports indicate adequate knowledge about COVID-19 symptoms and preventative measures, but experienced linguistic, financial, and cultural challenges during the pandemic. "Essential" low-paying occupations put the population at risk for COVID-19. Local mosques and nonprofits have provided essential social support and food. Conclusion  Syrian and Arabic-speaking refugees reported several problems suggesting the need for increased understanding of this understudied, marginalized, and vulnerable population. Making resources and governmental programs more accessible is critical, so refugees can better access information regarding jobs, housing, and education. Organizations central to community support, including mosques, should be assisted.

The Association of Conflict-Related Trauma with Markers of Mental Health Among Syrian Refugee Women: The Role of Social Support and Post-Traumatic Growth

Background

Syrian refugee women not only suffered the refuging journey but also faced the burden of being the heads of their households in a new community. We aimed to investigate the mental health status, traumatic history, social support, and post-traumatic growth (PTG) of Syrian refugee women.

Methods

A cross-sectional study was conducted using a structured interviewer-administered survey between August and November 2019. Syrian refugee women who head their households and live outside camps were eligible. The survey included items investigating socio-demographic characteristics and conflict-related physical trauma history. The Refugee Health Screener-15 (RHS-15) scale was used to screen for emotional distress symptoms of depression, anxiety, and post-traumatic stress disorder (PTSD), with a score range of 0−4 and higher scores indicating emotional distress. The Multidimensional Scale of Perceived Social Support (MSPSS) was utilized to assess the perceived support from family, friends, and significant others (score range 1−7), with scores of 3−5 and 5.1−7.0 representing moderate and high support, respectively. The PTG Inventory (PTGI) scale investigated the positive transformation following trauma; the score range was 0−5, and the cutoff point of ≥3 defined moderate-to-high growth levels.

Results

Out of 140 invited refugee women, 95 were included, with a response rate of 67.9%. Their mean (SD) age was 41.30 (11.75) years, 50.5% were widowed, and 17.9% reported their husbands as missing persons. High levels of conflict-related traumatic exposure were found, including threats of personal death (94.7%), physical injury (92.6%), or both (92.6%); and a history of family member death (92.6%), missing (71.6%), or injury (53.7%). The mean (SD) RHS-15 score was above average (2.08 (0.46)), and most women (90.5%) were at high risk for depression, anxiety, and PTSD symptoms. The mean (SD) MSPSS score was 5.08 (0.71), representing moderate social support, with friends’ support being the highest (5.23 (0.85)). The mean (SD) PTGI score was 2.44 (0.48), indicating low growth, with only 12.6% of women experiencing moderate-to-high growth levels. Spiritual change and personal strength had the highest sub-scores, with moderate-to-high growth levels experienced by 97.9% and 84.2%, respectively. Most women were more optimistic and religious, had feelings of self-reliance and better difficulties adapting, and were stronger than they thought. Statistically significant correlations of MSPSS and its subscales with RHS-15 and PTGI were detected.

Conclusion

Significant but unspoken mental health problems were highly prevalent among Syrian refugee women and an imminent need for psychological support to overcome traumatic exposure. The role of social support seems to be prominent and needs further investigation.

Trauma and resettlement: lessons learned from a mental health screening and treatment programme for Syrian refugees in the UK

Resettlement schemes can offer refugees an opportunity to rebuild their lives and to heal from loss and trauma. Mental health services in host countries may have an important role to play in aiding refugees in this journey to recovery. However, facilitating the process of healing for refugees raises challenges for mental health services working within Western medicalised settings. Recovery and wellbeing for resettled refugees also depends upon an interaction of variables at a wider systemic level, that go beyond the direct remit of mental health services. Based on the experience of delivering a mental health screening and treatment programme for resettled Syrian refugees in the UK over a 5-year period, this paper reflects on these challenges and suggests that future resettlement schemes in the UK be designed in accordance with the principles of trauma-informed care. This means putting safety, trust, choice, collaboration, empowerment and respect for inclusion and diversity at the core of the services provided for resettled refugees.

Self-rated health and quality of life among Syrian refugees in Ireland - data from a cross-sectional study

INTRODUCTION

As a response to the humanitarian crisis in Syria, the Irish government agreed to accept up to 4000 refugees for resettlement in Ireland in 2016. Prior to their arrival in Ireland, health screening was carried out by the International Organisation for Migration. However, no population-level measurement of the health status or needs takes place in Ireland to inform policy or health services requirements.

METHODS

Cross-sectional data from a self-completed questionnaire among 194 Syrian Refugees aged 16 years and older resident in reception centres in Ireland in 2017/2018 is reported upon. The questionnaire measured self-reported health including quality of life and all study material were available in English and Arabic. The data was examined applying descriptive statistics and regression analysis.

RESULTS

Syrian Refugees in Ireland consist of a relatively young cohort; in this study the majority of participants were younger than 35 years (69.5%). Two-thirds of the respondents reported their overall health status to be good or very good. The most common health condition was found to be headache and the most common medications used were painkillers. Chronic pain was experienced by one quarter of respondents; 27.5% were considered as suffering from anxiety and 10.0% had symptoms compatible with post-traumatic stress disorder (PTSD). A significant relationship was observed between chronic pain and self-rated health, as well as between chronic pain and anxiety. Quality of life (QoL) scores were lowest for the QoL environment domain.

CONCLUSIONS

Chronic pain is relatively widespread among these young and otherwise healthy refugees. Psychological distress and trauma are important factors in respondents' quality of life scores. Chronic pain is associated with one's mental health. Our findings and the literature suggests that the diagnosis and treatment of pain and providing care in a culturally sensitive manner should be a priority and included in the preparation and training of the relevant care providers. Additionally, the impact of living conditions on quality of life should not be underestimated.

Child marriage among displaced populations - a 2019 study in Kurdistan Region of Iraq

Background

Many of the factors that increase risk of child marriage are common among refugees and internally displaced persons (IDPs). We sought to address the gaps in knowledge surrounding child marriage in displaced and host populations in the Kurdistan Region of Iraq (KRI).

Methods

A multistage cluster sample design was employed collecting data of KRI host communities, Iraqi IDPs, and Syrian refugees. Interviews were conducted in eligible households, requiring at least one adult female and one female adolescent present, addressing views of marriage, demographics and socioeconomic factors. Household rosters were completed to assess WHO indicators, related to child marriage including completed child marriage in females 10–19 and completed risk of previously conducted child marriages in females 20–24.

Results

Interviews were completed in 617 hosts, 664 IDPs, and 580 refugee households, obtaining information on 10,281 household members and 1,970 adolescent females. Overall, 10.4% of girls age 10–19 were married. IDPs had the highest percentage of married 10–19-year-old females (12.9%), compared to the host community (9.8%) and refugees (8.1%). Heads of households with lower overall education had higher percentages of child marriage in their homes; this difference in prevalence was most notable in IDPs and refugees. When the head of the household was unemployed, 14.5% of households had child marriage present compared to 8.0% in those with employed heads of household. Refugees and IDPs had larger percentages of child marriage when heads of households were unemployed (refugees 13.1%, IDPs 16.9%) compared to hosts (11.9%). When asked about factors influencing marriage decisions, respondents predominately cited family tradition (52.5%), family honor (15.7%), money/resources (9.6%), or religion (8.0%). Over a third of those interviewed (38.9%) reported a change in influencing factors on marriage after displacement (or after the arrival of refugees in the area for hosts).

