Accumulated environmental risk in young refugees - A prospective evaluation

Health condition of Afghan refugees residing in Iran in comparison to Germany: a systematic review of empirical studies

BACKGROUND

The re-emerging dominance of the Taliban in Afghanistan in 2021 caused a new wave of Afghan refugees heading Iran and neighboring countries. Iran in the Middle East and Germany in Europe are two major host countries to the largest populations of Afghan refugees. In both countries, several studies have been done to assess the health condition of refugees.

OBJECTIVES

To systematically review the existing literature to identify similarities and differences of health conditions of Afghan refugees living in the two countries, and to synthesize evidence on the health status and health care access of these populations.

METHODS

Related electronic databases and grey literature of Iran and Germany on the health of Afghan refugees were scanned and searched up for the period 2000-2020. Key terms were formed by combining "Afghan refugees or immigrants or populations or asylum seekers", "Physical or mental health", "Healthcare service or access or use", "Iran or Germany". Empirical studies were considered if they contained samples of Afghan refugees with particular outcomes for Afghans. Results were categorized for both countries in the three main areas of physical health, mental health, and access/use of healthcare services.

RESULTS

Nine hundred twenty-two documents were extracted, of which 75 full-texts were finally reviewed. 60 documents belonged to the health condition of Afghan refugees residing in Iran including 43 in physical health, 6 in mental health, 8 in healthcare access and use, and 3 in multiple aspects of health, and 15 belonged to Germany including 7 in physical health, 4 in mental health, 2 in healthcare access and use, and 2 in multiple aspects of health. A less explicit evaluation of the overall health condition of Afghan refugees was observable, particularly for Germany. While matches on the study subject exist for both countries, in comparison to Germany, we extracted more quantitative and qualitative health studies on Afghan refugees of the mentioned areas from Iran. German health studies were rare, less qualitative, and more on the health condition of diverse refugee groups in general.

CONCLUSIONS

Wide gaps and unanswered questions related to mental health and overall health status of the Afghan refugee population are observable, especially in Germany. Our systematic review identified the gap in evidence, which we would recommend to bridge using a wider lens to comprehensively assess the overall condition of refugees considering associations between health and socio-economic and cultural determinants instead of a one-dimensional approach. Further, within health studies on refugee populations, we recommend stratification of results by the country of origin to capture the within-group diversity among refugees with different countries of origin.

Aetiological research on the health of migrants living in Germany: a systematic literature review

BACKGROUND

Germany has become an important immigration country and health services need to adopt to meet the needs of an increasingly multicultural population. For public health planning, it is essential to understand the aetiology of health problems among migrant populations. The main objective was to systematically identify, evaluate and synthesise population-based studies that investigated exposure-outcome relationships among migrant groups in Germany.

METHODS

In November 2019, we searched PubMed and LIVIVO, and updated this search in November 2020, to identify peer-reviewed publications that fulfilled our eligibility criteria: English or German language; study on disease aetiology among major migrant groups in Germany, according to the latest microcensus; publication date from inception to 01 November 2020 and observational or experimental study designs. For quality appraisal, we used the Critical Appraisal Skills Programme checklists. Outcomes under investigation were categorised according to the WHO major disease groups, and their associations with risk factors were synthesised as a heat map.

RESULTS

Out of 2407 articles retrieved, we included 68 publications with a total number of 864 518 participants. These publications reported on cross-sectional data (n=56), cohort studies (n=11) and one intervention study. The population groups most frequently studied were from the Middle East (n=28), Turkey (n=24), sub-Saharan Africa (n=24), Eastern Europe (n=15) and the former Soviet Union (n=11). The outcomes under study were population group specific. There were consistent associations of demographic and socioeconomic factors with ill health among migrants in Germany.

DISCUSSION

In this systematic review, we observed low risk of bias in two-thirds of the studies. There is an increasing body of evidence for aetiological research on migrants' health in Germany. Still, the directions of associations between a wide range of risk factors and major disease groups seem only partially understood.

PROSPERO REGISTRATION NUMBER

CRD42018085074.