Conclusions

Being an IDP in Iraq, unemployment and lower education were associated with an increase in risk for child marriage. Refugees had similar percentages of child marriage as hosts, though the risk of child marriage among refugees was higher in situations of low education and unemployment. Ultimately, child marriage remains a persistent practice worldwide, requiring continued efforts to understand and address sociocultural norms in low socioeconomic and humanitarian settings.

The posttraumatic stress interview for children (KID-PIN): development and validation of a semi-structured interview of PTSD symptoms among displaced children in the Middle East

BACKGROUND

In populations affected by mass disaster such as armed conflict and displacement, children are at risk of developing mental ill-health, in particular post-traumatic stress disorder (PTSD). Valid and reliable screening instruments are needed to assess the severity of PTSD symptoms among children and to identify individuals in need of treatment.

METHOD

In the context of an ongoing war in the Middle East, we developed the KID-PIN as a semi-structured interview for PTSD symptoms that can be administered by trained paraprofessionals. To achieve a culturally and contextually appropriate instrument, the development was based on open-ended interviews with affected children and involved both local and international experts. Using the KID-PIN and instruments for constructs associated with PTSD, 332 Iraqi and Syrian displaced children were interviewed. A subset of the sample (n = 86) participated in validation interviews based on experts applying the Clinician-Administered PTSD Scale for DSM-5-Child/Adolescent Version (CAPS-CA-5).

RESULTS

The KID-PIN demonstrated excellent internal consistency (Cronbach's alpha = 0.94) with good convergent validity. Confirmatory factor analyses of the KID-PIN showed an acceptable fit with the DSM-5 and other common models; the best fit was reached with the Hybrid model. Receiver operating characteristic analyses indicated that the cut-off score of 28 or higher on the KID-PIN is the optimum cut-off for a probable PTSD diagnosis.

CONCLUSION

The utility of the newly developed KID-PIN as a screening instrument for PTSD in children is supported by the measure's high internal consistency and good convergent and structural validity, as well as its diagnostic accuracy.

Integration Is Correlated With Mental Health Help-Seeking From the General Practitioner: Syrian Refugees' Preferences and Perceived Barriers

Despite a seemingly higher need, refugees in Europe tend to underuse mental health (MH) services. To better understand this underuse, it is important to understand refugees' willingness and ability to seek help from their general practitioner (GP) when experiencing MH problems. We employed a combined vignette and survey design to explore how the GP fits into the larger context of help-seeking preferences among a sample of Syrian refugees in Norway (n = 92), and what barriers they perceive in accessing help from the GP. We also examined how indicators of integration relate to seeking help from the GP. We take an exploratory approach. Participants were presented a vignette of an individual with symptoms in line with ICD-10 and DSM-5 criteria for depression. Participants were somewhat likely to seek help from the GP; however, seeking help from one's relationship with Allah/God and one's partner was preferred. Furthermore, while the GP was rated a somewhat likely help-seeking source, most participants indicated an average of two barriers to seeking help from the GP. Finally, social ties to the majority population in the form of social integration and feelings of connectedness with the host country (psychological integration) were positively correlated with likelihood of seeking help from the GP. Taken together, these findings suggest that the GP is considered a viable source of help among Syrians with a refugee background in the current sample, but that this may be influenced by perceived barriers and social as well as psychological integration. Addressing these barriers and promoting psychosocial integration with the host country are key to facilitating access and usage amongst refugees in need of MH services.

The postnatal experiences of resettled Syrian refugee women: Access to healthcare and social support in Nova Scotia, Canada

AIM

The purpose of this qualitative study was to understand Syrian refugee women's perceptions and experiences of access to formal health services and informal supports during the postpartum period in Nova Scotia, Canada and to identify valued and missing services and supports in the community.

BACKGROUND

The postnatal period is a critical time when mothers may need access to health services (e.g., family physicians, psychologists) and informal supports (e.g., friends, family) to support their positive mental and physical health after birth. Resettled refugee women commonly encounter barriers when accessing care during the postnatal period and often have limited social supports.

METHODS

Semi-structured, telephone or virtual interviews were conducted with 11 resettled Syrian refugee women who gave birth in Nova Scotia, Canada within the past five years. Data were collected in the summer of 2020. This study was conducted using elements of constructivist grounded theory.

FINDINGS

Four key themes were identified from women's experiences: (i) postpartum social support was critical, but often lacking, (ii) structural barriers (e.g., irregular interpreter services, limited childcare options) impeded women's access to healthcare, (iii) paternalistic healthcare providers limited women's decision-making autonomy, and (iv) the value and need for culturally competent, integrated care (e.g., newcomer specific healthcare centres), in-home services, and family support.

CONCLUSION

Resettled Syrian refugee women in Nova Scotia, Canada experience a range of barriers that limits their access to postnatal healthcare. Policy change, program development, and/or interventions are needed to improve access to postnatal services and supports for resettled Syrian women in Canada.

Variations in perceived stress among Syrian refugee parents resettled through different sponsorship programs in Canada

BACKGROUND

Little is known about the perceived stress level of Syrian Refugee (SR) parents residing in Canada specifically in relation to different sponsorship programs. This study aims to assess the relationship between the different sponsorship programs [Government-Assisted Refugees (GAR), Privately Sponsored Refugees (PSR) and Blended Visa Office-Referred refugees (BVOR)] and perceived stress among SR parents, with at least one child under the age of four, who resettled in the Greater Toronto area after 2015.

METHODS

A convenience sample of 155 Syrian Refugee (SR) parents was recruited. Perceived levels of stress were measured using the Perceived Stress Scale (PSS-10). Multiple linear regression analysis was performed to assess the independent relation between several types of sponsorship programs and PSS adjusting for demographic, economic and social factors.

RESULTS

The overall average PSS score was found to be 12.5 ± 7.2 with BVORs presenting the highest level of moderate stress when compared to GARs and PSRs (75.0% compared to 39.5% and 35.2% respectively). Multivariate analysis showed that the mean PSS was significantly higher among BVORs when compared with GARs (Adj β = 4.8; 95% CI 0.4, 9.2). No significant difference in PSS levels was reported when PSRs were compered to GARs. Increased PSS scores were found to be associated with worse family functioning (Adj β = 4.2; 95% CI 1.0, 7.4), while decreased PSS scores were associated with increased age (Adj β = -0.4; 95% CI -0.6, -0.1).

CONCLUSION

A better understanding of the various underlying factors associated with elevated stress is essential for improving the quality of life for SRs in Canada. Results of the study may help tailor more effective preventative measures or government interventions dedicated to reducing stress levels among this population.

Refugee Resettlement: Case Studies of Two Syrian Women in Rhode Island

BACKGROUND

Key elements of social integration of refugees overlap with the social determinants of health. Limited research exists about Syrian refugees' resettlement in Rhode Island (RI).

METHODS

Case study life history method: Two Syrian women in RI were interviewed and observed longitudinally. Content analysis cycles led to emerging topics. Key informant interviews informed the question guide.

RESULTS

Several themes emerged: (1) Interpreters, community health workers (CHWs), and patient navigators help access healthcare; (2) Education about healthcare maintenance is important; (3) Anti-refugee bias has compromised safety and psychosocial wellness; (4) Although hard work is prioritized, high hopes for education and employment conflict with reality; and (5) Syrian women have unique experiences during resettlement.

CONCLUSIONS

RI leaders can address resettlement challenges through investment in CHW programs, peer-led health initiatives, English language education, interpreter services, psychosocial support, migrant rights education, social opportunities, and job training and matching.

Views and experiences of family physicians about Syrian refugee patients in Turkey: a qualitative research

AIM

The aim of this study was to describe the attitudes, views and solution proposals of family physicians (FPs) about primary healthcare problems of Syrian refugee patients. This study would be the very first study for Turkey that evaluates the attitudes, views and solution proposals of FPs about primary healthcare problems of Syrian refugee patients.

BACKGROUND

Following the anti-regime demonstrations that started in March 2011, the developments in Syria created one of the biggest humanitarian crises in the world and the largest number of asylum seekers continue to be hosted in Turkey. There are some studies evaluating asylum seekers' access to healthcare services in Europe, and the common result is that refugees have free access to primary healthcare services in most countries; however, they face many obstacles when accessing primary healthcare services. While there are studies in the literature evaluating the situation of access to primary healthcare services from the perspective of asylum seekers; there are few studies evaluating the opinions/views of FPs.

METHODS

A qualitative methodology informed by the grounded theory was used to guide the research. A total of 20 FPs were interviewed face to face through semi-structured interviews, using 12 questions about their lived experience and views caring of refugee population. Interviews were analysed thematically.

FINDING

The following themes were revealed: Benefiting from Primary Health Care Services, Benefiting from Rights, Differences Between the Approach/Attitudes of Turkish Citizens and Refugees, Barriers to Healthcare Delivery, Training Needs of Physicians, Solution proposals. FPs reported that there is a need for support in primary care and a need for training them and refugees in this regard and they specified refugee healthcare centres are the best healthcare centres for refugees; however, the number of these and provided services should be increased.

Conducting research on building psychosocial support for Syrian refugee families in a humanitarian emergency

Background

This case study describes research, which is located in Turkey, where more than 750,000 Syrian refugees reside autonomously in Istanbul. The research developed and pilot tested a novel model for helping urban refugee families with limited to no access to evidence-based mental health services, by delivering a transdiagnostic family intervention for common mental disorders in health and non-health sector settings using a task-sharing approach. This case study addresses the following question: What challenges were encountered in developing and piloting a low intensity trans-diagnostic family support intervention in a humanitarian emergency setting?

Discussion

The rapidly growing scale of humanitarian crises requires new response capabilities geared towards addressing populations with prolonged high vulnerability to mental health consequences and limited to no access to mental health, health, and social resources.

The research team faced multiple challenges in conducting this research in a humanitarian emergency setting including: 1) Non-existent or weak partnerships geared towards mental health research in a humanitarian emergency; 2) Lack of familiarity with task-sharing; 3).

Insufficient language and cultural competency; 3) Fit with families’ values and demands; 4) Hardships of urban refugees. Through the research process, the research team learned lessons concerning: 1) building a coalition of academic and humanitarian organization partners; 2) investing in the research capacity building of local researchers and partners; 3) working in a community-collaborative and multi-disciplinary approach.

Conclusion

Conducting research in humanitarian emergency settings calls for innovative collaborative and multidisciplinary approaches to understanding and addressing many sociocultural, contextual, practical and scientific challenge.

Explanatory models and help-seeking for symptoms of PTSD and depression among Syrian refugees

OBJECTIVE

This study investigates how Syrian refugees explain and prefer to seek help for symptoms of post-traumatic stress disorder (PTSD) and depression.

METHODS

We conducted five semi-structured focus group interviews based on a vignette-technique with Syrian refugees (n = 21 men, n = 10 women). The vignettes describe a fictional person suffering from symptoms of PTSD or depression in line with DSM-5 and ICD-10 criteria.

RESULTS

Despite never mentioning PTSD, participants in the PTSD-interviews recognized the symptoms. They perceived them as a common reaction to extreme situations, mainly the war, the flight, and post-migratory stressors. Depression was labeled as either depression or feelings caused by social problems, and the participants were more hesitant to identify with these symptoms. Despite some differences, both the PTSD and depression vignettes were explained in terms of situational explanatory models and externally caused stress. The main finding is how participants described changing stressors resulting from migration and resettlement leading to a difference in how they would seek help in Syria and in Norway. Specifically, we found that preferred help-seeking and coping strategies are contextual.

CONCLUSIONS

These findings point to the need to consider transformations following forced migration when studying aspects of explanatory models, preferred help-seeking, and coping strategies in refugee groups.

Identifying the impact of social networks on mental and emotional health seeking behaviours amongst women who are refugees from Syria living in Canada

Between 2015 and 2017, over 24,000 Syrian women came to Canada as refugees. Refugees are two to three times more likely than native Canadians to suffer from depression and other mental health challenges. A qualitative approach was taken to understand roles of social networks in shaping the mental and emotional health resource-seeking behaviours of twelve Syrian women who are refugees. Semi-structured telephone interviews were conducted in both English and Arabic. Interviews were audio-recorded, transcribed, and thematically coded using NVivo 12. Findings reveal that (1) families play large roles in teaching and providing information about Canada's health system, including mental health services; (2) Social networks influence assumptions about mental and physical health services; (3) women feel more welcomed into social networks in Canada than in countries of first asylum; and (4) social networks act as alternatives to seeking formal mental and emotional health care. Through first-hand stories and experiences of Syrian women's transitions into Canada, this study identifies the ways in which social networks may help or hinder engagement with mental and emotional health services.

What do we Know about Bullying in Syrian Adolescent Refugees? A Cross Sectional Study from Turkey : (Bullying in Syrian Adolescent Refugees)

The aim of this study was to assess the bullying status of Syrian adolescent refugees in Turkey and identify factors that contribute to bullying. The adolescents aged between 12 and 16 years and who live in Kilis as a Syrian refugee assessed between the dates 01.01.2019-01.01.2020. Currently, 119 children and adolescents were enrolled in the study. Kiddie-Schedule for Affective Disorders and Schizophrenia (present and life time version - K-SADS-PL) was applied by a specialist of child and adolescent psychiatry. The Sociodemographic Data Form, The Strengths and Difficulties Questionnaire (SDQ) and Olweus Bully/Victim Questionnaire (OBVQ) were used for assesment of children and adolescents. Of the study sample, 31 adolescents (27.1%) were diagnosed with at least one psychiatric disorder. The most prevalent psychiatric disorder was Other Specified Trauma and Stressor Related disorder (13.4%) and Post- traumatic stres disorder (6.7%). The prevalence of bullying and victimization was found as 58.9%. The boys group was significantly more likely to be bully and both victim and bully (p = 0.04, p = 0.001* respectively) compared to the girls group. Our results demonstrate that besides the past experiences related to war and immigration, the adolescent refugees experienced bullying consequences of being a refugee in Turkey.