Preadult polytoxicomania-strong environmental underpinnings and first genetic hints

Considering the immense societal and personal costs and suffering associated with multiple drug use or "polytoxicomania", better understanding of environmental and genetic causes is crucial. While previous studies focused on single risk factors and selected drugs, effects of early-accumulated environmental risks on polytoxicomania were never addressed. Similarly, evidence of genetic susceptibility to particular drugs is abundant, while genetic predisposition to polytoxicomania is unexplored. We exploited the GRAS data collection, comprising information on N~2000 deep-phenotyped schizophrenia patients, to investigate effects of early-life environmental risk accumulation on polytoxicomania and additionally provide first genetic insight. Preadult accumulation of environmental risks (physical or sexual abuse, urbanicity, migration, cannabis, alcohol) was strongly associated with lifetime polytoxicomania (p  = 1.5 × 10^-45; OR = 31.4), preadult polytoxicomania with OR = 226.6 (p = 1.0 × 10^-33) and adult polytoxicomania with OR = 17.5 (p = 3.4 × 10^-24). Parallel accessibility of genetic data from GRAS patients and N~2100 controls for genome-wide association (GWAS) and phenotype-based genetic association studies (PGAS) permitted the creation of a novel multiple GWAS-PGAS approach. This approach yielded 41 intuitively interesting SNPs, potentially conferring liability to preadult polytoxicomania, which await replication upon availability of suitable deep-phenotyped cohorts anywhere world-wide. Concisely, juvenile environmental risk accumulation, including cannabis and alcohol as starter/gateway drugs, strongly predicts polytoxicomania during adolescence and adulthood. This pivotal message should launch more effective sociopolitical measures to prevent this deleterious psychiatric condition.

Mental Health, Alcohol and Substance Use of Refugee Youth

This study aims to explore the prevalence of alcohol and substance use among young refugees along with the indicators of experienced psychological difficulties. It is based on a sample of 184 children and adolescents aged 11-18 years old, residing at two refugee centers in the Republic of Serbia. Out of 184 participants, the majority was male (N = 155; 84.29%). More than a half of participants (53.3%) displayed significant symptoms of PTSD. 50% consume energy drinks, 28% use tobacco; 13% use alcohol; 4.6% use marijuana; 1.7% use LSD, amphetamines, glue, tranquilizers and cocaine. Female respondents were more frequently expressing emotional difficulties (p < 0.05) while male participants were more frequent users of alcohol or substances (p < 0.01). Younger children were more frequently expressing symptoms of hyperactivity and prosocial behavior, while they were less frequently using substances. There is also a significant negative correlation between the years of education and individual proneness to substance use. Furthermore, those who resided in a greater number of refugee camps were found to experience greater levels of emotional and behavioral difficulties and face a greater risk of physical abuse. The burden of migration increases proneness to substance use, as a consequence of scarce coping resources and the stress of adjusting. Migrants are vulnerable to substance use, since some of them have commonly witnessed and/or personally experienced pre-and post-migration stress and trauma, including loss of homes and livelihoods, violence, torture and family separation. Preventive programs need to focus on the problem of alcohol and substance use among this vulnerable population.

Global child health in Germany - Time for action

Child health is central to the SDG agenda. Universities in the UK and other European countries provide leadership in research and education for global child health to inform related policy and practice, but the German contribution is inadequate. German paediatricians and other child health professionals could make more substantial contributions to the debate at home and internationally, but lack opportunities for scholarship and research. We argue, that there is a momentum to advance global child health in academia and call on German universities to realise this potential.

Exploring Similarities and Differences of Non-European Migrants among Forensic Patients with Schizophrenia

Migrants diagnosed with schizophrenia are overrepresented in forensic-psychiatric clinics. A comprehensive characterization of this offender subgroup remains to be conducted. The present exploratory study aims at closing this research gap. In a sample of 370 inpatients with schizophrenia spectrum disorders who were detained in a Swiss forensic-psychiatric clinic, 653 different variables were analyzed to identify possible differences between native Europeans and non-European migrants. The exploratory data analysis was conducted by means of supervised machine learning. In order to minimize the multiple testing problem, the detected group differences were cross-validated by applying six different machine learning algorithms on the data set. Subsequently, the variables identified as most influential were used for machine learning algorithm building and evaluation. The combination of two childhood-related factors and three therapy-related factors allowed to differentiate native Europeans and non-European migrants with an accuracy of 74.5% and a predictive power of AUC = 0.75 (area under the curve). The AUC could not be enhanced by any of the investigated criminal history factors or psychiatric history factors. Overall, it was found that the migrant subgroup was quite similar to the rest of offender patients with schizophrenia, which may help to reduce the stigmatization of migrants in forensic-psychiatric clinics. Some of the predictor variables identified may serve as starting points for studies aimed at developing crime prevention approaches in the community setting and risk management strategies tailored to subgroups of offenders with schizophrenia.