Longitudinal investigation of the relationships between trauma exposure, post-migration stress, sleep disturbance, and mental health in Syrian refugees

Background High prevalence of sleep disturbance, which is associated with poor mental health, has been observed among non-treatment seeking refugees. However, no longitudinal research has investigated the chronicity of untreated sleep disturbance and its impact on refugees' mental health.

OBJECTIVE

This longitudinal study investigated associations between mental health (posttraumatic stress disorder, anxiety, depression), sleep symptoms (insomnia severity, pre-sleep arousal), and factors predicting mental health, over a 12-month period.

METHOD

Syrian refugees (N = 69) from a cross-sectional study (Time 1) participated in the current 12-month (Time 2) follow-up study. Participants completed a series of questionnaires examining sleep, trauma exposure, post-migration living difficulties, and mental health at both time points.

RESULTS

When compared to Time 1, participants showed a significant increase in post-migration stress at Time 2. However, there was an improvement in their mental health and levels of sleep disturbance. Half of the participants met criteria for moderate (36%) or severe sleep disturbance (15%) at Time 2. Forty-two per cent of the participants had moderate to severe sleep disturbance at both Time 1 and Time 2. When predicting mental health at 12-month follow-up, only pre-sleep arousal at Time 1 uniquely predicted mental health at Time 2. Mediation analysis indicated that change in pre-sleep arousal (from Time 1 to Time 2) significantly mediated the relationship between change in post-migration stress and change in mental health symptoms.

CONCLUSIONS

This study demonstrated that sleep symptoms have an indirect and long-term impact on mental health among refugees. Understanding modifiable factors, such as sleep, mediating the relationship between trauma exposure and PTSD symptoms is important, as such factors can be targeted in psychological interventions for refugees.

The Relationship Between the Types of Traumatic Events and Well-Being, Post-Traumatic Stress Levels and Gender Differences in Syrian Patients: A Cross-Sectional Controlled Study

This study aims to compare the types and frequency of traumatic events in Syrian patients. Additionally, the study investigates the relationship between the types of traumatic events and post-traumatic stress and mental well-being based on gender differences among the Syrians. Sociodemographic form, the Stressful Life Events Screening Questionnaire, the WHO-5 Well Being Index, and the Impact of Event Scale-Revised were administered to the Syrian volunteers (n = 207) and a control group. The total number of traumatic experiences were higher in the patient (study) group and men compared to the healthy control group and women. The most significant predictors of the variables for the level of traumatic symptoms were total number of traumatic experiences and having lived in a war zone. Traumatic stress symptoms may be associated with the number and continuity of traumatic events. The number of traumatic events in Syrians could be higher in males. Mental well-being is more associated with daily stress factors than traumatic experiences. Therefore, post-migratory risk and protective factors need to be investigated to comprehend PTSD.

The health-related quality of life of Syrian refugee women in their reproductive age

Background

Health-Related Quality of Life (HRQoL) for refugee women in reproductive age is highly affected by physical, political, psychosocial and environmental conditions in countries of asylum. HRQoL is enormously affected by the satisfaction of this vulnerable group with the physical, psychological, emotional and social care services provided in this critical time. Therefore, this study aimed toassess the HRQoL among Syrian refugee women of reproductive age living outside camps in Jordan.

Methods

A cross-sectional correlational study was conducted with a convenience sample of 523 Syrian refugee women in the host communities in Jordan.Health-related quality of life (HRQOL) was measured using the short-form 36 (SF-36) questionnaire.

Results

Significant negative correlations were found between SF-36 individual subscales score and the length of marriage, the number of children, parity and family income. The strongest correlations were between pain scale and length of marriage (r =  − .21), and between Energy/Fatigue and ‘number of children’ (r =  − .21). Conversely, antenatal care was positively correlated with physical, role emotional, pain, and general health. Physical functioning and general health were predicted significantly with less years of marriage, younger age at marriage, less violence and by higher family income.

Conclusion

This study suggests low HRQoL scores for women of reproductive age across all domains. Several factors such as years of marriage, age at marriage, the number of children, violence, antenatal care and family income affected the women’s general health. The provision of appropriate and accessible reproductive and maternal healthcare services in antenatal visits is critical for ensuring the immediate and long-term health and wellbeing of refugee women and their families.

Comparison of hearing screening results of Syrian refugees and Turkish newborns

OBJECTIVE

To analyze Turkish (Host) and Syrian (Refugee) newborn hearing screening results and factors of risk.

METHODS

All newborns between 02.12.2017 and 31.06.2019 were screened with Automated Auditory Brainstem Response (AABR) test. A total of 874 newborns were examined (172 refugee and 702 host newborns). All screened patients were questioned in terms of consanguineous marriage, speech disorder in family, delivery method (normal vaginal birth/caesarean birth), birth weight, birth week, newborn intensive care unit (ICU) necessity, newborn icterus and phototherapy.

RESULT

As for the host newborns, 360 (51.3%) passed ABR screening, 161 (23%) failed in either one ear, and 181 (25.8%) failed both ears. As for the refugee newborns, 60 (34.9%) passed ABR screening, 38 (22.1%) failed in either one ear, and 74 (43.0%) failed both ears. There was a significant statistical difference between host and refugee newborns' ears in terms of hearing loss detected in the screening test (p = 0.017). In terms of delivery method, the caesarean rate was higher in refugees, and a statistically significant difference existed between two groups (p = 0.023). There was a significant difference between refugee newborns and host newborns in terms of newborn ICU necessity rate (p = 0.014).

CONCLUSIONS

It was demonstrated clearly that hearing screening test results between the two groups were affected by low socio-economic level when host and refugees newborns were compared. In line with the findings of this study, it should be taken into account that bad living conditions depending on war and immigration throughout pregnancy, delivery method, and the need for newborn ICU in the newborn period may affect hearing results in newborns significantly.

Mental health of Syrian refugee adolescents: how far have we come?

Akgül S, Hüsnü Ş, Derman O, Özmert E, Bideci A, Hasanoğlu E. Mental health of Syrian refugee adolescents: how far have we come? Turk J Pediatr 2019; 61: 839-845. Among the consequences of war, its impact on the mental health of children and adolescents is one of the most significant. A previous study from our team evaluated the psychiatric symptoms of Syrian refugee adolescents living in one of Turkey`s Temporary Accommodation Centers (TACs) in 2016. Findings suggested that mental health had been compromised in these teens. Since then many measures have been taken to address this problem. The aim of the current study was to re-assess the mental health status of adolescents living in the same center. A total of 76 adolescents (35 female, 41 male) aged between 12-18 years (14.2 ± 0.83 years) received the Brief Symptom Inventory (BSI) which assessed their anxiety, depression, negative self-concept, somatization and hostility levels in addition to a Global Severity Index (GSI). Results > 1.0 indicated psychopathological symptoms. All BSI sub-scores decreased from 2016 to 2019 showing significant improvement in psychopathological symptoms. The most significant change was in the GSI score which decreased from 2.15 to 0.8. For the 2019 participants a significant correlation was found between years of stay at the camp and the depression subscale. Evaluation to assess gender differences found that adolescent girls reported significantly higher scores than males in anxiety, depression, somatization and the global severity index. This study has shown that interventions designed to tackle post-traumatic stress symptomology may have been effective in improving the mental health status of these teens and can provide a roadmap for tackling existing issues in vulnerable conditions. Additionally, females are under higher risk for psychopathology so gender targeted interventions may specifically be necessary to deal with such issues.

Comparison of the Macronutrient Content of Colostrum: Locals with Refugees

Background: Breast milk (BM) is considered the ideal and natural way of feeding for all infants. Although previous studies evaluated the factors influencing the content of BM, data concerning the effect of being a refugee on macronutrient contents of BM are rather inadequate. Therefore, we aimed to compare the macronutrient content of colostrum samples of Turkish and Syrian mothers. Materials and Methods: BM from lactating mothers who delivered term newborns was collected within the first 48 hours of lactation. Milk protein, fat, carbohydrate, and energy levels were measured by using a mid-infrared human milk analyzer. Demographic characteristics of the mothers and the infants were recorded. Results: Colostrum samples of 180 lactating mothers (Turkish: 96, Syrian: 84) were obtained. There were no significant differences between the groups in terms of body mass index of the mothers, mode of delivery, and infant gender. However, Syrian mothers gained less weight during pregnancy compared with Turkish mothers (p = 0.029). The median protein, fat, and energy levels of colostrum samples were found to be significantly higher in Turkish mothers than in Syrian mothers (p = 0.001, p = 0.017, p < 0.001, respectively). Cesarean delivery and being a Syrian refugee were independently associated with lower protein content of colostrum in logistic regression analysis. Conclusion: Lactating mothers who delivered their babies through vaginal route were found to be advantageous in terms of colostral protein content. Also, an association between being a refugee and lower protein content of colostrum was remarkable.

Vaccination rates for Syrian population under temporary protection in Turkey

OBJECTIVES

The aim of this study was to gather information on demographic and health indicators, primarily vaccination status, of Syrians under temporary protection in five provinces of Turkey and to develop infrastructure for vaccination planning.

METHODS

The population under study consists of 89,986 Syrian children, 0-4 years of age, residing in Ankara, Mersin, Gaziantep, Izmir, and Bursa. Initially, we planned to evaluate 2,339 children, although a total of 2,827 children were evaluated by the end of the study.

RESULTS

Of these children, 74% were born in Turkey, while 20% were born in Syria. In addition, 22.4% (n = 634) of the children were never vaccinated, and of these, 67.0% (n = 425) were born in Turkey. In other words, one in five Syrian children born in Turkey (20.3%) had never been vaccinated. Of the Syrian children under temporary protection, the missing vaccinations were as follows: hepatitis B (54.7%); Bacillus Calmette-Guérin (62.5%); five-component combined vaccine (64.6%); conjugated pneumococcal vaccine (58.0%); oral polio vaccine (70.8%); measles, mumps, and rubella (76.6%); varicella (66.8%); and hepatitis A vaccine (76.0%).

CONCLUSION

It is important to increase the immunization rates of Syrian children under temporary protection and establish regular vaccination procedures.

Psychiatric symptoms in traumatized Syrian refugee children settled in Hatay

Aim: After the beginning of the Syrian civil war in 2011, its cruelty and violence forced about millions to leave their homes. These experiences might create serious mental problems, especially in children and adolescents who might have an increased risk of developing post-traumatic stress disorder (PTSD) and depression. In this study, we aimed to investigate the mental health status of Syrian refugee children who exposed to a variety of traumatic events.Method: The sample consisted of 1518 drug-naive Syrian refugee children and adolescents aged between 8 and 16 years who were admitted to the Child and Adolescent Psychiatry Department in Hatay State Hospital between June 2016 and December 2018. The CRIES-13 (Children's Revised Impact of Event Scale-13) was used to evaluate PTSD symptoms and CDI (Children's Depression Inventory) was used to examine depressive symptoms. The sample was divided into three groups according to the type of trauma and the CRIES-13 and CDI scores were compared between the groups.Results: The mean age of the children was 12.4 ± 3.1. 46.9% of the children were male and 53.1% were female. The total score and intrusion and arousal subscores of CRIES-13 were significantly different between the three groups. The total CDI score was also significantly different between the three groups. The likelihood rates of PTSD and depression differed significantly between the groups.Conclusion: Traumatized Syrian refugee children may present PTSD symptoms more likely than depressive symptoms. War-related traumatic experiences may have more adverse effects on Syrian children's psychology than other traumas.

Trends in the performance of Syrian physicians in the National Resident Matching Program® between 2017 and 2019

Purpose:

International medical graduates (IMGs) make up one-fourth of the physician workforce in the US and a significant proportion of them come from Syria. The aim of this study was to assess the performance of Syrian physicians seeking residency positions in the US and to examine the effects of visa restrictions on their Match outcome.

Methods:

An online survey administered to IMGs from Syria was used to probe their residency application characteristics as well as their experiences with visa restrictions. We evaluated the factors that affected their Match outcome and number of interviews offered to applicants.

Results:

A total of 223 IMGs from Syria completed the survey with an average match rate of 70.4% (76.6% in 2017 vs. 69.9% in 2018 vs. 64.4% in 2019). The proportion of applicants who required visas was 29.2%. In a multivariate analysis, higher USMLE Step 2CK score increased the match rate, whereas requiring a visa and failure in any USMLE exam decreased the match rate. Among those requiring visa, the match rate decreased from 78.6% in the cycle before the travel ban (2017) to 64.9% in the cycles following the travel ban (2018 and 2019) (P = 0.22). Similarly, the total number of interviews offered to these applicants decreased significantly following the travel ban (9.4 [7.5] vs. 6.2 [5.3], P = 0.04).

Conclusion:

Syrian IMGs seeking residency positions in the US have a higher match rate than non-US IMGs. Requiring a visa and failing any USMLE exam negatively impacted the match rate and number of interview invitations to Syrian applicants.

Treatment of multiple sclerosis in special populations: The case of refugees

Multiple sclerosis was long considered a relatively rare entity in the Middle East, but research over the past 10 years and the publication of the Middle East North Africa Committee for Treatment and Research in Multiple Sclerosis guidelines for multiple sclerosis have allowed diagnosis and treatment to occur more efficiently. Most of the first and second-line disease-modifying therapies approved by the Food and Drug Administration and the European Medicine Agency are available in the Middle East. However, the availability of disease-modifying therapies is quite variable, with some countries having access to all multiple sclerosis disease-modifying therapies, while in others there is only one therapeutic option. Economic limitations remain a challenge for the management of multiple sclerosis, especially in countries of war. Moreover, the burden of multiple sclerosis treatment in Syrian and Palestinian refugees is likely high due to the non-availability of funds to cover the high cost of disease-modifying therapies.

Predictors of adverse maternal and perinatal outcomes in a refugee population from an active conflict country, Syria

Objective

To elucidate predictors of adverse maternal and perinatal outcomes in refugees emigrating from an active conflict region (Syria).

Materials and Methods

This study included Syrian pregnant women who gave birth in Etlik Zübeyde Hanım Training and Research Hospital between 2013 and 2016. Adverse perinatal outcomes were defined as preterm labor, premature rupture of membranes, early membrane rupture, intrauterine growth retardation, hypertension, perinatal excites, and erythrocyte-transfused cases. Factors associated with those adverse outcomes were assessed using multiple logistic regression analysis.

Results

Having an active smoking habit [odds ratio (OR): 2.647, 95% confidence interval (CI): 1.767-3.965; p<0.001], obesity (OR: 2.272, 95% CI: 1.396-3.699; p=0.001), and adolescent age (OR: 1.732, 95% CI: 1.204-2.491; p=0.003) were found to be the most important predictors of adverse maternal and perinatal outcomes. Eighty of 129 (62%) smokers, 45 of 81 (55.65%) obese individuals, and 91 of 169 adolescents (53.8%) had adverse maternal and perinatal outcomes.

Conclusion

Prevention strategies for obesity, smoking, and adolescent pregnancies should be implemented primarily to reduce maternal and antenatal adverse outcomes. Pregnant women with these risk factors in a refugee community emigrating from a conflict-zone nation should be followed up closely.

Oral health-related quality of life among Syrian refugees in Jordan: a cross-sectional study

INTRODUCTION

Reports examining the impact of oral health on the quality of life of refugees are lacking. The aim of this study was to examine factors influencing oral health-related quality of life (OHRQoL) among Syrian refugees in Jordan.

METHODS

A cross-sectional survey was conducted on a convenience sample of Syrian refugees, who attended dental clinics held at Azraq camp. The survey assessed the refugees' oral hygiene practices, and measured their OHRQoL using the Arabic version of the United-Kingdom Oral Health-Related Quality of life measure.

RESULTS

In total, 102 refugees [36 male and 66 female; mean age 34 (SD = 10) years] participated. Overall, 12.7% did not brush their teeth and 86.3% did not use adjunctive dental cleaning methods. OHRQoL mean score was 56.55 (range 32-80). Comparison of the physical, social and psychological domains identified a statistically significant difference between the physical and the psychological domain mean scores (ANOVA; P = 0.044, Tukey's test; P = 0.46). The factors which revealed association with OHRQoL scores in the univariable analyses, and remained significant in the multivariable linear regression analysis, were: age (P = 0.048), toothbrushing frequency (P = 0.001) and attending a dental clinic in the last year (P = 0.004).

CONCLUSION

The physical aspect of quality of life was more negatively impacted than the psychological aspect. Toothbrushing frequency and attending a dental clinic at least once in the last year were associated with more positive OHRQoL scores. Older refugees seemed to be more vulnerable to the impact of poor oral health on OHRQoL.

Obstetric Outcomes of Syrian Refugees and Turkish Citizens

BACKGROUND

To present the differences in prenatal, labor and neonatal outcomes for Syrian refugees and Turkish citizens.

METHODS

Between January 2013 and December 2016, all patients in our hospital were screened retrospectively. Totally, 17000 pregnant women included in the study were divided into three groups: group 1: 4802 pregnant in Syrian refugees group; group 2: 6752 pregnant in the low-income Turkish citizens (LI groups); and group 3: 5446 women in high-income Turkish citizens (HI groups). The groups were compared for demographic parameters, prenatal, labor and postnatal results.

RESULTS

Age, gestational week, birth weights, antenatal follow-up, antenatal iron supplementation and prenatal hemoglobin (Hb) values were significantly lower in the Syrian refugee group (P < 0.001). Only moderate preterm delivery and moderate low birth weight were higher in the refugee group (P = 0.023 and P = 0.001). Stillbirth rates were similar in all three groups (P = 0.203), but all other neonatal complications were higher in the Turkish citizens group.

CONCLUSION

In comparison to non-refugee control patients, adverse perinatal outcomes were not observed in pregnant refugees. The refugee health policies of the Republic of Turkey seem to be working. However, further larger multicenter studies may provide more convincing data about obstetric outcomes and health results in the Syrian refugee population.

Dimensional Structure and Cultural Invariance of DSM V Post-traumatic Stress Disorder Among Iraqi and Syrian Displaced People

While the factor structure of post-traumatic stress disorder (PTSD) symptoms has been investigated among various traumatized populations in Western and high-income countries, knowledge regarding the validity of factor structure of PTSD among culturally diverse populations in low-and-middle-income countries is limited. The current study examined the factor structure and cultural invariance of PTSD in 521 Iraqi and 993 Syrian war-affected displaced people who were living in the Kurdistan Region of Iraq. Results from confirmatory factor analyses demonstrated that alternative factor models for PTSD, including a new model derived from this population (anhedonia and affect model) resulted in a better fit than the current DSM V models. Taken together, the results showed that a good fit, as well as the measurement invariance of PTSD factors, could be obtained by applying the anhedonia and hybrid model. This study provides further support for the anhedonia and hybrid model of PTSD and fills an important gap in knowledge about the validity of PTSD symptom clusters among Arab and Kurdish populations.

Neonatal outcomes in Syrian and other refugees treated in a tertiary hospital in Turkey

Background/aim

Turkey accepts refugees from many countries, principally Syria. More than 2.7 million refugees live in Turkey.We evaluated the neonatal outcomes of refugees.

Materials and methods

We retrospectively reviewed the clinical and demographic characteristics of refugee infants born in our hospital between August 2013 and September 2016.

Results

Refugees (718 Syrian, 136 Iraqi, 32 Afghani, and 21 of other nationalities) accounted for 907 of 49,413 births. The mean refugee maternal age was lower than that of Turkish women, whereas the gestational age (GA) and birthweight were similar. Refugees required fewer cesarean sections but exhibited greater small- and large-for-GA rates (P < 0.05). Refugee and Turkish infant mortality rates did not differ significantly (0.8 vs. 0.4%). Eighty-nine (12.3%) refugee neonates and 6682 (13.5%) Turkish neonates were admitted to our neonatal intensive care unit (NICU). Jaundice and perinatal asphyxia were significantly more common in refugees, whereas respiratory distress syndrome, GA ≤32 weeks, and infant birthweight <2000 g were more common in Turkish infants. The total NICU admission cost of approximately 450,000 USD was paid by the Turkish government.

Conclusion

The numbers of refugees and refugee births continue to grow. The Turkish people and government have provided medical, social, and economic support to date; international assistance is needed.

The oral health status of Syrian refugee children in Jordan: An exploratory study

OBJECTIVES

To examine the oral health status and dental treatment needs of children Syrian refugees in Jordan.

METHODS

A convenience sample of Syrian refugee children who aged between 6 and 12 years at al-Zaatari camp was used for the purpose of this study. Examination was performed according to the method proposed by WHO. DMFT and gingival indices were examined and reported by a trained dentist.

RESULTS

A total of 125 children were examined. The mean DMFT score was 3.64 ± 9.83, and the mean dmft score was 2.98 ± 4.7. More than half of children (50.4%) were found to have high caries risk according to CAMBRA scale. Most of the DMFT score was contributed by decayed and missing teeth. Nearly, half of children (44.8%) showed fluorosis and almost all children had chronic gingivitis. More than half of the participants (55.2%) reported that they needed dental treatment during their stay at the camp, but only half (52%) received treatment mainly tooth extraction and prescription of medication. Only 6.4% of children received conservative dental treatment.

CONCLUSION

Syrian refugee children in Jordan were found to have high levels of unmet dental needs. Accessibility of dental services was found to be a primary barrier to care.

External fixation for primary and definitive management of open long bone fractures: the Syrian war experience

AIMS

To report on the experience of one field hospital in using external fixation as a primary and definitive treatment for open long bone fractures during the Syrian war.

METHODS

A total of 955 patients with open long bone fractures (femur, tibia, humerus) who were operated and followed up at a field hospital in Aleppo, Syria, from 2011 to 2016, were retrospectively reviewed. Different types of uniplanar and some multiplanar external fixators were used solely as a primary and definitive tool until bone union was achieved. Union rate and infection rate were reported in association with age, gender, Gustilo/Anderson classification, type of fixator, and presence of neurovascular injuries.

RESULTS

Out of 955 patients, 404 (42.3%) continued to follow up until bone union or until removal of the external fixator. The average age was 27.5 ± 11 years, with 91.6% males and 8.2% females. The overall union rate was 68.3% (276/404), with 60.9% (95/156) in open femur, 70.3% (137/195) in open tibia, and 83% (44/53) in open humerus fractures. The overall infection rate was 16.7% (67/401), with 18.6% in open femur, 18.1% in open tibia, and 5.8% in open humerus fractures.

CONCLUSION

The use of external fixation for definitive treatment of open long bone shaft fractures caused by high energy trauma during times of wars or conflicts is reliable and should be used in early frontline intervention and in areas with limited access to resources.

Investigation of the mtDNA mutations in Syrian families with non-syndromic sensorineural hearing loss

OBJECTIVE

Hearing loss is a common sensory disorder, and at least 50% of cases are due to a genetic etiology. Several mitochondrial DNA mutations (mtDNA) have been reported to be associated with nonsyndromic hearing loss (NSHL) in different population. However, There is no previous available data about the frequency of mtDNA mutations as etiology for deafness in Syrian. The aim of present study is to investigate the incidence of common mt DNA mutations in our families with congenital hearing loss and not related to the ototoxicity or aminoglycosides.

METHODS

A total of 50 deaf families were enrolled in the present study. Direct sequencing and PCR-RFLP methods were employed to detect seven mt DNA mutations, including A1555G, A3243G, C1494T, G3316A, T7510C, A7445G, and 7472insC.

RESULTS

Our results revealed a high prevalence of mt DNA mutation (10%) in deaf families (5/50). In surprising, the unexpected mutations were observed. The G3316A mutation was found in 2 families as homoplasmic genotype. Also, we found the homoplasmic and heteroplasmic genotype for the C1494T mutation in two families. In one family the heteroplasmic genotype for T7510C mutation was observed; this family harbor 35delG mutation in GJB2 gene. None of the common mtDNA mutations (A1555G, A3243G) and other mutations (A7445G, 7472insC) were detected here.

CONCLUSION

Our findings indicate to significant contribution of the mt DNA mutations in our families with NSHL. The presented data is the first report about mt DNA and it will improve the genetic counseling of hearing impaired in Syrian families.

Improving peace and well-being among Syrian refugee youth through a higher education initiative in Jordan

Forced migration affects overall health, especially when it happens at a young age. Focus group discussions and the Peace Evaluation Across Cultures and Environments (PEACE) survey were used to compare the effects of the programme on two groups: refugee university students who received full tuition support and a monthly living stipend (intervention group) and unsponsored Syrian students who were preparing for the end of high school examination (control group). The overall mean PEACE score among the intervention group was 152.0 (95% confidence interval [CI]: 147.4-156.5), while the control group mean score was 134.1 (95% CI: 129.1-139.1), p < 0.01. In addition to significantly higher mean total PEACE scores, the intervention group demonstrated better results for each of the seven constructs in the scale (t-test p < 0.05), with the largest differences seen in personal safety, group cohesion and agency. This effect was further elucidated in the focus group discussions, highlighting the psychosocial benefits of the scholarship programme due to improvements in their academic and financial status. This combined education and economic intervention for Syrian refugee youth has measurable positive effects on feelings of peace, security and well-being and can be used as a framework from which to design similar initiatives in other contexts of displacement.

HLA class I alleles frequencies in the Syrian population

Objective

The HLA system is known to be the most polymorphic genetic loci in humans. Distribution and frequencies of HLA alleles are highly variable among different human ethnic groups. The HLA system has an important role in disease susceptibility and resistance, especially in autoimmune diseases and cancer. This study is the first report about HLA genetic variability and haplotypes among Syrians. Frequency of the HLA class I (A, B and C) alleles was determined in 105 healthy unrelated Syrian individuals from different regions in Syria. We also studied the associated haplotypes frequencies. Alleles frequencies were compared with those reported for other populations.

Results

Fifty-eight HLA class I alleles were observed in Syrians including 15 for HLA-A, 28 for HLA-B and 15 for HLA-C. We observed 37 HLA-A/C haplotypes, 32 B/C, and 31 A/B haplotypes. The most frequent haplotypes were A*01/C*04, A*02/C*07, A*02/B*35, and B*35/C*04. In conclusions, our preliminary study suggests a high variability in HLA class I alleles in the Syrian population. This study also gives a general reference database about the genetic pool distribution of HLA class I alleles among Syrians and can be consulted for HLA related diseases.

Health and health care access for Syrian refugees living in İstanbul

OBJECTIVES

The study was conducted to assess the health needs of urban refugees living in İstanbul.

METHODS

A mixed methods approach was adopted to interview Syrian women from households, doctors, decision makers and NGO representatives. The data were collected between June and October 2015.

RESULTS

The main challenges were the cost of living in İstanbul, increased rent and language barrier. Almost half (49.6%) of the interviewed women did not know about free health care rights for Syrians. In the last 30 days preceding the interview, 58.6% of the participants sought health care primarily through state hospitals, primary health care centres and pharmacies. The participants had difficulty in accessing health care due to the language barrier and a lack of knowledge of the Turkish health care system. Waiting time at hospitals and negative attitudes of health care staff reduced satisfaction in these services.

CONCLUSIONS

In relation to life in Turkey, the main issues for Syrian refugees were not directly related to health. They have been given the right to access health care, although had many difficulties in understanding and accessing services in a crowded city.

User-Centered App Adaptation of a Low-Intensity E-Mental Health Intervention for Syrian Refugees

Introduction: The aim of this study is to describe the initial stages of the iterative and user-centered mobile mental health adaptation process of Step-by-Step (SbS), a modularized and originally web-based e-mental health intervention developed by the World Health Organization (WHO). Given the great need for improving the responsiveness and accessibility of health systems in host countries, the EU-funded STRENGTHS consortium studies the adaptation, implementation and scaling-up of SbS for Syrian refugees in Germany, Sweden and Egypt. Using early prototyping, usability testing and identification of barriers to implementation, the study demonstrates a user-centered process of contextual adaptation to the needs and expectations of Syrian refugees. Materials and Methods: N = 128 adult Syrian refugees residing in Germany, Sweden and Egypt took part in qualitative assessments. Access, usage, and potential barriers regarding information and communication technologies (ICTs) were assessed in free list interviews. Interactive prototypes of the app were presented in key informant interviews and evaluated on usability, user experience and dissemination strategies. Focus groups were conducted to verify the results. The interview protocols were analyzed using inductive and deductive thematic analysis. Results: The use of digital technologies was found to be widespread among Syrian refugees. Technical literacy and problems with accessing the internet were common barriers. The majority of the respondents reacted positively to the presented app prototypes, stressing the potential health impact of the intervention (n = 28; 78%), its flexibility and customizability (n = 19; 53%) as well as the easy learnability of the app (n = 12; 33%). Aesthetic components (n = 12; 33%) and the overall length and pace of the intervention sessions (n = 9; 25%) were criticized in regard to their negative impact on user motivation. Acceptability, credibility, and technical requirements were identified as main barriers to implementation. Discussion: The study provided valuable guidance for adapting the app version of SbS and for mobile mental health adaptation in general. The findings underline the value of contextual adaptation with a focus on usability, user experience, and context specific dissemination strategies. Related factors such as access, acceptability and adherence have major implications for scaling-up digital interventions.

A community-based survey on Syrian refugee women's health and its predictors in Şanliurfa, Turkey

Reproductive characteristics, mental health symptoms, micronutrient deficiencies, and symptoms of sexually transmitted infections (STIs) were determined among married Syrian refugee women aged 15-49 years who were living outside of camps in 2015, using probability sampling. Of the 458 participants, 51.3 percent married before the age of 18 years. Early-age marriages and number of desired children increased after the war. In multivariable analyses, education (adjusted odds ratio [aOR] = 1.2; 95% confidence interval [CI] = 1.2-1.3) and length of stay in Şanlıurfa (aOR = 1.2; 95% CI = 1.1-1.2) were independently associated with early marriage. Approximately 16 percent of women were pregnant, and 26.7 percent of them had not received prenatal care; 47.7 percent had had a pregnancy loss; 50.8 percent reported symptoms of STIs. Of those who were sexually active, 37.8 percent were not using contraception. The prevalence of iron, B₁₂, and folic acid deficiencies was 50 percent, 45.6 percent, and 10.5 percent, respectively. Early marriage (aOR = 2.2; 95% CI = 1.4-3.5) and number of desired children (aOR = 5.03; 95% CI = 3.2-7.9) were associated with not using contraception. Most (89.7 percent) women reported at least two mental health symptoms; lack of social support (aOR = 2.6; 95% CI = 1.3-5.3), language barrier (aOR = 2.3; 95% CI = 1.01-5.2), and B₁₂ deficiency (aOR = 1.8; 95% CI = 1.01-3.4) were associated with such symptoms. The findings demonstrate the need for reproductive health and psychosocial services.

First report of prevalence c.IVS1+1G>A and del (GJB6-13S1854) mutations in Syrian families with non-syndromic sensorineural hearing loss

OBJECTIVE

Mutations in GJB2 and GJB6 genes are a frequent cause of congenital non-syndromic hearing loss (NSHL). Mutational screening has usually focused on coding region of GJB2 gene. A few studies have been conducted on the non-coding region and exon 1. c.IVS1+1G>A (a splice site mutation in GJB2 gene have been detected as disruptive mutation. Del (GJB6 D13S1830) is found in many populations, but del (GJB6 D13S1854) is reported from a few restricted countries. This study was carried out to investigate the prevalence of splice site mutation c.IVS1+1G>A and two common deletions in GJB6 gene as the genetic etiology of hearing impairment in 70 Syrian families.

METHODS

The frequency of the c.IVS1+1G>A mutation and two deletions were determined by PCR-RFLP and A multiplex PCR assay.

RESULT

Our results showed a high prevalence of IVS1+1G>A mutation (20%) and del(GJB6-D13S1854) (15.7%) in deaf families. The homozygous genotype (c.IVS1+1G>A/c.IVS1+1G>A) was observed in one family and the compound heterozygous genotypes (c.35delG/c.IVS1+1G>A) and (c.IVS1+1G>A/V153I) were observed in 7 families and one family respectively. Also, the heterozygous state (c.IVS1+1G>A/unknown) was detected in 5 families. The study of del((GJB6-D13S1854) was showed a compound heterozygous genotype del((GJB6-D13S1854)/c.IVS1+1G>A) in the same families (5 families) having heterozygous genotype of c.IVS1+1G>A mutation. Also, del(GJB6-D13S1854) is combined with c.35delG mutation in 2 families and it was observed in the heterozygous state del(GJB6-D13S1854)/unknown) in 4 families. In contrast, the del(GJB6-D13S1830) described in many population was absent in our patients.

CONCLUSION

Our findings indicate to significant contribution of the splice site mutation and del(GJB6-D13S1854) in our deaf families and these mutations were important causes of hearing impairment.

The Syrian civil war: The experience of the Surgical Intensive Care Units

Objective:

Since the civilian war in Syria began, thousands of seriously injured trauma patients from Syria were brought to Turkey for emergency operations and/or postoperative intensive care. The aim of this study was to present the demographics and clinical features of the wounded patients in Syrian civil war admitted to the surgical intensive care units in a tertiary care centre.

Methods:

The records of 80 trauma patients admitted to the Anaesthesia, General Surgery and Neurosurgery ICUs between June 1, 2012 and July 15, 2014 were included in the study. The data were reviewed regarding the demographics, time of presentation, place of reference, Acute Physiology and Chronic Health Evaluation II (APACHE II) score and Injury Severity Score (ISS), surgical procedures, complications, length of stay and mortality.

Results:

A total of 80 wounded patients (70 males and 10 females) with a mean age of 28.7 years were admitted to surgical ICUs. The most frequent cause of injury was gunshot injury. The mean time interval between the occurrence of injury and time of admission was 2.87 days. Mean ISS score on admission was 21, and mean APACHE II score was 15.7. APACHE II scores of non-survivors were significantly increased compared with those of survivors (P=0.001). No significant differences was found in the age, ISS, time interval before admission, length of stay in ICU, rate of surgery before or after admission.

Conclusion:

The most important factor affecting mortality in this particular trauma-ICU patient population from Syrian civil war was the physiological condition of patients on admission. Rapid transport and effective initial and on-road resuscitation are critical in decreasing the mortality rate in civil wars and military conflicts.